Candidate 129

Final FRCS   

Centre: UK     Tripoli                   

Date:    April 2009 

My name is Ahmed Abdel-Maksoud. I appeared for the FRCS (Glasgow) exam held in Tripoli on April 2009. I have passed this exam by the grace of God almighty from the first attempt. Personal thanks goes to my mother, my wife, my colleagues. Professional thanks goes out to Dr. Hussein Swelem, Dr. Ayman Elghoneemy, Professor Muthu online university, Dr. Mohammad Saad Rashad, Professor Chua for his amazing web site and all my friends and family from Egypt.

Professor Muthu online university is a free online university that provides lecture notes as well as training for answering the problem solving paper, which also helps in the vivas and clinicals. He sends you questions that you answer them and email it to them, which they then assess and send you a detailed discussion of your answer. It helps you to understand how the examiner thinks. His advices were invaluable and itís a completely volunteer work thatís helping people attend the exam from all over the world. Words alone fall short to thank these people. I would advice them to anyone attending the exams.

Same goes to Professor Chua, Dr. Ayman and his amazing FRCS yahoo group, FRCOphth yahoo group. Dr. Hussein Swelem and Dr. Mohammad Saad for there amazing lectures and notes and there support throughout this exams.

Its well known that those who fail these exams, do NOT lack knowledge, but lacks the way to think and present your information to the examiners in the various phases of the exams. And for this, you need training more than you need studying. The above list of people will help you get there.

Last but far from least, my wife, a brilliant young dermatologist, had summed up the whole chapter of ophthalmology and systemic disease in Kanski and others, to a series of notes, concentrating on body parts. For example, if you see a picture of a neck in the exam, think chicken skin appearance of pseudoxanthoma elasticum, scar from previous carotid end-arterectomy or a goitre. If you see a hand, look for Rheumatoid arthritis, if the same picture but the nails are affected, think Psoriasis. As well as X-rays of various areas of the body. It was brilliant! I will type these notes on a word document or a power point presentation and share it with others on the yahoo groups and with the chua site, if they are interested.

I will hereby narrate my experience for anyone attempting the exam in the future. Of coarse everyone is aware by now that the set up for the exam will change starting the end of this year, and I am sure this will stir much debates over which was the better regimen. More details about that can be gathered from the college web site.

Books I studied for this exam over a period of 2 months before the exam, not all these books I read entirely, this is merely a list of the books I opened at least once in the period before the exams, most of which I have read before for my M.S. and ICO exams:

ē Kanski latest edition. Multiple reads.
ē Lecture notes
ē Will's Eye manual
ē Wong ophthalmology examination review
ē A manual of systematic lid surgery by J.R.O Collins
ē Chua site, mainly for pathology and instruments and viva challenges.
ē Examination technique & Cases for Final MRCOphth/MRCS by Prof. CN Chua (Strongly recommend this book for the clinicals)
ē Oxford handbook of Ophthalmology (very selected chapters, mainly British driving and flying criteria, and legal registrations)
ē Oxford handbook of clinical medicine (mainly Emergencies and selected chapters)
ē Selected readings from the America Academy of Ophthalmology, specially Optics and Refraction for instruments, Pediatrics, lens and Retina.

Sunday, April 26th was the written paper, here are the questions with some comments on the different answers attempted by the candidates.

1) A 65-year-old man attends your clinic with a one-month history of right-sided headache combined with complaints of drooping of the upper lid and some intermittent blurring of vision on his right eye. He has a history of heavy smoking with chronic bronchitis and chest infection. What is the possible diagnosis and how would go bout assessing and managing the case?


Most candidates attempted this as a guided work up towards a differential diagnosis of either surgical 3rd nerve (aneurysm?) or Horner syndrome (pancost tumour) or GCA, with other diagnosis coming later.

2) A 32-year-old man, who had previously spent time in prison for assault, is referred to you by his optician with raised pressure in one eye. On examination, acuities are 6/6 right and 6/12 left, with intraocular pressure of 18 mm/HG right and 34 mm/HG left. There is a left afferent pupillary defect. How would you manage this case?

Perhaps the most debatable question in the exam. Itís a left acute rise in IOP, most probably of a secondary cause. 3 words should catch attention here, assault, prison and left RAPD. was he assaulted ? ( Angle recession, others?), did he catch something from prison? (TB, syphillis, AIDS, sexually transmitted?), and left RAPD in relation to all this, or is it not related (Posner Schlosssman, others?)

3) A 22-years-old girl who has previously suffered from Steven Johnson Syndrome, attends your clinic complaining of reduced vision. She has severe dry eye, with trichiasis and pannus, and her vision is 6/12 in the right eye and 6/18 in the left. There is some posterior Subcapsular Cataracts in both eyes. Indicate how would you manage this difficult case and explain the risks and complications of any intervention.

Perhaps the most straight forward question of all 3. The diagnosis is given. Key points here is needing a team work approach involving multiple specialties, starting conservatively, controlling the disease process medically first. Then attending to the lid problems to prevent further damage. Now go slow from here and discuss with the patient and consultants the risks and benefits of corneal, lens or combined procedure with the risk of activating the disease process by any of those. The use of systemic cyclosporin in this case should be mentioned and discussed too.

My Viva day was next day. Monday, April 24th.

My first Viva was Ophthalmic surgery and pathology. 2 examiners always, their nationalities are irrelevant, and not always known!

The first examiner showed me a slide of something I never saw before in my life! The lids had madarosis, some conjunctival injection, then there was "something" covering the iris. I was not sure of its level, is it corneal contact lens with a weird shape, or is it intraocular, he said its intraocular, I said I am not sure what it is, he said itís a rare device implanted inside the eye, why would we implant such a device, I said could be a case of aniridia or albinism with such an implant to prevent glare and photophobia. He agreed that this is a "possible explanation", then started asking me about aniridia, its mode of inheritance, presentations, complications and management. He then showed me a picture with a transverse break in the decemet's membrane and asked about differential diagnosis. He wanted to reach endothelial dystrophies and started a discussion about fuch's dystrophy, its management and started a discussion about cataract surgery in the presence of fuch's. The bell rang and the other examiner started asking about a scenario of a myopic patient with complaining of floaters, and a discussion about retinal tears, where they occur and why not oral (strong attachments at the vitreous base) and how to manage if there is an area of subretinal fluid, I said pneumatic retinopexy and buckle, he asked why not laser, I said cause of subretinal fluid, although some do laser around the subretinal fluid not the tear, and this lead to a discussion about the rules of scleral bucking, how to do and complications (he was specially waiting for diplopia). Then another scenario of a post cataract surgery case complaining of pain and reduced vision and there's a small hypopyon, I said we have to manage as endophthalmitis, he said how, we started talking about aqueous and vitreous taps, antibiotics, and why not Amikacin, and other drugs that could cause maculopathy (he wanted gentamycin). Finally, back to the fuch's and cataracts case and how to manage and advantages and disadvantages of separate and combined triple procedures. Bell rang. All in all, it went very good.

My second viva was General medicine and Neurology, the most dreadful viva ever. Here I must say that luck does play a role. I was starting to hear questions before I enter concerning hypokalemia and hypermagnesaemia with an examiner known to ask about these topics. God's grace and will led to me the other examiner who started with a scenario about a breathless patient in your clinic waiting area, how to manage, I started A B C D for life support, asked about differentials, gave him, he asked about tension pneumothorax, its signs and management, then athma signs and management. And finally a detailed discussion about the risk factors for pulmonary embolism, the most diagnostic investigation (said no time for that in an emergency situation, but CT angiography has a high sensitivity and specificity to diagnose it), then management and dose of heparin, indications and contraindications of thrombolysis, answered, asked what else do we need thrombolysis for, said MI, wanted more, I said I couldnít recall. All in all, It was one of the best vivas I managed! I have learned that the general medicine viva either goes too good or too bad, no middle way!

The other examiner started showing fundus pictures. Ok, they were one of the weirdest fundus pictures I ever saw, but he was helpful and I was in a good mood for passing the general medicine, and that helped a lot. The first picture was a fundus of an area of retinal oedema in an arcuate fashion above the fovea of a patient complaining of right paracentral scotoma. I started giving differentials, he said one diagnosis, I said either CSR secondary to an optic disc pit that was apparent in the picture or cilioretinal artery occlusion. He said where is the cilioretinal artery, I followed an artery in the picture and said I am not sure if itís a branch or a cilioretinal artery. He said it is a cilioretinal artery, how would you manage, I asked about the age, he told me 65, I started talking about GCA and how to manage from history to investigations, to treatment, then cardiac and carotid emboli and thrombosis, he asked which is more probable in this age, I said carotid, he went into cardiac causes, I answered. Then a picture of a palid disc oedema. I said most probably arteritic AION, I asked about the age and vision and then started GCA again, he then showed me a picture of the same patient several months later. There was an area of hypoflourescence, I said it could be a choroidal infarct from GCA, he said how, I said posterior ciliary arteries. He was satisfied. Now another picture of a girl with bilateral ptosis, I went into differentials, he said what could cause such picture, he then pointed me out that one of the eyes was slightly exotropic, I said maybe its 3rd nerve but it wouldnít be bilateral. Then went into mysthenia and CPEO. He said if its CPEO would she complain of diplopia, I said no, cause in the picture the visual axis is obscured and CPEO affects the muscles symmetrically. He said how would you manage, I started in Kearns syre he asked what would you find in the heart and pointed to his fellow examiner that he is a cardiologist, then asked how to diagnose. I said itís a mitochondrial inheritance, he asked whats that and what else in ophthalmology (leber's hereditary optic neuropathy) he said ok, whats the enzyme to look for in the blood. I smiled and said I donít know. (I looked that up after the exams, couldnít find it, it would be interesting to know that). Then a scenario of a senior ophthalmologist friend of mine who fell into a coma, and I was asked by the neurology team to help them with the diagnosis and localization of the lesion. I started to discuss corneal reflex, pupils, doll's eye maneuver and disc oedema or retinal hemorrhages from Terson syndrome (I would advise everyone to read this part in WONG's Ophthalmology examinations review, and from Oxford Handbook of Clinical Medicine on how to eye signs in a comatosed patient that could help localizing the lesion. Itís a very important and interesting aspect of neuro-ophthalmology thatís extremely useful in in-hospital practice). He asked what if he had sixth nerve palsy, I said could be a true or false localizing sign, he said whats meant by false localizing sign. I explained, he was satisfied and the bell rang. He showed a picture of a face, taken with the fundus camera, he had reddish spots on his face. The optic disc showed an aggressive yellowish exudate in and around it. He said quickly give me 2 explanations that could cause this. I said Poly arteritis nodosa or AIDS causing Kaposi sarcomas. He was satisfied. Remember, be quick and fluent. The more you get questioned the better.

I was very desperate for a 7 in a viva to compensate for any 5 I get, and I believe one of the above 2 vivas, if not both, took care of that. Now I have the ophthalmic medicine viva. Ok, itís the most one related to ophthalmology and our daily work, but still, I was very nervous.

Ok, my final viva, Ophthalmic medicine. first examiner started asking some common questions. I answered perfectly. There was some PUK, corneal dystrophies, a picture with neovascular glaucoma and management in details, up to cyclocryo ablation. I am saying this because I cannot remember all his questions. The reason for that is because the questions of the next examiner completely erased the first ones. The second examiner, a female Indian doctor. (I remember that cause it was pretty obvious, and remarkable), very serious face and questions. Started with a video of twitching in the eyes with the twitches at the side of the face, I said aberrant regeneration of facial nerve, she said no, others, I said hemifascial spasm. She said how to manage, I said we will need neuroimaging cause it may not be benign, specially if it persists during sleep. She said how to we differentiate it from Meig's syndrome, I said I donít know. (I read it later that in Meig's the neck muscles are affected). She asked how to manage, I said Botox, she said where to inject, I said I donít know, I will transfer him to an occuloplastic consultant, she said what if itís a female, I discussed cosmetology, and that Botox will abolish wrinkles and may need to be done bilaterally for symmetry (beauty is symmetry) she said what else. I fell short, she then told me ok, lets put it like that, what are the contraindications of Botox injection, and here it striked me, pregnancy. She wanted pregnancy (always suspect that when asked about a condition affecting a female, pretty obvious right, well not in the exams its not, where all mental blocks occur). She said ok, and shifted to another picture of an old lady with dermatochalasis and obvious facial palsy on the right side. She said is it upper or lower motor, I said lower, she said why I said its involving the whole face, while upper motor spares the upper face, the patient had dermatochalasis but the examiner pointed me towards her right frontalis muscle, it was high in the sky. I said she is overacting her frontalis to compensate for the dermatochalasis, this is an upper motor, she said good. What could be the causes and why the upper face is spared, answered, said ok, what if this a child, and bilateral. I stopped. I started discussing CP angle tumours and acoustic neuromas and gradenigo, middle ear. And then I said all those are unilateral. She asked me what the origin of the facial nerve, I couldnít remember the name of the nucleus in the pons! I then got it that she wanted central causes, Milliard Gobler maybe, she empathised and shifted to another question. A child with bilateral leucoria. I cant believe it, back to ophthalmology again! I discussed DD I details with need to exclude Retinoblastoma, she said could it bilateral, I said yes dr, and started to discuss its inheritance, she asked where, I said 13q14, she said what happens to it, I said RP gene, she said yes, what happens to it, I said I was not sure if itís a deletion or something else, she said it IS a deletion (pure luck here). Thatís it. I believe that could have been a bare pass. But I didnít care. I knew I will pass to the clinicals. And it was.

One more note about the vivas, and itís about the language. Being fluent in English gives a very good impression and makes the questions flow faster, which is a very useful thing in the exams.

Clinicals :

I Entered the hall, very nervous, started with a female, with one eye more prominent than the other. I checked the slit lamp, it was bilateral secclusio-pupillae, with iridotomies. Asked about what the IOP could be. They wanted to hear that one eye is going into phthisis. The next case was a fundus for indirect ophthalmoscopy. I was fearing that. I am a 90 D person, I do not prefer indirect except in examining detachments, and I do it with the patient semi-lying down. I started examining, nothing. I stated searching the peripherae, he said no need. My tension was rising, I cannot find a thing. The patient said she operated in this eye. I saw a conjunctival wound and thatís it. I was honest, I said the patient said she was operated, maybe there is silicone, I cannot detect it. The lead examiner told me are you sure there's nothing, my heart sank. I failed the exam. I said I was not able to detect an abnormality sir, and I need to re-examine on a slit lamp with my volk. The examiner mounted the indirect ophthalmoscope (I helped him) and started examining. 2 minutes later he said "The gentleman is absolutely right, there are no findings in this case, lets move on". My GOD. Ok, I was elated, I am still in the game, but how could this happen! They didn't examine the patients before the exam starts! Next was a crying child, he wanted me to do ocular motility! I said ok, and I tried to imagine what I will do in my clinic and that this is not an exam to prevent myself from getting nervous and rude with the child or the mother, but the child would not allow me. I said its an esotropia, and I couldnít examine more. He asked for differentials and was specially interested in Duane and its types, answered them. I started to get the feeling that this a viva exam not a clinical one. Next was a case post PKP in one eye and corneal leucoma and distichiasis in the other. I discussed whats there and trachoma. He said how will you manage the other eye and a discussion of triple procedure, its pros and cons again (as I said, this was a viva, not a clinical exam!). Then a child with myopic glasses. He said how would you manage. I didnít even examine the child! I talked about associations general and ophthalmic. He asked about how would you manage if he later developed a retinal tear, (again, this was the same examiner by the way. I though we only see the same examiner once in the exams). I answered. Finally, a young man for fundus with 90 D. Nothing but a dimmed foveal reflex. I started to talk differentials, he asked me in this age, what? I said CSR, he said what if its recurrent and vision is 6/12, I said FFA and smoke stack and ink blot and finally how to laser, I said first area of leakage.

Ok, they passed me in the clinicals, and they were very polite and helpful examiners, and I am forever indebted to them, but they were not prepared for the cases and there were virtually no cases for me to examine. Looking back, maybe it was for the better. Better than having difficult cases!

I want to emphasize that I am in no way generalizing here. I have only attended these examinations once, and so I am not an expert in the conduct of these examinations, I am sure this is the exception rather than the rule. This is merely a personal experience that I am sharing with others as it might happen with them. I want to emphasize that the exams not necessarily will go classical as you expect and you may not have a chance to show your knowledge or skills, you should be prepared for that and deal with it in the exam. If this happened, it could fail a good candidate if not dealt with carefully during the exam session. The key is to be polite with the examiners. Do not put your feet in the examiners mouth, but at the same time, 2 very important advices. Be confident, and never, ever, no matter what you do, never lie! Donít try to say something you didnít see just for guessing, or out of panic. I had the urge to do that, but stopped myself. Remember this, if you said nothing, sometimes is better than saying something wrong. Saying nothing will take from your marks, but saying something wrong or not there will probably fail you. If you are sure that there's nothing in the case or a different finding or diagnosis that what the examiner know, the key is to argue in a very polite way. Confident, but polite. Sometimes the examiners haven't seen the cases before the exam and just took what the residents wrote in the charts before the exam, which is not always right. I know I am in no position to criticize the exam or the examiners. And they did pass me in the clinicals, and were extremely polite and helpful but with me, this was a poorly conducted clinical exam!

Went to the hotel, too nervous even to breath. I was telling myself, how would they pass or fail me in the clinicals. I could never get a 7 in this clinical exam, but please God not a 5! I was not even properly examined. I was over prepared for the clinical part and it went very strange. Went back 6 hours later. I went in. They were having photos with the examiners. I went in and shared in the photos. During that, a colleague was asking me about another colleague, I said I donít know, I asked him why are they taking pictures if we donít know the results yet, he told me the results are out! I stayed as I am dismayed, my heart sinking until all the pictures were taken. Looking back, this was extremely funny and silly from me. My number was in the pass list! First time to attend this exam, and by the grace of God, the last time too. Most of those attending the exams with me had already sat this exam more than once before and I was the youngest person attending the exams, and that did shake my self confidence during the exams. Being recognized by an international examining body like that fills me with great honor. The examiners were shaking hands with me, I was thanking them, they said its my hard work. Most of them remembered me from the exam, and that mostly had to do with the language and the presentation more than the knowledge. I was on top of the world. And I still am. Good effort and honest prayers always gets the job done. I hope the best for everyone.

My email is . Please email me if you have any questions.

Best of luck to everyone.
Ahmed Abdel-Maksoud
M.S. ICO. FRCS Ophthalmology