FRCS PART 3 GLASGOW MUSCAT 2010
MY NAME IS AYMAN MOHAMED RASHAD FROM ALEXANDRIA EGYPT AND
WORKING NOW IN SULTANATE OF OMAN IBRA HOSPITAL . THANKS GOD
ALHAMDOLLELAH I PASSED FINAL EXAMINATION FOR FRCS GLASGOW PART 3
I WOULD LIKE TO THANK ALL PEOPLE WHO SUPPORT ME AND WITHOUT WHOM THIS
WOULDNOT COME TRUE. SPECIAL THANKS TO MY MOTHER WHO SACRIFY
MANY THING FOR ME, ALSO MY WIFE ALYAA AND MY SONS ZIAD AND MAZEN.
MY BROTHER MOHAMED MOHAMED RASHAD WHO ISSUE ALL MY CERTIFICATE
FOR MY SUBMISSION
ALSO WOULD LIKE TO THANK MY HOD IN MY HOSPITAL DR KISHAN KUMAR
GUPTA WHO ALWAYS SUPPORTED ME AND INSISTED ME TO APPEAR IN THIS
EXAMINATION AND PROVIDED ME WITH MANY POINTS THAT COULD HELP ME TO
PASS THIS EXAMINATION
ALSO MANY THANKS TO MY PROFESSOR DR SERRY SULIMAN AGLAN
CONSULTANT OPHTHALMOLOGY IN ALEXANDRIA WHO ALWAYS GIVING ME HOPE FOR
THE FUTURE , MANY APPRECIATION TO DR KHALID MOUNIR AND DR OSAMA
SABRY WHOM I WISH THEM ALL THE BEST.
CHUA WEB SITE WHICH IS THE MAZING SITE FOR ALL CANDIDATE WHO ARE
PLANNING TO APPEAR FRCS AND PERSONALLY I GOT BENFIT FROM IT AND
ESPECIALLY PATHOLOGY SLIDES AND PAST CANDIDATE EXPERIENCE AND MANY
MUTHUSAMY ON LINE COURSE A WOUNDERFUL SITE AND ITS VIRTUAL UNVERISITY
WHICH WAS GUIDING US TO RIGHT WAY TO ANSWER QUESTIONS AND POWERFUL
POINT IN THE EXAMINATION
MY READING SOURCES:
KANSKI, AMERICAN ACAEDEMY, WILLIS EYE MANUAL, OXFORD HAND BOOK OF
OPHTHALMOLOGY AND THAT OF GP FOR EMERGENCY
ALSO REVIEW PATHOLOGY SLIDES FROM CHUA WEBSITE, AA AND LUCKLY I GOT
ORGINAL YANOFF FOR PATHOLOGY
SURGEY RUBIN AND SMITH ALSO I HAVE OTHER BOOKS BUT DID NOT WENT
DEEPLY THROUGH THEM LIKE WONG, OPHTHALMIC SECRETES
Viva examination: FRCS
Glasgow part 3 Muscat 2010
First viva: neurology
Question: one patient in the waiting area in your clinic has got fit
what you will do?
Answer: I will go in a hurry to the patient calling for help, isolate
the patient from the surrounding to avoid self injury, rapid review
for vital signs like pulse and BP, patient can be observed for few
minutes as in most cases spontaneous recovery will occur
but I have to insert airway inside mouth to avoid tongue biting,
otherwise patient can be given IV valium 5 mg and dose can be repeated
to 10 mg if not improved until arrival of the neurologist. The
examiner told me that BP unnecessary as the patient is shivering that
will hinder BP measurement.
Question: one patient 50 years old man presented with unilateral
headache how you will manage?
Answer : I have to consider DD like refractive errors and eye strain,
acute glaucoma, arteritic type of AION, intra cerebral causes like
hemorrhage, SOL, sinus related like sinusitis , polyp.
I will take history of onset course , associated manifestation like
blurring of vision, vomiting , tinnitus or change in consciousness,
systemic disease like hypertension , SLE, migraine although the last
one is common in females
Examination will include aided and unaided visual acuity and
cycloplegic refraction, test ocular motility for any cranial nerve
palsy, IOP measurement, test for RAPD for any compressive lesion on
visual pathway, dilated fundus examination
Investigation like CT AND MRI especially if there is papilledema.
Question: one patient has got fainting what you will do?
Answer look for vitals and support for ABC, I gave differential
diagnosis like vasovagal, hypo or hyperglycemia.
Ask me how to differentiate hypo and hyperglycemia, answer clinically
by sweating and glaucotest, ask me if this test was not available he
wanted to give IV glucose 25% any way in both condition as hypo is
more serious and that I realized later and told him the same
Other to be given is glucagon IV
He presented to me a color photo and asked me to describe what I see ?
Answer I could see right fundus with dot and blot hemorrhage, macular
hard exudates area of retinal hemorrhage along inferotemporal arcade
which could harbor neovessles, and old scar of PRP
Ask me what the management is.
Answer: history of systemic problem in addition to diabetes if he has
hypertension, any renal disease or if the patient is female could be
diabetic retinopathy with pregnancy
Control of systemic condition in cooperation with physician and
Ocular examination include aided and unaided vision, anterior segment
evaluation for iris neovessles or glaucoma, examination and evaluation
of other eye
Coming to diagnosis is proliferative diabetic retinopathy
Investigation: FBS, RFT, FA to exclude neovessles and retinal
He stopped me and presented to me a color photo of optic nerve head
swelling? What is your impression and if the other disc also swollen?
Answer: bilateral disc swelling may be pseudopapilledema or true
Pseudopapilledema like hyperopic disc, optic disc drusen
True papilledema is bilateral disc swelling due to increase intra
DD pseudo tumor cerebri, neoplastic, vascular, inflammatory disease
that affect intracranial cavity
Asked me how will you manage?
Answer: history, examination and investigation
Asked me what investigation?
Visual field, CT and MRI brain
Then he showed me automated perimetry both eyes of the same patient it
was bitemporal hemianopia and I answer it is due to tumor at the
Asked me like what?
Answer pituitary adenoma
Ask me what is the function of pituitary gland?
Answer : anterior pituitary secretes hormones like GH, TSH, FSH and
posterior pituitary secretes oxytocin and ADH
At the end I mentioned I have to make consultation with
endocrinologist and neurologist
It was difficult to me initially but ends with good answer later
Question: 30 years old man with night blindness what is your
I gave retinitis pigmentosa and congenital stationery night blindness
and high myopia
Question: if he has retinitis pigmentosa how can you manage?
Answer : family history as it could be AD, AR or X-linked
Ocular examination vision aided and unaided, dilated fundus
He ask me what is ocular association ?
Answer: POAG, posterior sub capsular cataract, myopia, keratoconus
What is characteristic fundus finding?
Answer: salt and pepper pigmentation but he wanted, I think bone
spicule fundus changes also I mentioned vascular attenuation and waxy
pallor of optic disc
He ask me how you can by ERG differentiate retinitis pigmentosa from
I could not answer this question.
Then he presented to me color photo of patient 14 years old with
conjunctivitis that has complaint of 3 weeks of discharge but has no
history of previous allergic condition
I give differential diagnosis of trachoma and inclusion conjunctivitis
and mention papillary conjunctivitis.
Ask me what is the management?
Answer eye hygiene, treatment of surrounding as trachoma is chronic
Investigation like Conjunctival scrapping for intracytoplasmic
Tetracycline and doxycicline
Ask me if associated with systemic problem
Answer: genitourinary infection
What decongestant do you know?
Naphazoline….what else … getting blocked and couldn't mention others
like mast cells stabilizer and antihistamine eye drops
35 years old female patient presented to you with unilateral
protrusion of the eye globe, how you are going to manage this patient?
I start by the most common diagnosis is thyroid eye disease as it is
the most common of unilateral or bilateral proptosis in middle age
female but I have to exclude other causes of proptosis like vascular,
neoplastic , inflammatory…
I will take history of the onset pain any visual disturbance
Asked me why vision can be affected in thyroid eye disease and what
you will do?
Answer: vision can be affected due to severe proptosis and
consequently exposure keratopathy, also may be due to compressive
optic neuropathy which consider an urgent situation it is due to
swollen orbital soft tissues and extra ocular muscles
Also choroidal folds can affect the vision
Management include history, measurement of proptosis and its
progression, visual acuity monitoring, anterior segment and ocular
motility, very important to test for RAPD and color vision
Investigation: B-scan ultrasound, CT and MRI which will show
enlargement of EOM
Treatment include stop smoking , if there is signs of optic nerve
compression systemic steroids can be given started with high dose of
methyl prednisolone followed by oral prednisolone in a dose of 1 to 2
mg/kg and can be followed by radiotherapy
If no improvement or progressive optic neuropathy we can do orbital
Question: classification of uveitis??
I said sun working group 2004
He Saied another classification? I said anatomical, pathological,
He wanted granulomatous and non granulomatous
Question: What is systemic disease associated with uveitis??
I mentioned many like ankylosing spondylitis, VKH disease, behcet
disease, sarcoidosis, intermediate uveitis; syphilis, tuberculosis and
discussion went into behcet disease
What is sight threatening uveitis?
Answer: all uveitis that is complicated with corneal decompensation,
secondary glaucoma, complicated cataract, cystoids macular edema,
optic nerve affection and inflammation and retinal detachment that
could end with phthisis bulbi.
Question what is the manifestation of behcet disease?
Ocular, systemic and neurological
Recurrent acute anterior uveitis, posterior segment affection like
The disease is common in Japanese Middle East and midetranian sea area
He said behcet was a dermatologist
I said yes and patient has characteristics recurrent oral and genital
ulcer, erythema nodosum
He said did you see any cases in this area?
I said yes I saw many cases of behcet disease in Middle East
What is the management?
I have to confirm the diagnosis by history, clinical examination is
very important as the diagnosis mainly by clinical picture
Steroids can be given by all mean topical peri ocular, systemic by
parentral or oral which may necessitate long term steroids therapy
with its potential complications and even by intra ocular injection
In case of complications or uncontrolled disease with steroids
cytotoxic drugs can be given
Asked me like what?
Answer: methotrexate, azathioprine
Ask me what is the dose and complications of methotrexate?
7 to 10 mg per week and complication liver toxicity and bone marrow
Third station was
surgery and pathology:
Question: a young lady come to you seeking advice for her lid
Answer: Muller muscle resection or mullerectomy
Levator muscle recession
Insertion of device in upper lid golden wt
I said sympatholytic eye drops but forgot to mention guanthidine drops
as in kanski
He presented color photo and asked me to describe what I see?
It was pigmented peripapillary choroidal mass and breaking through
Bruch's membrane in collar stud pattern and I diagnosed immediately
Asked me how to manage this patient?
Discussion went into the prognosis and state of the other eye patient
counseling and options of conservative treatment in case of only
seeing eye and very old patient and the following can be given like
external beam radiotherapy, radioactive plaque, TTT,
Or enucleating of the eye with pre operative radiotherapy
Question: what are the types of ectropion?
Question what are surgical options for ectropion?
Lateral canthal sling
Question: what do you know about Fuchs endothelial dystrophy?
Abnormality in the descemets membrane with absent or abnormal function
endothelial cells which affect corneal endothelial pump mechanism
What is this pump and for what?
Actually there is active pump ATP s sodium- potassium pump and passive
diffusion of fluid across the endothelium from the aqueous humor to
corneal stromal tissues it prevent over hydration and regulate
nutrition and fluid to the corneal tissues but in Fuchs corneal
dystrophy there will be excessive fluid passage to the cornea and
manifested by recurrent corneal edema, pain and blurring of vision
What is the management?
Hypertonic saline, bandage contact lens
Pre operative precaution in cataract surgery
What investigation before surgery?
Corneal pachymetry and endothelial cell count, using excessive
viscoelastic substance for protection of endothelial cell layer and
low power of phaco ultrasound
She presented photo of epibulbar mass near the limbus 3x4 mm gray
white with hair on the surface
I had described the lesion and asked me what is that?
Answer :dermoid cyst
Ask me hair is confirmatory or not
Answer :yes confirmatory with other skin appendage like sweat gland
follicles on histopathology
Asked me what to do?
Answer excision in block under local anesthesia….. She interrupted me
but he is a child …. Correcting myself and said yes should be under
Asked me what about refraction
Answer: very important for any astigmatic errors which will need
correction to avoid amblyopia
Asked me what associations with dermoid
Answer: Goldenhar syndrome and facial hemiatrophy.
Question: A child with +4 diopter glass and has equal vision in both
eyes, but still has esotropia, what to do?
Answer: surgical correction. Either mono ocular MR recession, LR
resection or simultaneous both MR recession or both LR resection
Asked me what is the amount?
I said there is table for the amount of recession and resection.
Asked me on what basis?
Answer: each 1 mm recession MR correct 2 degree and each 1 mm LR
resection correct 1 to 2 degree of squint.
examination: FRCS Glasgow part 3 Muscat 2010
station was neuro ophthalmology
There were 2
female examiner and had given me 4 patient in this room
patient is around 8 year's girl asked me to
examine ocular motility
I did Hirschsburg test no deviation in primary
position, but she interrupt me and told me don’t use light for not to
Ask the examiner about glass told me yes she has but
Cover test for far and near reveal exophoria more in
far than near.
patient was a boy I noticed that left small
palpebral fissure ptosis
I thought jaw winking, and test ocular motility but
not sure mentioned superior oblique pals primary action of superior
girl 20 years with abduction defect and left
narrow palpebral I mentioned diagnosis
Duane syndrome type 1
Examiner asked me to examine the pupil in an old male
Patient had Left RAPD asked me the causes. It is due
to unequal function of optic disc with more damage in the left side
like glaucoma, optic atrophy, AION either arteritic or non arteritic,
compressive optic neuropathy
station it was oculoplastic although expecting
the worse but was the best to me very
rapid diagnosis with very frequent questions
and spontaneous answering to all questions
25 years old female patient with left
Examiner asked me to sit in front of the patient and
he started asking me
Describe what you see ? answered left eye drooping of
the upper eyelid, with absent lid crease
What is your diagnosis, answered left congenital
How you can manage the case , answered history ,
clinical examination I put my finger on frontalis and measured levator
function I said 4 to 5 mm , I measured MRD it was 0 to + 1 mm , ask
what is the normal palpebral fissure answered 11 mm and normally upper
lid cover 1 to 2 mm of upper limbus . Ask what else you will do...
answer I will check for bells phenomena why? Answer to avoid post
operative exposure keratitis if absent bells phenomena also I would
like to check for superior rectus function as there is association
between levator tendon and superior rectus that can affect surgery
Could be horner syndrome? Answer I have to check for
anisochoria and heterochromia and at the same time ptosis in horner
would be mild around 1 to 2 mm of ptosis
What else could be the cause of ptosis? Answer jaw
winking syndrome … what is that? Answer synchinesis between third
nerve and nerve supplying jaw muscle
What surgery you will do
Answer levator resection either transcautaneous or
What amount of resection? Don’t know
around 40 years male patient has right eye periorbital inferior
What is the cause?
I gave differential diagnosis said it could be
traumatic, inflammatory, neoplastic or vascular mass
What you will do
I will take history of onset, course, any pain
decrease vision or any previous trauma
He asked if trauma? I said there will be bluish
discoloration, emphysema …. He replied named hematoma. And asked me to
examine the patient and tell me what you are doing?
I said by observation no proptosis , I palpate the
mass no tenderness no hotness , it was soft mass , I test for
retropulsion but it was normal ask me why you do retropulsion ??
answer to exclude retro bulbar or intra conal extension which can
compress the optic nerve and I have to test for pupillary reaction and
color vision if suspected any compressive optic neuropathy..
He said it is AV fistula.
Answer it can be closed by surgery or if patient
refuse to report to ophthalmologist if any visual disturbance
station was anterior segment station
First case Slit lamp examination for male patient 35
I described what I seen patient has corneal scar at
12 o clock of previous phaco section, has deep AC, irregular reactive
pupil with pupillary iris atrophy pseudophakia, posterior chamber IOL
Question: what is the etiology of cataract in this age
Answered : could be metabolic ,dm, chromosomal
Question : what is the most common cause of cataract
in this age group? I got silent and he repeated the question twice
more rapidly come to my mind traumatic…. He got happy and said yes it
was traumatic and I continue especially patient has irregular pupil
and traumatic iris atrophy.
- The second case was middle aged female for slit
lamp examination she has left eye limbal section, ac deep, peripheral
iridectomy, posterior synechia 360 degree, and aphakia with organized
lens opacity in the center, no red reflex
Examiner asked me to look at her face, she has
exotropia and there was a scar on the tip of the nose and above eye
brow in the same side, he asked me what was the scenario and why
surgery was difficult ? I suggested may be scar of previous herpes
zoster ophthalmicus and the patient has had uveitis, iris atrophy and
complicated cataract and secondary glaucoma
Question : what you will do for her ?
Answer: she can be subjected for another surgery for
synechiotomy, removal of after cataract and vitrectomy with scleral
Asked me you think vision will improve? Answered no
sir as she might has amblyopia and posterior segment problem.
station was posterior segment, last one and the
best to me as I was practicing well
indirect ophthalmoscope and examination with +
90 and + 78 lenses
patient examiner ask to examine with +78 d lens
, there was vascular attenuation, mild pallor of optic disc and bone
specule pigmentary changes and I give the diagnosis of Retinitis
pigmentosa , he asked me about the macula I answered CME and I have to
check for vision , ask what is the treatment I said systemic
patient was 12 years old boy ask me to examine
the fundus. indirect ophthalmoscope and + 20 d lens was there, she ask
the boy to lie down supine initially I diagnose mylinated nerve fiber
which was peri papillary then ask me to see the periphery it was
localized recurrent retinal detachment ask me it was pars plana or
buckling I could found conjunctival scar of buckling and retinal
indentation I said it could be a squelle of previous ROP or familial
patient on slit lamp he was aphakic with
inferior peripheral iridectomy. asked me to examine the fundus with +
78 d lens there was macular scar with pigmentation and immediately
come to my mind post pars plana vitrectomy with silicon oil inside the
examiner was happy and asked me if the other eye has the same problem
I said macular hole, myopia and pre retinal membrane this was my last
patient and the end of my examination
Results were announced after 15 December 2010 through
internet but I reviewed on 3rd January 2011 and my number
was pre last number in pass list and I got so happy for this and
prayed for Allah and also my wife got very happy
I wishes all the best to all candidate who are going
to appear for this examination
I will be very happy for any help , please send me