Candidate 180


Centre:   Amman

   Date:   April,  2014

I am Dr Muhammad Naeem awan from Lahore Pakistan, I appeared for FRCS ophthalmology Glasgow in april 2014 ,at Amman Jordan.It was my first attempt and with grace of almighty  Allah I passed.

When I was preparing for my exam CHUA Eye Page was my favourite , I used to read previous candidates experience,exercises ,viva etc. So it gave me confidence for exam and helped my a lot in my self assessment.

The books , as all people know are Kanski , Will s Eye Manual , Examination Review ( Wong) , oxford hand book of medicine.These are must and other books can also be read.

I am highly obliged and thankful to Chua Eye Page  for my preparation of FRCS 3 and also Prof Muthu ,who guided me during my preparation of FRCS 2.


This exam is two days exam.

Day 1 , clinical cases , comprising of four clinical stations with 8 examiners.

Day 2 , Three table viva with six examiners.


Day 1, 29 April 2014 Tuesday , Lasik Center , King Hussein Medical Center , Amman Jordan

Our reporting time was 10 to 10:30 am.Pre exam briefing was given by Ms. Hilary Dunk and DR Arvind Singh.He said if you examine lot of patients in your practice and make right decisions you will pass.Our aim of examing you is that how safe you are , while practicing as ophthalmologist

Our batch consisted four candidates and exam started on10:56 am .

12 minutes on each station and two min gap for shift over


Station  1                     Lids & Oculoplastics

One female 60 years , sitting on couch , command was to observe and examine lids,both examiners were side by side.On observation , significant finding was dermatochalasis both eyelids.I told examiner this is a case of dermatochalasis .He said what do you want to examine further.I said I want to see lid laxity , and it looks to be pseudoptosis ,so I want to examine regarding that.He said ok,how you will treat patient, I said blepharo-plasty . He asked procedure, then asked indications of blephroplasty , complications of blephroplasty.We discussed lid lag, exposure keratopathy and management.

Then he asked what are causes of lid edema.? I told him ocular causes.He then asked systemic causes of perorbital edema.I told cardiac failure ,renal failure then he said what about thyroid disease. I said yes there is lid and periorbital edema , then we discussed thyroid eye disease signs, symptoms,classification,risk factors etc

Second examiner showed me , a young man looks to be 25 year old with right facial palsy.Command was to observe and examine this patient.I said this is case of right facial palsy.He asked UMNL or LMNL.I said LMNL.he asked what tests you want to perform.I told and performed test for VII nerve palsy, we discussed about bells phenomenon,then exposure keratopathy,management and surgical options for paralytic ectropion.Then he asked if patient presents to you like this how will you proceed..i said I will ask detailed history, then examination…we discussed briefly all cranial nerve examination to know any associated cranial nerve involvement, then I told him I will do investigations like CT scan or MRI to rule out any space occupying lesion or any effect of trauma…Bell rang


Station 2            Anterior Segment

I was asked to examine and comment the anterior segment of  patient sitting at slit lamp. On examination , Right eye showed there was corneal graft with edema ,very hazy view of anterior chamber with white debris on endothelium..difficult to decide patient  phakic,pseudophakic,or aphakic.I asked examiner I want to examine left eye to know possibility why penetrating keratoplasty was performed.He said  sure. On examination in left eye cornea was clear , pupil updrawn with subluxated IOL. I told all findings to examiner,he said ok what is it ? I said failed corneal graft . He said how will you manage , I answred ,second corneal graft,but I am not sure this patient s lens status due to hazy view.Examiner said this patient is aphakic then I said I will plan corneal graft with Scleral fixation PCIOL but I want to know status of posterior segment of this patient.He said Posterior segment is ok. Then he asked what are complications of Scleral fixation IOL.Then he asked what can be cause of left eye subluxated IOL. I told eventful surgery, trauma .He then asked management. Examiner was satisfied..we had a good discussion

Second examiner asked to examine a 16 year old girl at slit lamp.On first look I noted she is having large corneas,then on slit lamp I noted cornea was large but very deep anterior chamber , I became little confused but scenerio cleared when I asked patient to look down there was a big bleb then I searched for iridectomy,,,,so there it was was small iridectomy I made my diagnosis. I asked examiner  can I see left eye he said ok..there were same findings in left eye.Examiner asked me what is your diagnosis.i said Congenital Glaucoma , with trabeculectomy done.He asked is this bleb working, i said yes and he asked how do you classify congenital glaucoma,then he asked secondary associations of congenital glaucoma.He asked Axenfeld reiger anomaly signs and cause of glaucoma.He asked treatment options for congenital glaucoma.Then he asked do you perform trabeculectomy ,I said yes. I told him whole procedure of trabeculectomy.He asked any antifibrotic agents you use,I told preferably MMC.we discussed possible complications of trabeculectomy and their management like patient came after 7 days with raised IOP and well formed anterior chamber.what to do?


Station 3                Posterior segment

60 year female sitting at slit lamp, and command for me was to examine posterior segment and comment your findings simultaneously,I started my examination with a quick look on iris and lens. Pupil was mid-dilated with no neovessels on iris, but there was cortical plus posterior sub capsular cataract , I told examiner he said I know but you have to see posterior segment. View was a little bit hazy I told him optic disc is normal and there are exudates in posterior pole and macular area,there are haemorrhages in all quadrants but I have not seen any neovessel. Then he said ok examine other eye,it was psuedophakic eye and view was better,optic disc pale , with vascular changes , this fundus had multiple chorio retinal atrophic patches also, The examiner said what is your diagnosis now, I asked is she diabetic ,examiner said yes,then I told him this is case of NPDR with Maculopathy.He became a little bit angry and asked what you said and what does it mean NPDR, I said sorry sir it is Non Proliferative diabetic retinopathy , with maculopathy. He asked how you will treat this patient, I said I want to take detailed history regarding ocular and systemic problems, examination,investigations like FFA ,OCT and I will strictly manage systemic problems like DM, and hypertension, on FFA I want to see any leakage , Examiner said do you expect leakage in this case..? I said yes because there are exudates in posterior pole area.Then I have two options focal laser for leaking aneursms and we can use ANTI-VEGF to treat macular edema.

He did not look satisfied.So I was disturbed after this patient

Next patient 50 year female sitting on couch ,examiner handed over to me Indirect ophthalmoscope(IDO)  and said examine posterior segment of right eye and also told me this IDO has dim light but manage to see with this.I tried to fix head band on my head ,it was loose then I tried to get my binocularity, it also became difficult for me to do my time wasted on IDO, with loose head band and improper binocularity I examined patient,suddenly light gone..i was disturbed what is happening ,I searched,wire was disconnected.Ok , then I saw patient and  just had look of posterior pole and inferior quadrant, patient was uncooperative , she refused for examination and even not following commands to look straight , look up and look down.One arabic speaking Doctor was there but patient was very un-cooperative. Then examiner said to me ok tell me your finding , I told him ,disc is normal and there are pigmentary changes in inferior quadrant,other part of posterior segment I was unable to examine.Then he asked what can be the possibilities,I said may be patches of healed choroiditis. In the mean time he called a young patient , and said to examine this boy,I put on IDO, started examining but pupil was un-dilated..bell rang

I was very annoyed and disappointed on this station


Station 4                      Ocular Motility and Neuro-ophthalmology

16 year old girl sitting on chair,command was to perform extra-ocular movements in this girl. I asked examiner should I perform cover/ uncover test ? He said  OK you should, then he he came very near to me and said  how do you perform cover/uncover test show me.He observed my methods very keenly,then asked what are findings.I said eyes orthophoric. He said ok perform ocular movements ,I found left abduction defect and retraction of globe in adduction . I told him this is a case of duane s syndrome.He said what other findings I said inferior oblique overaction,then he asked how do you check inferior oblique action show me. I performed ,he had some objection then I told him that inferior oblique elevates and abducts eye. We had discussion on actions of inferior oblique muscle. Then he asked what surgery you will perform to this patient..will you are not.?  I was telling him this is a complicated surgery , we have to tell the patient that……….

Next examiner called me,come here and check pupils of this patient.This was a 70 year old man, I performed all steps with light off and on, patient was having anisocoria due to left eventful surgery. I told examiner all my findings ,he then asked did you check for RAPD ,I said yes.He said do it again.I performed he then objected why you are putting light from front. I said sorry sir, then I brought light from sides and performed swinging flash test.He said ok. No RAPD was there.

Then he showed other case and said this youg girl has left esotropia ,how you will measure ? I said alternate prism cover test.He said ok perform test . Prism was there on table. I performed for both distance and near .Examiner had objection on my cover by occluder but I performed test completely  ,he asked what are findings. Then he suddenly said check temporal visual field of  an old man….bell rang

In this station attitude of both examiners was very aggressive.


Day 2, May 1 ,Thursday 2014, Hotel sheraton Al Nabeel  Amman Jordan

Our reporting time was 10 30 to 11 am and exam started at 11:30 am


Station 1       Ophthalmic Medicine


Examiner 1

Photograph showing mild corneal staining, mid dilated pupil with atrophic patches  on iris ,lens opacities. What is diagnosis.? I did not noted corneal lesion in first view bc it was very   mild staining .He asked what it can be I said post acute congestive glaucoma, post viral uveitis.he said ok how do you treat acute congestive glaucoma,then he pointed to corneal lesion and said if this patient is having  HSV epithelial keratits and viral uveitis how will you treat..i told treatment ,then he said will you give IOP lowering drug ,I said yes because  there is rise of IOP in viral uveitis.

Photgraph showing optical corneal section with grey colored KP on edothelieum..i said this is Fuch s hetreochromic iridocyclitis.He asked clinical features in detail then about glaucoma and angle in these patients.


Examiner 2

Photograph showing hazy cornea ,with hypopyon,five sutures on limbus. What is diagnosis.i said post operative endophthalmitis.we discussed treatment of post op endophthalmitis.He said Vision is hand movement in this patient .Next scenerio ,he said if surgery was ok ,after five year this patient got blunt trauma of this eye ,what will happen and how do you treat.i told all possibilties then we discussed types of hyphema and medical and surgical management of hyphema.

Fundus photograph venous phase showing hyper flourescent spots in periphery ,a few patches showed leakage.he asked what it can be first I told the spots with no leakage can be telangiectasias ,then he asked if patient is from afro-caribean origin what it can be…I said sickle cell disease.he said ok.what are manifestations of sickle cell disease.

He said will you treat this patient.i said if there is evidence of leakage we should treat with photocoagulation.he said will it work.i said theoretically it should work but I never come across a patient  with sickle cell disease.He asked if this is a case of proliferaive diabetic retinopathy ,will you treat,I said yes its emergency and should be treated.

He showed me photograph with marginal infiltrates on cornea.He asked what is this , I said marginal keratiatis..he said good..bell rang


Station 2 Ophthalmic Surgery and Pathology


Examiner 1

Photograph of involutional ectropion,what is diagnosis.classify ectropion,what are treatment options ,if generalized ,if only medial, if associated lid laxity.

Scenerio 2 year old boy with white pupil,what are possibilities,I told DD of white pupil,then he said if it is retinoblastoma , what other clinical features,then classify retinoblastoma,how do you proceed. I started from history ,examination under anaesthesia ,investigation I said Bscan,CT Scan and MRI he said why..?then he asked treatment options for retinoblastoma.


Examiner 2

Photograph of corneal abscess with thinning and perforation,how you will proceed, I said history , corneal scrape ,conj swab for culture and sensitivity to know organism then I will start antibiotic treatment.He asked any test you can do in ten minutes to have idea of organism ..i was confused on this question ..what to answer then 1st examiner gave me hint do you know any staining ..i said ok we can do gram staining and giemsa can help…he asked  have you performed staining by yourself..i said no.He said if etiology is fungal , I said we will you use anti-fungal therapy depending on filamentous and non filamentousfungi..Natamycin or amphotericin B.He asked what antibiotics you want to start.I said ceftazidime and vancomycin fortified prep…under cover of antibiotics I will plan tectonic corneal graft..he said no graft will not stay in this situation,other option I said glue he said no glue will not stay..other I said conjunctival flap,,he said ok….this is needed do you perform conjuntival flap..i told procedure.


Station 3

Medicine and Neurology

Examiner 1      Medicine

40 year old male presented to you with severe headache one side and drooping of eyelid and difficulty in upgaze,what can be diagnosis , I said this is case of third nerve palsy other possibilities are myasthenia gravis,myositis, myotonica dytrophica,CPEO/kearns sayre synd..he asked what is significance of headache in this case I said then Migraine is possibility bc it can cause cranial nerve palsy. Then he asked causes of third cranial nerve palsy.

Photograph showing optic disc edema , he said what are possibilities I told him causes of unilateral disc swelling then bilateral disc swelling.He asked what do you want to see more in this photograph I said macula for edema and macular star in Hypertension , vein occlusion ,artery occlusion he said what else I said haemorrhages.he said ok.

Then he gave scenerio of idiopathic intracranial hypertension, discussed in detail ,medical and surgical treatment .then asked why it is important for ophthalmologist to know.i said it can lead to optic atrophy.


Examiner 2   Neurology

Photograph showing peripheral corneal thinning with mild congestion .He asked what is this? I told peripheral ulcerative keratitis/ peripheral corneal thinning..what are other possibilities.I told mooren ulcer,terrien marginal degeneration etc.He said tell me causes of peripheral ulcerative keratitis ,I told all systemic causes like RA.then he asked if patient is having epistaxis then what ..i said likely possibility is wagner granulomatosis.He said ok how you will manage.i said I will confirm diagnosis by test c ANCA , then I will start treatment with cyclophosphamide.He said ok

Photograph showing swollen white chalky optic disc,he said this is 80 year male,with loss of vision with pain…diagnosis.? I said arteretic anterior ischemic optic neuropathy.cause? giant cell arteritis.He said ok tell me systemic features of GCA.then investigations.then treatment options.aim of treatment.I told him all in detail.bell rang and it was over.

I was happy and satisfied that day but worried about my posterior segment sement station because of that indirect ophthalmoscope event.

Result came after one week.My friend zeshan  told me on facebook that you passed but he was not sure about my Roll number..i confirmed my roll number ,so I have been passed..Thanks to ALLAH Almighty………So a dream of my life came true.


My email ID:

Skype ID: awan_naeem

My cell number: 00923214299307


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