I am Rishikesh and I passed FRCS (Glasgow) in
September 2008 in first attempt. I would like to thank my family members for
their support and Sankara Nethralaya, where during my post-graduation, the basic
foundations of clinical ophthalmology were taught to me. I had taken the exam
only because I had cleared my part-1 and had decided not to attempt again if I
did not clear this time. For guidance, I went back to what I trusted most during
my DNB exam i.e. Kansky, Wong, Chua’s website and Dr. Muthusamy (mvupgo.com). In
addition, Dr. Ayman’s presentations were of great help. My special thanks to all
the candidates who have shared their experiences through this website…….that was
really helpful and comforting throughout my exam period.
Clinical Case interpretation
1. A 57-year old man presents with a one-week history of severe headache and has
also become aware of a field defect in both eyes. He has a history of atrial
fibrillation and is on Warfarin. Visual acuity is 6/9 RE and 6/18 LE with
possible RAPD LE. Describe how you would investigate and manage the case.
2. A 40-year old woman attends your clinic enquiring about refractive surgery.
Her acuities are 6/18 with -9.00DS RE and 6/6 with -4.00DS LE. She previously
had RD surgery 20 years back. You note early cataract in RE and clear lens LE.
How would you manage this case and possible problems you would like to discuss
with this patient?
3. a 75-year old woman presents with intermittent diplopia. She has previously
been seen at the clinic with right-sided epiphora. On examination, there is some
limitation of abduction of the right eye, which is displaced laterally. She had
lost a considerable amount of weight recently with recurrent chest infections.
What are the possible causes of these symptoms and how would you manage the
To prepare for mcqs I read Kanski and solved mcqs of this website twice. At
least this gave me the thought process to attempt mcqs with negative marking. In
the first go, attempt the sure-shot ones and if they exceed 200, don’t go any
further. Learn all inheritance patterns, HLA-types, sexual predilections,
chromosomal associations and specific pathological features of ocular conditions
(eg. palisading for BCC), by heart. Also remember incidences of uveitis in
various systemic diseases and glaucoma secondary to various ocular conditions
(pigment dispersion, PXF etc).
Day 2 (VIVAS)
Mine was in the first session of second day.
Clinical photo, red free photo, FFA and OCT of CSR. Listen to the examiner’s
question carefully, he asked me the diagnosis, and I went on describing the
photos, though the diagnosis was obvious. He started asking me various phases of
FFA. Moral of the story: if diagnosis is obvious, tell it straightaway. Let
examiner decide whether to ask for justification of diagnosis or further
management. Second photo was a corneal pathology and AC details were not clear.
I thought it was fungal ulcer, but time got over
HVF showing inf.arcuate scotoma. Discussion on possible disc changes, medical
management of glaucoma. Next was bitemporal field defect and discussion on
chiasmal compression and MRI.
General Medicine and Neurology
X-ray of hilar lymphadenopathy and pulmonary fibrosis. I was not very sure of
this, but examiner nodded and hence got relieved. Discussion went into systemic
and ocular manifestations of sarcoidosis, investigations and management. Next
was a clinical photo of lady with goiter. Asked medical management of
hyperthyroidism. Next was classification of diabetic retinopathy and I answered
before time was over.
Question- Person on slit-lamp suddenly collapses suddenly. What will you do?
Told him about the possibilities of vaso-vagal shock and hypoglycemic coma. He
nodded and then stretched out his hand and drew an ECG of ventricular
fibrillation. Asked me about further management and details of defibrillation.
Next, clinical photo of a man with café-au-lait spots. Discussion on
neurofibromatosis, ocular and systemic features. Then clinical photo of a middle
aged lady with proptosis and lid-retraction. Asked commonest cause and I said
thyroid. Bell rang.
Ophthalmic pathology and surgery
Gave me a photo and said it’s an orbital tissue. I started describing the
lymphocytic infiltration. He showed me an area and told me it was muscle tissue.
Oh no, not again, it was thyroid myopathy. Then a pathological photo of
capillary hemangioma, molluscum contagiosum (not very clear), and said I am not
sure. Then a clinical photo of swelling in lacrimal sac area and discussion went
into management of acute dacryocystitis. Then he showed me Kerryson’s punch and
details of DCR.
Photo of filtering bleb. He said it is 5 years old and now the IOP is 5mmHg.
What can be the causes? I thought of choroidals, but then he showed me a photo
of Seidel’s test. He asked me the details and how to manage a wound leak. Not
very satisfied with the answer. Next, complications of RD surgery, and
comparison of C3F8, SF6 and silicone oil. I went on answering and his frown
started disappearing. Next, he gave me 2 readings, 15 prismD XT for near and 30
prism D XT for distance, vision BE 6/6, how would you manage. At last, there
they entered into my field, squint. I described patch test. Then he asked when
to do surgery, squinting for >1/2 waking hrs and deteriorating stereopsis. What
surgery, I said bilateral recession. He asked why, divergence excess I said. I
wanted to go into details about surgery but time was over.
Results came in the afternoon and 34 out of 61 proceeded to clinicals and I was
I think the best way to approach the clinical is to think as if you are working in
your outpatient dept. I am a squint person so I had decided to try to finish
examining squint and neuro-ophthal cases early, so that I can spend extra time
for fundus cases.
To my good luck, the first case examiner asked me to check motility. Within no
time I concluded it was Duane’s-type3 and he asked when shall you do surgery and
what will you tell patient about the condition. The discussion must have lasted
for a minute or so.
Second case- 90D exam. I dimmed the room lights and took my time to diagnose it
as CRVO. He started asking about filters on slit-lamp, then when will you do FFA
for this patient.
Third case- Direct ophthalmoscopy (I am not good at it), anyway I saw the disc
and said NVD. Then he asked to do indirect of the same patient. I am more
comfortable with that and saw it was old STBRVO. Described the findings. He said
what field defect do you expect, I said nasal. He asked to do confrontation
fields for the same patient to conform.
Fourth Case- Again a squint, but I messed it up a bit. Ocular motility. Patient
had left exo and adduction limitation with lid retraction on attempted
adduction, but motility did not fit into any type. I described the findings, he
asked what do you think, I replied I am thinking of partial III nerve with
aberrant regeneration but I am not sure. He showed me the glasses of the
patient. High hyperopia, more in LE and asked me to look closely at LE
conjunctiva. She had a scar. I said she probably has undergone squint surgery
for the LE and being anisometropic amblyope, squint has recurred. He nodded.
Fifth case- young male with proptosis and lid retraction. I was asked why
proptosis and not ptosis in the other eye. I said superior scleral show. Asked
to elicit lid-lag. Probable cause thyroid, but also CCF. I said I would like to
check motility, pupils and slit-lamp. Examiner asked me to perform pupillary
examination, but was normal.
Sixth case- child, asked me to quickly check with torch. I said RE
microphthalmos with iris coloboma. He asked about LE, but I could not see and
coloboma there. He was not very satisfied, but the bell rang.
My heart sank and I thought I had messed up a squint case and the coloboma in
the end. Was tensed and tried to calm myself by reading newspaperand watching
TV, but the thought of exam could not leave me. In the afternoon, when I was on
my way to the centre, got a call from my friend that I have cleared. I thought
entire world at my feet. I confirmed the result myself 5 times and have also
taken a photo of the result sheet on my mobile. 10 years back when I was in my
medical school, I would not have dreamt to be FRCS one day. My medical career
has been full of ups and downs, but I consider FRCS passing as one of my
greatest successes so far.
In case of any queries, feel free to mail me at firstname.lastname@example.org or