Candidate 161


Centre:   Glasgow

   Date:    June 2012

My name is Dr.Fahad Faisal, I passedthe third part of the FRCS exam at Glasgow which was hold from the 12th till the 15th of June 2012; I'll try to write about my experience in this exam but first I want to say Alhamdulillah and I want to thank my family for their support.
Here are some instructions which I think are important:
In the clinical examination there is a rule which is "bare below elbow" where the doctor should wear short sleeves or fold the sleeves above elbow, not to wear watch, bracelets and even rings and not to wear ties.
The second thing is that you don't have to wear white coat, don't have to bring any tools as everything is available (may be better to bring occluder, torch and fixators), you don't have to introduce yourself but if the examiners introduce themselves you may say your name, you don't have to ask the patient for permission or to thank the patient but it is better to say thank you after you finishfor the patient and doctors.

The first day, we started with the clinical exam:

My first station was neuroophthalmology

First case: the first doctor asked me to examine the pupils of a middle age man where there was right RAPD then he asked me to examine the fundus of the patient where I saw total optic disc cup with mild chorioretinal degeneration, then asked me to find if this is bilateral, the other eye fundus was not clear but there was cupping which is mild so he asked what other tests you will do and what you will search for.

The second case: the doctor asked me to examine the extra ocular muscles in a patient with ptosis (which was moderate) and I started with the cover uncover, alternate cover uncover and then I examined the nine positions of gaze, the patient showed absent movement in all positions except limitation of the abduction, the doctor asked me what else do you want to examine I answered him the pupils, the fourth CN with the slit lamp, sensation for V1 and fundus for optic disc, signs of ophthalmic artery occlusion as the patient had injected conjunctiva so he said examine the pupils and the involved eye pupil was dilated , I diagnosed her with third cranial nerve palsy pupil involved so he asked me why the ptosis is not complete I answered maybe she did surgery, he asked me what type of surgery and I answered mostly frontal suspension because the ptosis is complete in third cranial nerve palsy. He asked about the differential diagnosis I said cavernous sinus lesion, superior orbital fissure syndrome and orbital apex syndrome so he asked me if it is cavernous sinus problem what may cause it and I start to answer but the bell rang.

The second station was oculoplasty

The first case: the doctor asked me to examine the anterior segment of the patient where she had bilateral blepharitis, signs of dryness and Rt. lower punctual occlusion with silicon plug, we discussed the causes of dryness and I answered keratoconjuctivitissicca , Sjogren syndrome and dryness may be due to blepharitis so he asked does blepharitis cause dryness I answered yes because it affect the sebum layer and thus may cause dryness, he asked have you ever seen a patient with dryness because of blepharitis treated by plug? I answered no ,he asked do you like to examine anything else so I answered the doctorthat I want to examine the patient systematically to find if there was systemic cause , he told me OK from your place examine her, I told her may you show me your hands? And her hands showed obvious signs of Rheumatoid arthritis and my diagnosis was the patient with rheumatoid arthritis cause secondary Sjogren syndrome.

The second case: was patient with bilateral eyelid swelling, bilateral ptosis and bilateral small masses on the lateral bulbar conjunctiva where I gave differential diagnosis for fat prolapse, dacyops, dermolipoma and lacrimal gland mas or prolapse then he asked what else do you want to examine? I told him I want to do palpation and I reached to the diagnosis of fat prolapse so he asked about the treatment and I said surgery, he asked me what you will tell the patient where I got stuck because I didn't understand what he wanted but then I told him that I will tell him that there are complications and we spoke about that

The third station was the anterior segment

The first case: When I was asked to examine the patient anterior segment with the slit lamp the slit lamp didn't work and we had to go to the other case so they fix the slit lamp(I lost time because of this), The first case was band keratopathy, endothelial dystrophy and peripheral anterior synechia I asked I want to examine the other eye to diagnose if it is dystrophy, the other eye had the same abnormality except the band keratopathy and the doctor asked me what was the cause of the band keratopathy and I told her may be uveitis because of the synechia and then she asked what is the type of the dystrophy? I answered posterior polymorphous dystrophy( after the exam I figured out that the diagnosis was Fuchs dystrophy)!she asked me about the treatment for band keratopathy but there was no time so I start to answer her in the corridor until we reached the second case.

The second case: which had nystagmus and Rt. esotropia, with the slit lamp examination I found bilateral iris coloboma and cataract the doctor asked me what is the cause of poor vision? I said there may be posterior segment coloboma he agreed and asked me about the operation for the patient for cataract and which eye I will do and what are the precautions? How to deal with the weak zonules? Capsular rings. He asked me how you can differentiate if this is congenital coloboma and not optical iridectomy? Where I didn't know (till now) and the bell rang.

The last station was posterior segment, I felt that this station had shorter duration may be because they adequate good time for examination.
The first case was Rt. eye choroidal scar and abnormal RPE around it in young female patient I gave differential diagnosis for CNV, posterior uveitis (toxoplasmosis) and choroidalrupture.....The doctor asked me if it was CNV what is my diagnosis in this young patient so I told him I think there is history of trauma, he asked me to ask her about history of trauma, I asked and she agreed. Then ask me how you will treat and I told him with anti VEGF! He asked me do you give anti VEGF to young patient?I answered him that I don't know if there are any contraindications for young.

The second case was patient with secondary optic atrophy with maculopathy. The doctor asked about causes of secondary optic disc atrophy and asked me to examine the anterior segment. There was iridectomy and I missed the bleb! he asked me what do you think the cause and I answered Glaucoma!

The second day was oral examination

My first station was neuroophthalmology and general medicine

The interest start to ask you supposed you want to do cataract surgery and you found that the patient has atrial fibrillation how will you proceed
I told him that I will shift him to an internist to be managed then he asked me how do you manage I said it depend whether the condition is acute or chronic and if it is acute weather the patient is haemodynamicly stable or not so he stopped me and said this is atrial problem off course he is haemodynamicly stable so I told him the I will give anti coagulation and drugs which slow the heart rate like verapamil, diltiazim and digoxin.(in all medical emergency books they mention atrial fibrillation may be acute or chronic)
He asked what are the causes of AF? I mentioned 10 or more causes and still he wanted more because I forgot the hyperthyroidism then when I told him hyperthyroidism he shift to another question
If you are going to give local anesthesia what are the systemic side effects so I answered anaphylaxis, brain stem anesthesia, then he asked what are the general side effect of anesthesia if you inject in any place in the body? And I told him I don't no further to allergic reaction and infection at the site of injection (I think he wanted me to mention slow heart rate)
If somebody while giving him fluorescing startedto have shortness of breath, what is your differential diagnosis? I answered anaphylaxis, asthma, heart problem he asks about signs of anaphylaxis then he asked how you will treat syncope? I told him I lay the patient down oxygen; elevate his legs if it is not cardiac shock, ABC…..
Then he asked how you will treat respiratory complications of anaphylaxis
I answered oxygen, salbutamole, hydrocortisone aminophylline.He said what you will do if the respiratory system is blocked I didn't understand first but then he told me what is the procedure you do to overcome blockage where I answered tracheostomy
The ophthalmologist showed me case of scleromalaciaperforans and asked about causes and treatments then asked me the following scenario: suppose a patient in her twenties came to you with failure of addiction and contralateral nystagmus? I answered hen I will think of Internuclearophthalmoplesia.She asked where is the lesion? MLF on the same side of addiction defect, she asked what if she told you she can read? I told her that is because the convergence is preserved. She asked what other possible diagnosis? I answered myasthenia gravis. She asked what is the common cause in this age group? I answered MS what ifshe is 60? I said I will think of vascular cause
Another scenario: a patient after trauma developed abnormal pupillary reaction, referred from the emergency doctor so I said I will think about optic nerve avulsion compressive optic neuropathy trauma to the sphincter muscle and may be old problem.
She asked if it is old anisocoria what willyou do? I answered first I will examine in light and dark to know the abnormal pupil and start to give differential diagnosis and we spoke about the pharmacological tests and causes of second order neuron Horner syndrome.
Then there was still time so the internist asked about pancosttumour symptoms and signs and X-ray findings.

The second stop was ophthalmic medicine the worse one I did at

The first doctor showed me a photo of giant papillae and shield ulcer and asked me to diagnose. I answered the differential diagnosis of giant papillae and then because of shield ulcer what do I think? I told him vernal conjunctivitis. He asked about other findings, treatments.After that he showed me visual field it was right eye with lower visual field defect which respect the horizontal midline and the other was circular defect the only part which is not defected is the central vision and he asked what you think the diagnosis? I answered glaucoma and he asked what else I answered anterior chasm and when he asked what else I told him that I don't know
Then he showed me photo showingproptosis and periocular swelling and discharge the doctor asked about the difference between axial and non-axialproptosis the differential diagnosis and treatment for orbital cellulitis
The second doctor asked me that a patient came to you with IOP 28 in one eye and 27 in the other how will you proceed? I answered that I will examine the patient looking for optic nerve head cupping, nerve fiber layer defects,perimetry, corneal thickness looking if there is any scar which may cause false high reading, he asked why you said you will measure the corneal thickness? I answered that this is a risk factor for glaucoma. He asked what if there was no other risk factor only the IOP? I told him observation. He said ok he came three months later with IOP 34, 32 what you will do I said I will start medications and he asked why I told him that this is an indication for treatment even if there are no other risk factors and this may cause central retinal vein occlusion.
We talk about drugs types, complications and he said assume that you gave these treatments but he came back with visual field defect so I told him that if I used three medications and still deteriorate then I will indicate trabeculectomy. He asked about the complications and when to use 5FU and mitomycin.

The third stop was ophthalmic surgery where I did the best

The first doctor shows me patient with trichiasis, corneal opacity corneal neovascalarization and discharge and asked me about the diagnosis and I answered trachoma, Ocular cicatricalpemphegoid and chemical burn. He said which you think the diagnosis I said trachoma. He said yes it is what are the measures to reduce should be taken to reduce the chance of infection? I answered him about the SAFE and then he asked about patient four months old with upper eyelid mass which increase in size rapidly in the lateral side what you will think I answered capillary haemingioma he said what else I answered dermoid he asked what else I couldn't know so he said what about Chalazion I said yes off course it may cause this then he asked about the management I told him that my first concern is amblyopia which may occur due to anisometropia or deprivation amblyopia, then I said corticosteroid injections, systemic steroids, radiation and newly beta blockers he asked what do you think about beta blockers? I answered well I haven't try but I read that it is very effective and promising.
Then the other doctor started, he showed me a picture of squamous papilloma and asked about diagnosis and treatment and causes.
Then he showed me a photo of choroidal mass with hyper pigmentation and asked about the diagnosis I answered choroidal melanoma as I couldn't think of any other diagnosis as it was very obvious and large then I add metastasis, he asked about treatment and what are the important factors which will decide my choice I told him about the size, vision, other eye, psychological factors, patient choiceand extra ocular extension, he asked how will you check extra ocular metastasis and I answered LFT, MRI, CT scan, bone scan ...
He asked me what type of local anesthesia you use in phacoemulsification? I answered peribulbar, he asked about the complications, I told him perforation, retro bulbar hemorrhage, brain stem anesthesia and he asked how you will know that you caused perforation I answered that you will feel that and the patient cannot move his eye and if he can then there will be movement of syringe.
He asked me about the post cataract surgery patient came with drop of vision and pain what do you think? I answered I will think about endophthalmitis, malignant glaucoma, he asked about the management of endophthakmitis, the risk factors how to do vitreal tap.
Then he asked about the complication of squint surgery, the anesthesia problems in squint patients and oculocardiac reflex

There are few subjects which are very common in the FRCS
In emergency medicine atrial fibrillation, warfarin and loss of consciousness.
In neuro ophthalmology: Cranial nerve palsy, Interneuclearophthalmoplasia and MS.
Choroidal melanoma, retinoblastoma
Trachoma, Ocular circatricalpemphegoid
Endophthalmitis, vitreal tap

Finally I would like to thank Dr. Chua site and all the other doctors who share their previous experiences.




More candidates' experience