Candidate 126

Final FRCS (passed)                          

Centre: Muscat, Oman                         

Date:    Dec. 2008 

I am Dr. Naeem Munir from Pakistan. I am currently working in Saudi Arabia. I appeared in FRCS Muscat in December 2008. This was my 1st attempt and ALHAMADULILLAH, I passed with the grace of God. I dedicate my success to prayers of my mother, wife, children (Maham, Amal and Abdullah) and my patients. It will be unfair if I do not acknowledge the support and guidance extended to me by my consultant Dr. Abdul Rehman Gaber Sulman whenever it was needed.

In this exam, one needs to complete all the course at least a month before examination date. In the last days before the exam, one must practice for problem solving papers, MCQ’s, viva questions and concentrate more on clinical skill as all these will be required in the examination.

The books which I studied thoroughly were:
- Kanski
- Willis Eye Manual
- Wong (only encircled topics for management of clinical problems)
- Oxford hand book of Medicine
- American Academy of ophthalmology systemic disease section.

Chua page is very important and goldmine for practicing for the exam. after reading all books. Past candidate experiences must be read because they modify your approach towards exam.

Now I would narrate my experience

DAY 1 (30th November 2008)
First, the theory paper.
Two hours are given, it is better to formulate a plan for each question before starting writing the answers. A key for each question is mandatory

Q1. A 40 years old lady is seen at your clinic with a history of intermittent pain, redness and watering in the left eye for 6 months, occurring particularly at night. During the last attack 5 days ago, the vision in the eye had become blurred and she had been aware of colored haloes. On examination acuities were 6/6 with refraction and both eyes were quiet with normal IOPs.
What are the possible different diagnosis and how would you investigate and treat this patient ?
Q2. A 25 year old female patient is myopic and has always had reduced vision in the left eye. Her best corrected VA is 6/6 right with -4.00 DS and 6/60 left with -7.00DS. She usually only wears a soft contact lens in her right eye. Two days before her wedding she is referred to your clinic with pain and redness in her right eye and an obvious corneal opacity.
How would you investigate and manage this case ?
One thing important about answer was that after all management options, if it turned out to be microbial keratitis, wedding must be delayed after consulting with parents and patient as the problem was in the better eye of the patient

Q3. A 75 years old lady who is a carer for her invalid husband presents with sudden loss of vision in the right eye, with the left having been poor for many years. On examination acuities are counting fingers left and 6/60 right and she has a macular BRVO in the right eye. On left side there is a dense cataract.
What are the possible treatment options for this patient and how should she be managed ?

Important thing was to refer this patient to Social Services after all treatment options.

MCQ paper
-60 MCQs (5 stems each) in 2 hours

I attempted 190 stems in the 1st go and extended it to 210 in the revision.

I had my viva the very next day which was a good thing.

Pathology and ophthalmic surgery British examiner & An Arabic Examiner

British Examiner

After introduction he showed me a slide of involutional entropion. He asked about diagnosis, pathophysiology, and management. Steps of Weis procedure and sutures used during surgery. How much time vicryl takes to get absorbed. Then he showed me another slide of pseudo exfoliation. Asked about risks associated with it during surgery. He asked also what difficulties a surgeon can come across during cataract surgery in this case. He was interested in the management of meiosis and zonulodialysis. He asked how I will deal with meiosis and zonulodialysis. also asked about complications of trabeculactomy during and after surgery. He was interested in suprachoroidal hemorrhage. He also asked about bleb failure and its management. Role of antimetabolites in glaucoma surgery. Bell rang.

Arabic Examiner

He started with phacoemulsification. He asked how would you manage if PC is ruptured before nucleus is cracked and after it is cracked. Management of dislocated nucleus in the vitreous. Various options for IOL implantation in this case. Complication of AC IOL. Then he asked me the pathology of chalazion, showed me a slide of BCC. And last he asked how you do vitrevtomy while doing phaco. Bell rang I answered all questions and I was happy.

Ophthalmic Medicine
Best viva I have ever come across.

1st Examiner – A British Lady

She was an expressionless lady. She showed me a laptop picture of papilloedema. Asked about its causes , how would you manage this case. She was interested to hear about malignant hypertension and pseudo tumour cerebri. Then showed me a photograph of buried drusens. Asked about it and different ocular associations with it. Then another photograph of right eye esotropia with cataract of a child of 3-4 years old. Asked about D/D, management of unilateral congenital cataract in detail, D/D of leucocoria.
Bell Rang.

2nd examiner - An Indian Dr. Khalid Sharif

He started with corneal manifestation of HSV. He asked details of disciform keratitus. How to treat it. Then he asked how you will treat it if patient refuses steroids. He asked about Lotemax. Next question was vortex keratopathy, causes. Then he asked if patient is using tablet amiadrone, would you stop the medicine. Next he inquired about indication of cyclosporine in ophthalmology. Also asked about AMD, use of anti VEGF and its dosage and complications.
Bell rang. I didn’t drop any question. I was happy and sensing to go to clinical.

General Medicine And Neuro-ophthalmology

1st Examiner Dr Gupta

He started with causes of vertical diplopia, which diplopia can recover spontaneously, management of restrictive myopathy due to TED. How and when to use  otolinum toxin and its complications. He showed a projected slide of a patch of choroiditis. Asked about D/D , started discussion on tuberculous choroiditis, drugs used for ocular T.B, their side effects and details of visual field defects caused by them. Also asked about other causes of centrocecal scotoma. Then he inquired about Leber's optic neuropathy, its mode of inheritance. He also asked about different ocular manifestations due to deficiency of different vitamins. Bell rang.

2nd Examiner Dr Maedi

He was a difficult examiner. He started with emergency treatment of pulmonary oedema, its signs and symptoms, causes. He was interested in nearly all causes. Then he asked about hyperosmolar hyperglycemic non ketotic acidosis, its management. Next a strange question for me. What is metabolic disease. Next question was about management of pneumonia, its causative organism and its complications. I was not satisfied with my answers. Then he asked my favourite question, complications of steroids. I gave detailed answer. I narrated systemic and ocular complications. Then he asked about management of osteoporosis. Lastly he inquired about indications of steroids for systemic and ocular diseases. Bell rang.

Clinical Examination (Third day 03-12-2008)

I was given 36 minutes and I saw 7 patients in this time. I was quick in picking up findings and telling to the examiners at the same time to save time. I was dealing with patients in Arabic Language, so it also saved time.
A British examiner and An Indian Examiner

Ist Case:
Examine left eye of a young girl on slit lamp. She had PKP. I told all positive findings. He asked what will you see in this case. I said sings of rejection. Asked about sings of rejection, then asked how old PKP. I said more than a year as all sutures were out. Asked about refraction in such cases and its management. Then asked me to see the other eye. She had keratoconus. I told him about Vogt’s lines, deep AC, apical protrusion etc., He asked about other signs of keratoconus away from slit lamp. I told him oil drop reflex sign on ophthalmoscope, scissor reflex on retinoscope. He asked me to demonstrate oil ropd reflex test and Munson sign. In the end he asked about keratometry readings for mild, moderate & severe keratoconus.

2nd Case
A young patient had left Duan retraction syndrome. It was type 1. I was asked to check the ocular motility. I asked the examiner that I would like to start with cover, uncover test. He said no need. I did ocular motility examination. I told my findings, I gave my diagnosis. He asked why Duan’s. I said due to retraction of globe in adduction. He asked mechanism of retraction and about management of this case. Patient was orthophoric in primary position. So I said refraction.

3rd Case
Examination left eye of an old man with +90D. Patient had optic atrophy with monocular RPE disturbance. Examiner asked is it glaucomatous. I said it does not seem to be glaucomatous even then I will like to examine the other eye. He said go ahead. I examined the other eye. I told that as other eye has normal cup, neuroretinal rim so left eye has optic atrophy which is not glaucomatous. He asked what can be the cause I said in this age group ischaemic optic atrophy(common cause), optic neuritis, compressive optic neuropathy etc. He said how will you manage this patient. I started with history etc. He said any investigations, I said ESR to rule out GCA and other investigations . He was satisfied.

4th Case

An old lady for slit lamp examination of right eye. She had many findings. I first examined her on chair for a second than took her for slit lamp examination. She had dermatochalasis, trichiasis, entropion trachomatous conjunctival scarring and diffuse stormed corneal opacities, aphakia, iridodonesis, PI at 2’O clock ( It was difficult to see beneath the hazy cornea). Examiner asked about the level of corneal opacities. I said stromal, then he asked why aphakia. I said due to diffuse corneal opacities, It was not possible for surgeon to manage ECCE or phaco. Examiner was happy.
Then he asked me to see left eye also she had PKP, aphakia, vitreous in AC, peaked pupil. The he asked what corneal opacities may be in right eye. I said corneal dystrophy which type, I said macular dystrophy asked bout inheritance pattern and the age where PkP is needed usually.

5th Case

A young man sitting on chair. I was asked to see fundus of left eye with ophthalmoscope, I asked sister in the room to dim the light and examined the fundus. He had macular pigmentary disturbance at fovea, I said, I would like to see with + 90D, examiner said OK. I saw with 90D on slit lamp and asked to see the other eye also. Examiner happy and allowed. The other eye was normal but pupil was pharmacologically dilated. I gave D/D but stressed on post CSR fundus. Examiner asked how will you proceed. I said FFA, asked about different patterns on FFA. I answered smoke stack, ink blot then he asked me the indications of laser treatment in CSR. I answered.

6th Case

A young boy for slit lamp examination of left eye. He had trauma to left eye with many finding. He had corneal repair with 10/0 nylon, entry wound in iris at 3,o clock, irregular pupil, Big PC defect, anterior hyaloid phase broken, limbal sutures also. I was asked how old the surgery. I said less then six weak. Why, I said corneal sutures are still present. He ased which repair has been done. I said primary. How will you mange this case. I said as there is no PC and already corneal injury, I will like to go for scleral fixation of PC IOL

7th Case

Cover uncover test of a young patient. He was wearing glasses. I checked glasses ( Myopic astigmatism ), He had alternate esotropia of 21degrees. No A/V pattern. He asked how will you measure I said with prisms. He asked about possible refractive error. I said myopia, he asked which glasses he is wearing I said myopic astigmatism more on left side. Knock came on the door, time was up and I was smelling success in the exam.
Result was announced in the evening .
Thanks to Almighty Allah, I passed, I wish god luck in next exam. for all. I will be happy to help anyone who is interested. My Email is