Candidate 118

Final FRCS (passed)                          

Centre: New Delhi                             

Date:    Sept. 2008 

This is Dr. Ranjith Kumar Puligadda (Paediatric ophthalmologist and Strabismologist) from vijayawada, India. Passed FRCS in September New Delhi 2008. I am very much thankful to Chua for his stupendous website which was the backbone of my success.

I am grateful to my parents (Mr.P.V.Narasimha Rao, Indira Devi), brother(Dr.P.U.V.S.Prasad M.V.Sc., Phd-Italy), wife (Dr.Sireesha ), and my son for their constant support and encouragement in achieving my lifetime Goal.

And my consultants K. Chandra Mohan MS, DNB, FRCS, Muralidhar MD, DNB, FRCS, MRCOphth, Praveen Krishna MS, Shashikant Shetty MS, who gave me very good guidance and building up confidence in reaching the target. Finally my best friend Srinivas Vegesna MS, DNB, FRCS who was of immense help in guiding me regarding examination procedures and emergency management protocols.

I wish to tell the pattern of the exam because this is most frequently asked question and which was hardly answered elswhere.
1st day - morning 9.30am to 11.30am (2hrs.) Essay questions -3, All must be answered
Afternoon-MCQs with negative marking (I was exempted).

2nd day -VIVA, 3 sessions of 20min. each. You face 2 examiners at a time at each table (every examiner asks for 10 min) Only 50% (aprox.) will be allowed to attend on 3rd day

3rd day – Examination of patients (45 min) as many patients you can see. You face 2 examiners.
Neuro ophthalmology, fundus, ocular motility cases are compulsory. No examiner will be repeated at any time (There will be 12 examiners in total but you will face any 8 of them- 6 on 2nd day and 2 on 3rd day)
Books to read:
Oxford hand book of medicine (Emergencies-last 30 pages, mainly CVS, RES and ECG)
Kanski new edition and Oxford ophthalmolgy (hand bok)
American Academy of ophthalmology (selective volumes-Pathology is must)
Wills eye manual or Wong (must be read min 3 times)
Preferred practice patterns in ophthalmology (Sankara nethralaya) - short cases, viva challenge, Instruments, electronic books, suture
materials, systemic cases, FFA, USG, CT, MRI, Pathology,
past candidates' experience***…. ( all should be read min.3 times)

1st day written

1. A 57 yr old man presents with a one week history of severe headache and has also become aware of afield defect in both eyes. He has a history of atrial fibrillation and is taking warfarin. On examination, the visual acuity is 6/9 in the right eye and 6/18 in the left with a possoble RAPD in the left eye. Give possible dd for this presentation and describe how you would investigate and manage this patient.
2. A 40 yr old woman attends your clinic enquiring about refractive surgery .her acuities are 6/18 with -9D in right eye and 6/6 with -4.00d in left eye. She had previous retinal detachment surgery20years before .you note she has an early cataract in right eye and clear lens in left. How would you manage this case and what risks and possibel problems would u specifically discuss with the patient?

3. A 75 yr old woman presents with inermittent diplopia. She has a previously been seen at the clinic with right sided epiphora. On examination there is some limitation of abduction of right eye which is displaced laterally. She has lost a considerable amount of weight recently with recurrent chest infections. What are possible causes of these symptoms and how would you manage the case?

2nd day VIVA

1st table (Neuro ophthalmology):


1st Examiner –photo on laptop – ( ccc, chemosis, corneal edema, coin like black fungal colonies at the center of the cornea)- fungal corneal ulcer. I could not guess but I described it. Next fundus photo- I described as right eye, clear media, with a white lesion of 5 DD with clear margins, obscuring vessels, inferotemporal to the fovea. Then I said DD- Retinoblastoma (asked features of exophytic type and endophytic type), parasitic cyst (CF, asked how do check for a live cyst –I told that I will throw light to check movement inside cyst, impressed), infectious causes like toxoplasmosis (CF-told), finally told- I am giving clue of few superficial haemorrhages along the margins, I could not tell, He told It was a old subhyaloid h'ge which became white.

2nd examiner: Given me HFA of hemianopia, respecting vertical midline, aasked me where the level of lesion if the other eye having same type of field defect-I told type of field defects in chiasmal and retrochiasmal lesions. What you do for this pt.-I told I examine for features of acromegaly, ask for symptomps of galctorrhoea, amenorrhoea, infertility ,loss of libido and I do imaging (CT brain) and refer to neurosurgeon and endocrinologist (Examiner put smiling face). Then showed me altitudinal field defect (inferior), I pointed out the field defect is denser inferonasally than inferotemporally (again examiner pleased). Asked me causes- I told AION, hemiretinal artery/vein occlusion (sup), RD, occipital cortex lesions.

2nd table ( Emergency medicine)

1st Examiner: Showed me photo of a young lady with unilateral ptosis and given me symptoms of myasthenia, asked me what it is and how you manage-I told repetitive saccades, fatigue test, cogan lid twitch sign, ice pack test and refer to neurologist. What tests he will do- repetitive nerve stimulation, single fibre EMG, Ach receptor ab, thyroid profile. What earliest test you expect-told tensilon test, how do you do it-with resuscitation ready, rule of 2s(from wong). If suddenly pt collapses what you do - ABC oxygen, atropine. If pt develops VF-I start resuscitation at 30:2 and connect defibrillator and give 360j (biphasic).If still VF continues what you do-I give shock again. How many times you give shock and how much energy you use-3-4 times, I reduce energy according to the response with biphasic machine. While doing FFA if pt collapses what you do-immediately stop drug, ABC, oxygen, elevate foot end, adrenaline 0.5ml im every 5min, i.v chlorpheniramine 10mg, i.v hydrocortisone 100mg

2nd Examiner: Photo of Both clsod eyes with erythema of lids, I could not catch, gave me clue as raised CPK, Still I didn't. Then another photo of Rhinophyma-I told CF, stages, asked corneal changes-told, then treatment-tetracyclines, where contraindicated-in children, pregnant woman due tendency to bind to calcium cause teeth malformation, side effects-told BIH, Definition of BIH-raised ICT with out SOL, normal imaging and normal CSF study with rised opening pressure, common in forty, fatty, fertile females. Asked other causes-told other drugs excess vit.A, estrogens and corticosteroids.Rx of BIH-told. Asked side effects of coticosteroids (bell rang up) told 10 causes very fast (Examiner was pleased)

3rd table: Pathology and ophthalmic surgery

1st Examiner(tough time) 40 yrs male, RE noPL, LE corneal opacity due to fungal ulcer with out new vessels, how do you manage- I see pupil reaction, search for optic atrophy cause in RE, take family history, deafness (DIDMOAD syndrome)-Asked what is that syn. probably examiner may not know about it, said everything normal- then I do PKP. From where do you take graft-donor, then asked from where else, it didn't strike me. Examiner told can you take from other eye- yes sir, what do you call it- auto graft, what are risks with auto grafts -recurrence of disease(?). For RE what you do-PKP,from where-donor, why don't you put LE cornea to RE- cosmetically not good and recurrence of disease(?).The given me prescription of 30pd BI-D and 20pd BI-N, I told divergence excess type of exotropia, I do patch test, then B/L LR recession, How much- 6mm each.

2nd Examiner: taken over each mm corrects how much-2 to 3 pd. Given me photo of histology slide-I started describing it, high power field, H&E stained with clearly differentiated cells of muscle(EOM) and infiltration of inflammatory cells, what it is-myositis, pseudotumor, finally got thyroid eye disease-Examiner happy. Another photo- d said retina cross section- (Ex. Stunned), no sir retina won't be so thick, it is skin. Ok what it is- I picked up black cells invading the junction of epidermis and dermis, also dermis- compound nevus. Then photo of cut section of eye ball with retinoblastoma-described extent of tumor, calcification, no extra ocular growth. How do you manage-I examine fellow eye, family members, screen for metastasis ( LP, BM aspiration, CT brain, USG abdomen),at this stage(involving >50% of eye ball) if other eye is normal I do enucleation. Then shown me entropion clamp-I told, bell rang up.

I entered last day for clinicals
(I did very well on 3rd day, I didn't leave even single question)

3rd day
- 45 min. ( Examination pattern is important, prepare how to manage each case- think of fellow eye, systemic management, family members for each case)


Ant.seg. nasal conjunctival scar, young male, nasal zonular dialysis, cataractous lens, no phacodonesis-I told pt. had penetrating injury with iris prolapse, underwent iris abscision (asked what is abscision?) and anterior vitrectomy, eventually developed cataract. How do you manage- ECCE+IOL or phaco by expert surgeon +/- CTR. When do you place CTR, after nucleus delivery or after rhexis.

Case 2-

80 yr old female, fundus Re with 90D- macular hole with cuff of SRF, How do you manage- I look for aetiology- what is most common cause-idiopathic. Rx is Surgery, I look for pvd in other eye, assess whether pt can maintain face down posture post operatively. What are steps- Vitrectomy with C3F8, would you do ILM peeling ,Yes, after staing with ICG.

Case 3-

Fundus with 20D of young male-RP- I saw boy spicules, but I completed 360 deg, disc, macula with atrophy. Asked what is prognosis- said vision gradually deteriorates (central or peripheral?) central vision stays longer. How you manage- I examine family members, give LVA, good illumination, reverse telescope and high minus glasses for field expansion, using torch at night, caution in traffic because of tubular vision, regular follow up PSCC, keratoconus, POAG. Also systemic examination for deafness, obesity, polydactyly, heart blocks, gait, dry skin .Asked associated syndromes and type of inheritance.

Case 4-

Young male- ocular motility examination- RE- 3rd cranial nerve palsy. I sated with Hirschberg (exotropia), cover test-asked primary, secondary deviation, anisocoria,
Aberrant regeneration noted on ocular movements, checked torsion said 4th is intact. Asked duration –said >6 months because of aberrant regeneration. How to manage- Ex. said imaging is normal and no diplopia- needs Sx for cosmetic purpose only, muscle transposition or globe fixation, what muscle- sup.oblique- Ex. Said good

Case 5-

55yr male RE LL entropion, LE there is a sututre hanging at lateral canthus. Asked how to examine- demonstrated pinch test and snap test for lid laxity. What you do- I do jones procedure( invol. Entrpion) and lateral tarsal strip( for laxity). Other eye pt. underwent lateral tarsl strip (how can you say) - because of suture location, in other procedures sutures will be along lid margin. Asked steps of lateral tarsal strip and jones procedures. Examiner is very happy.

All the best for those appearing exam and I am glad to answer for any questions