Candidate 109 

Final FRCS (passed)                          

Centre: Glasgow                              

Date:    2007 

Dear colleagues,


My name is Elham Eltohamy, from Egypt…I attended the FRCS exam 3 times, and passed in the third attempt…I wrote my experiences in the way that can facilitate revision for you before the exam...I wrote the written exams together...then the viva of each section together...

I confess that answering the previous experiences of the others before the exam helped me very much.

My impression about the it is very easy to pass and easier to fail..but it will be easy if you practice to answer the exam itself and studying in groups or at least with one honest colleague..And too many discussions about the exams….try practice clinical also as much as you can….

For problem solving (which is helpful also in Viva) questions, Prof. Muthusamy was a great helper by his continuous advises and correcting problem solving answers for me and all his students, and very supportive...His web site is  Also, Dr. Ayman Elghoneimy and Dr.Ahmed Sallam course online and their FRCS notes at(FRCS yahoo group) were a great help in viva and clinical exams..,the web site contains every detail about the exam…e.g(the book that you need to read before the exam…the dates of the exam, how the examiners evaluates you..b eside the scientific notes which downloaded as power point presentations) you can open the web site and download all their lecture notes..

FRCophth group also by Dr.Samer Bashir was very helpful by the files, and FAQ…

Chua page is very very important for practice the exam...after reading all books that you should read(Kanski,Wong,Willis eye manual, Oxford hand book for ophthalmology) and any other books..please try to answer questions of chua page,it is very important and it is the exam at your hand.

Wish you all Good luck….hope my experiences are useful (not boring ) to   you..and sorry that I forgot many of viva questions..



I didn’t pass the first exam because I did a lot of guess in MCQ, and was hesitated in one of the viva exam…so, please answer  only what you are sure in MCQ and ,be confident.

In the second attempt, I didn’t pass the neurology and general medicine  viva station.

In the third attempt, I passed...thanks godJ.


Elham Eltohamy



 Problem solving:


*Problem solving1(Tripoli 2006):


1- A 13-year-old girl is brought to your clinic by her mother complaining of reduced vision. Visual acuity  was 6/18 in both eyes, reading N8 unaided. Her parents have just been divorced. How would you manage this patient and what investigations may be appropriate?


2- A 55-year-old man, who works as an engineer, has attended the eye clinic previously with latent angle closure glaucoma and has bilateral peripheral iridotomies performed. His refraction is +7.50 DS in the right eye and +8.00 DS in the left. On this occasion vision is reduced to 6/12 in each eye because of cataract.What potential risks would you perceive with this patient and how would you manage his cataracts?

3- A 33-years-old woman has been aware of a degree of left-sided proptosis for several months. She presents to your clinic with a 1-week history of pain and redness in the left eye. Reduced vision and an apparent corneal ulcer.
Explain the possible causes of this patient's symptoms and how you would manage her?


Problem solving2 (Tripoli 2007):


1-A 32 year old woman is 35 weeks into her pregnancy when she come to see you complaining of reduced vision.On examination her acuities were 6/12 in each eye.

Describe the possible reasons for her poor vision and how they might best be managed.

2- A 70 year old diabeteic man presented to your clinic complaining of distortion in his right eye for 1 month.His vision in the right eye is 6/36 compared to 6/9 in the left.

What is the DD?how would you investigate and manage this case?

3-The parents of a 2 year old boy bring him to see you complaining that the left eye looks larger than the right.

What  possible conditions could this child have and describe how you would manage the case?


*Problem solving3(Glasgow 2007):


Q1 50 years old woman complains of a recent onset of vertical diplopia .On examination there is a small right hypertropia

What is the DD,and describe how would you investigate and manage this patient?

Q2 A 47 year old man has been treated for ocular cicatricial  pemphegiod for several years and had a right cataract extraction  performed  6 months ago.He is sent to your clinic with pain in his right eye and you diagnose right corneal decompensation with bullous keratopathy and vision of Counting fingers.  The left eye has a vision of 6/24 with a cataract.

State what treatment options are for this patient and what management plan you would recommend.

Q3 A 24 year old man was assaulted one year ago and had a left malar fracture repaired by the Maxillo facial surgeons. He is now referred to your clinic by his optician who has found the vision in the left eye to be reduced to 6/18 and has noticed a left RAPD.

What are the possible  diagnosis with this patient and how would you manage him?




General medicine and neurology

 First attempt (Tripoli 2006)


 English and an Arabic examiner:

I lost confidence in this station so,I lost

The English examiners asked me: 60 years old female patient come with diplopia(6 nerve palsy)..what you will do?

I started with history of systemic illness, then...I said:I have to start with history of onset of her problem and if it was associated with pain or not..He asked about the importance of pain here? My answer : related to aneurysm or infection( he wanted giant cell arteritis) and he guided me to the answer by telling that she felt pain on combing hair....and asked me if GCA can cause 6 nerve palsy or not..I was not sure as I always read it with this was confusing to me a little...then ask about investigations(ESR,C-reactive protein),what can you do in the clinic( he wanted measuring blood pressure)..he asked if I do this by myself, I said yes( wrong answer, as the nurse who usually do that)..and asked me if I would give the steroid injection treatment by my self...I couldn't answer..and I never think about that before, and didn’t practice it in my life, the correct answer is to admit the patient and start immediate investigation and IV steroids after steroids work up(by the way…This is a very common viva question).

The Arabic examiners questions:

Effect of systemic blood pressure on the body?

Systemic manifestations of infective endocarditis and how can it affect the eye?

Mythenia gravis?Tensilon test?

Eye manifestations of thyroid dysfunction?


Second attempt (Tripoli 2007):


An Arabic and an English examiner 


Q: how would you manage a recently diagnosed diabeteic patient?

Q: complications of diabetes?

Q: systemic causes of anisocoria?

Q: Hyperthyroidism? level of TSH, in thyrotoxicosis and why??Difference  between T3 and T4? When all level of thyroid hormone are elevated?

Q: CRA occlusion causes?




Third attempt (Glasgow 2007):


English and Indian Examiners:

Q: DD of patient with acute chest pain...Cardiac causes, pulmonary causes…the acute chest pain in healthy young adult with no previous systemic or chest illness (Pneumothorax)...Management?


Q Systemic neurological diseases associated with eye manifestations (MS,GCA,Phacomatosis..

Q Systemic diseases that affect the lens...those that cause cataract...DM, Mytonia Dystrophica…

 And those that cause lense…

Q 18 years old female, recently got diabetes…what risks that she can face, and what you will tell her?

(DKA, hypoglycemia…and long term complications of DM (neuropathy, nephropathy, retinopathy..

Q Diabetic patient with vitreous hemorrhage and…? My answer started with counseling the patient that the laser will not improve vision but will keep it from deteriorating...then he stopped me saying that ,that is all what I want to hear..





Viva 2:

Ophthalmic pathology and surgery


First Attempt (Tripoli 2006):


One Nigerian and one Arabic examiner


laptop photo of 40 years old man with right hypotropia and mild proptosis(dd .of  hypotropia was muscular or neurological causes

how can you differentiate?(forced duction test) investigations(thyroid function test)he said the patient was Euthyroid, the CT Scan,,he showed photo of his CT and there was enlargement of EOM(thyroid ophthalmopathy(manag ement)IR recession guided by

adjustable sutures(he liked my answer and smiled)

Laptop pic of sub retinal dark pigmented lesion...(DD,malignant melanoma,navus,hemangioma,hemorrhage,metastasis)how can you differentiate?(US to check thickness and internal reflectivity)…He agreed...bell rang.

English Examiner

Slit lamp photo of a child with right convergent squint (history of onset)…he said it started when he was 2.5 years old (accomodative esotropia)..Management? (cyclopegic refraction and fundus examination to exclude any organic lesions..he said his vision was 6l6 both eyes,refraction +4D both eyes..fundus normal,would you give him glasses?I said yes as hypermetropia can be overcomed by the accomodation of the child...after correction still residual esotropia(partially accomodative esotropia)management?.Bilateral medial rectus recession a vision is equal in both eyes.

Q: Refractive surgery and LASIK?If I would advise him to do a surgery or not? then asked about complications of LASIK and if I would advise him  to do LASIK or no(I said no,but I think that was a wrong answer).

Q pathology of malignant melanoma (types of cell and which has worst prognosis (,epitheliod cells)…Best prognosis.(spindle A cells)…(this is a very common question in pathology)bell rang


Second attempt(Tripoli 2007):


 An Indian and a Nigerian examiners

Q: laptop picture of histopathology slide..showing different kinds of cells…no definitive tissue to I start to describe the slide(many spidle shaped cells…few pigmintations..)Q:what is the lesion? choroidal melanoma.

Q: Laptop picture of an eye with keratoplasy PKP and sclera ring (intraoperative pic)..I said PKP with sclera ring to prevent sclera from collapse.

Q:lap top movie of patient with frequent blinking..( essential blepharospasm) Q:Management?he draw the eye and asked where you will inject the Botox?

Q:Direction of nasolacrimal duct in children?and how to do probing in children?

Q: Treatment options for  myopic patient with – 4 D myopia…glasses,CL,lasik,lasek,Intacs..but he wanted phakic IOL also..I was objecting as it is very invasive procedure for such degree of myopia..( he smiled).


Third attempt(Glasgow 2007):


Q Laptop pic of Lisch nodules..definition…clinical picture of neurofibromatosis 1.

The examiner told me that there is a proptosis in this patient?what do you expect?and what is the fundus picture..( choroidal folds,astrocytoma,glioma,optic atrophy…he was not satisfied

Q Laptop pic of child face with unilateral leucocoria..DD.

Q what is the most important and single question to ask to the mother?....( family History).


Q Complications of phaco and how to manage PCR and nucleus drop?

Q an old man with a mass in the lower lid..DD?Management?

Q How to do PRP in details?spot many shots..power….




Viva 3:

Ophthalmic medicine


First attempt(Tripoli2006)


English and Arabic examiners


Q: diseases of RPE?how can you see RPE detachment clinically?(dome shaped elevation) can you differentiate from CSR as there is dome shaped elevation also(Flourescin angiography,ICG)..why sometime dome shaped elevation in RPE detachment sometimes look notched?( tear in this layer and folding of tear).


laptop pic of :

1-coloboma of the iris?causes?

2-subretinal white lesion occupy half of the retina?I didn't know but I Tell for differential diagnosis(he liked the answer!!!!)

3- corneal dystrophy(dystrophy then said opacity)what is the difference between dystrophy and opacity?

4-FFA of non proliferative DR?which stage of DR and which stage of flourescin? management?(good metabolic control and follow up every 3 to 6 month) he insisted to choose between either  3 or 6 month follow up( I said 6 month as there is no signs of ischemia).

5-dragged optic disc?(DD)..ROP? causes?(prematurity with Oxygen supply).concentration of Oxygen?(was not sure).bell rang



Second attempt(Tripoli 2007)


2 Indians examiners


Q: How different types of laser work?(laser tissue interaction)?the answer is found in wong  in laser in Ophthalmology chapter  and Rifaii Egyptian book for refraction.

Q: Management of idiopathic increase ICT?

Q: GCA..managemnt? what is steroid work up?


Sorry don’t remember the all questions.



Third attempt(Glasgow 2007):


An Indian and an English examiner


Laptop pic of Retinoschisis….DD.

Intravitreal injection of  anti VEGF…how to do intravitreal injection in details…

Problems of Anti VEGF…(v.expensive).

A pic of sclera nodule..DD..scleritis, to differentiate?

Q side effects of cidamex(diamox)?

Q a 35 years old woman with bilateral disc swelling,visual acuity normal,DD?how to manage?

Q Causes of idiopathic increase ICT?

Q How to cofirm the diagnosis ?..lumbar puncture..opening pressure..



Clinical( the only attempt):


4 cases (3 slit lamp cases ,and one ocular motility case)


And by the way,in each case they changed the slit lamp setting,so,I have to readjust the slit lamp setting for each be very careful of such tricks..


Case 1:

54 years old female,with sudden painless loss of vision RE since 6 months,

Q1 Take a short history(DM,HTN,Trauma,Pain at  muscle or on combing hair-she was diabetic and   hypertensive for 8 years)…asked about the nature of visual loss..she explained that it was altitudinal…

Q2 Examin the patient…Pupil(RAPD..RE)….Iris,no rubeosis…fundus shows pale dic swelling.

Q3 Then the examiner asked me about my conclusion..AION..

Q4 Investigations?C-reactive protein,ES…

Q5 DD, Arteretic AION.


Case 2:

Old lady (about 80 years old)

Q:examine the anterior segment( cataract with pseudoexfoliation)..asked me to examine the anterior chamber???..there were pigments on the corneal endothelium and irirs transillumination..

Q:exmine posterior Segment(ARMD-Dry type) Q How to increase vision in this patient,and recent management of ARMD ?(low vision aids,vitamins intake antioxidants…

Q Risk of cataract surgery in this patient?( pupil dilatation,zonular dialysis,dropped nucleus,vitrous loss.


Case 3:

Old male ,asked to examine the posterior segment.Very strange lesion to me,I couldn’t diagnosis it from the first look,so I started  to describe the lesion(pale disc ,attenuated vessels,the whole retina looks white.

Then asked to examine the other eye, there was a rim of retina adjacent to the optic disc…I said Choroideremia...

Q:what else? A:Gyrate atrophy.

Q:How could you differentiate? then said from history.

Q:asked me again to take short history…

onset:Since child hood, all his son have the disease, all his daughters are carriers..his brother also has the same illness..

Q: mode of inheritance? A: X-linked.


Case 4:

Ocular motility case

Middle aged lady,asked to examine her…there was ptosis in left eye…asked to come nearer and examine the upper lid of right eye…there was a scar Q: what it could be? A scar of ptosis surgery.

Q: Asked to do cover and uncover test…I asked the patient first if she has a glasses, the the examiners told me never mind..go on…then asked the patient to look straight ahead (the room was small..about 3 meters distance)..and then did the cover and uncover for distance…There was mild exotropia….

I wanted to do it for near, but time was up.