Candidate 189



Centre:   Glasgow

Date:    June, 2014

I am Dr. Tariq Farooq Babar working in the Department of Ophthalmology, PGMI, Hayatabad Medical Complex, Peshawar. I am presenting my experience how I passed FRCS Glasgow Exam.

I studied the following books for this Exam:-

a. J.J. Kanski A—Z
b. Wills Eye Manual (Just two topics – treatment of ACG & Multiple Sclerosis).
c. Wills Eye series atlases of Ophthalmology – a seven volume set – easy to revise within hours before viva.
d. Short Oxford of Ophthalmology,] studied twice and then make my own notes from it.
e. Wong
f. American Academy of Ophthalmology Series- I have studied them once but practically
no need to waste time. But if you are also preparing for MCQs – then you need to study
Medical Ophthalmology volume of American Academy of Ophthalmology
g. Chua Web site ( a gold mine for FRCS students preparing for
various sections of Exam
Whats important in it:-
- Past experience of candidates - must go through it – at least twice or thrice.
- How to read CT scan / MRI, FFA
- Systemic diseases related to Ophthalmology.
- Important topics in pathology & how to read pathology slides.
h. Short Oxford book of Medicine
Candidates only prepare last 70 pages of emergency medicine.
- But it’s better to prepare all important medical topics and read whole book.

i. The Massachusetts Eye and Ear infirmary review Manual for Ophthalmology. Latest
edition. Rama D Jager, Jeffrey C Lamkin (a goldmine for MCQ portion of FRCS Part 2 Exam).
j. Rapid interpretation of EKGs by Dale Dubin (only from page 334 to 363). This book gives review of ECGs – understanding of which is must for emergency medicine section of viva.
My advice to candidates is that there are four sections in the practicals – anterior segment, posterior, segment Oculoplasty& Orbit and Neuro- ophthalmology and Strabismus. You have to pass each segment individually. One segment marks can’t be compensated by the other segment. If you are weak in one segment don’t take Exam- why to waste Rs. 5 lacks / attempt. The Examiners are interested in findings but not in diagnosis as will be clear from my experience. See as many cases as possible – practice makes ones perfect. Regarding oral viva- practice with your friend so that your speaking power develops. The Examiners are interested in findings. If you miss the findings the remaining theoretical details are irreverent. For practicals – the ideal set up is at Al Shifa Trust Eye Hospital, Rawalpindi where Ophthalmology is divided into multiple segments like:-
a. Oculoplasty& Orbit
b. Vitreo-Retina
c. Pediatric Ophthalmology
d. Cornea
e. Glaucoma
f. Refraction or Optometry

The only missing component is Neuro- ophthalmology, which is to some extent compensated by very well developed Oculoplasty / Orbit and Optometry Department.

I am thankful to the staff of Al-Shifa Hospital which I visited thrice to four times / week for three months from Peshawar to have an experience of various sub-specialities of Ophthalmology. My special thanks to Dr. NadeemQureshi& Dr. Sara (Vitreo-Retina) Dr. Shama Khan (Cornea) and Dr. Tayyab Afghani (Oculoplasty& Orbit)

Majority of time I was alone in this Journey but occasionally I was accompanied by Dr. Jawad (from Lady Reading Hospital, Peshawar) Dr. Inayat (from Shifa Hospital Islamabad and Dr. Imran (from WahCantt)

I went to Glasgow along with my friend Dr. Jawad on 30thMay, 2014. My practicals were on 3rd June while Dr. Jawad’s on 4thJune, 2014 at Calodian University. Orals were scheduled on 5th June and 6th June, 2014 respectively at RCPSG, St. Vincent’s street. During these three days we revised important topics together.

3rd June, 2014 – (Practical Exam)

The day was reserved for my practical Exam. Our Hotel was situated about 2 km away from Exam place. We went for walk in rain because a taxi driver refused to go as for him the place was very near and profit less.

We were five candidates in the group. The practicals started fifteen minutes late.

A. Anterior Segment
My first station was anterior segment. I was welcomed by two young Indian Examiners. After using hand sanitizer was asked to examine the first case.

i. I saw an old lady in her 60—70 years at Slit lamp. From distance the patient was blinking excessively. One of the Examiners asked me what’s your differential diagnosis?

I said two differential diagnoses.
Ok what are they?
I said
a).Essential blepharospasm or
b).Dry eyes

Then the Examiner asked me to proceed?
I said “Can I start with slit lamp Examination (SLE)”

Then I started SLE and gave him running commentary of my findings. Lids and conjunctiva were within normal limits. In the right eye there was punctal plug. Corneas showed filamentary Keratopathy Rt. > Lt. Marginal tear strip was absent. Anterior chamber was quiet. Examiners stopped me and said whats your diagnosis? I said filamentary keratopathy due to dry eyes.

One of the Examiners said “What are the causes of filamentary Keratopathy”

I said the causes may be:-

- Keratoconjunctvitissicca (KCS)
- Essential blepharospasm
- Contact lens wearers
- NeurotrophicKeratopathy.

The examiner said “Give me diagnose in this case”
I said “KCS”.

He said “what is the main factor deficient in KCS – lipid. mucus or aqueous”?
I said “aqueous layer deficiency” Then the examiner said that’s’ fine and took me to another room to show me their second case.

ii. My 2nd case was another female patient of about 70 years. The examiners said just examine the anterior segment of both eyes. I said “ok”
I started my examination from the lids, conjunctiva and sclera which were normal. When I saw (Rt.) cornea I thought its lattice dystrophy. But my joy was very short lived as the lesions in the cornea were at the level of epithelium and not stroma and were unilateral. There were criss cross lines at the periphery of the right cornea at epithelium level which I couldn’t fit it in any disorder. They said OK. What else you find in the corneas?

I re-examined the cornea in further detail. To my surprise both the endothelium showed small blackish spots Rt. > Lt. The examiners said whats on endothelium?

I said I will give you two diagnoses?

The examiners said “OK”.
I said
1. Posterior polymorphous dystrophy &
2. Fuchs’ endothelial dystrophy.

The examiners said what’s your impression?
I said “Can I see the patient again?

The examiners said proceed.

The lesions in the endothelium were more localized. There were no band like lesions or vesicles in the Rt. Eye as seen in posterior polymorphous dystrophy and the lattice like lesions were purely unilateral. The Lt. Eye was normal. The examiners said give one diagnosis? I said corneal guttata due to Fuch’s endothelial dystrophy”

They said “Great” What about epithelial lesion? I said I have never seen such a lesion in my life They said “OK” Can you give differential diagnosis. I said my first diagnosis is corneal verticillata due to Fabry’s disease or amiodarone induced. But it is not because in that case they are central greyish, bilaterall and arranged in a whorled pattern.

My 2nd diagnosis is ghost vessels as seen in interstitial Keratitis due to congenital or acquired syphilis or Cogan syndrome. But they are never arranged in a criss- cross pattern as in this case. Then he acquired the pathogenesis of these ghost vessel which I elaborated to him.

“There is primary inflammation of corneal stroma without involvement of endothelium / descement’s membrane and epithelium. Invasion of cornea by blood vessels and fibroblasts. The blood vessels leak, deposition of blood in corneal stroma, blood re-absorb, leaving ghost vessels in cornea”

My 3rd diagnosis is prominent corneal nerves. But they never arrange in a criss cross fashion.

I told them that they do not fit in either dystrophy or degeneration.

After the Exam I consulted my atlases but couldn’t find such a lesion. It may be remnant of anterior stromal puncture for recurrent corneal erosion although I have never seen such a procedure in my life.

B. Neuro-ophthalmology and strabismus.

I was greeted at the station by an Indian and a British examiner.

i. My 1st case was a squint. I was asked to look at the patient and do relevent tests. My initial observation revealed Rt. Esotropia. I said “ I will do cover test and extra-ocular movements”. The examiner said proceed. I demanded on occluder and a fixation target. To my surprise they were not available. Luckily I had brought my own instruments to the examination hall. When I told them “Can I use my instruments”. They were delighted. The message is clear always bring your own instruments to exam hall. Don’t trust college, I started the examination by doing cover test. On inspection I said there is no AHP’, proptosis or enophthalmeos or ptosis. There is Rt. Esotropia, about 15—20o which increases to 30o after removing glasses. On covering Lt. Eye the Rt eye goes out and took fixation. On uncovering the Lt. eye, the eye had deviated inward but immediate took fixation. I said its basically Rt. Esotropia and fixating eye is the Lt. one and with good VA.
Extra-ocular movements were full with no I00A or DVD or Duane retraction syndrome synodrome. Then one of the examiners handed over the patient’s glasses and said comments on these glasses. I put a cross on a piece of paper and move the glasses along with it. There was against movement. I said “Its hyperopic glasses”. The examiners said “OK, anything else”. I said “yes there is a prism in it. They were delighted. The examiner then said, “why it is mainly central and what is the name of the prism. I kept quiet and then said, “Probably for centralization of the image”. But I forget to tell them the name of the prism which was “fresnel prism”.

The bell then rang and the examiners then took me to another room to show me their second case.

ii. My 2nd case was an elderly female in her 70’s. Again the examiners asked me to observe and then do relevant tests. Inspection revealed Lt. ptosis. I said I will do cover test, extra-ocular movements and ptosis measurements. They said “Proceed”.

I started my examination with a cover test Observation revealed Lt. side ptosis with exotropia On covering Rt. Eye , the Lt. eye failed to take up fixation. On uncovering the Rt. Eye there was no deviation. Extraocular movements revealed limitation of abduction in Rt eye and total Ophthalmoplegia in the Lt eye. there was moderate ptosis with good levator function on Lt. side. The Examiner smiled and said “whats your differential diagnosis? I said “its some type of ophthalmoplegia. They said “Yes you are right”, how you proceed I said in practical life I will take history from patient to get clues. Give me just one clue. The examiners said OK. Patient has heart block. I said the patient has asymmetrical ophthalmolplegia and ptosis. The examiners said” you are right but he is a confirmed case of CPEO. Then he asked me the features of CPEO and how you investigate and treat?

I said usually bilateral symmetrical ophthamolplegia with ptosis rarely asymmetrical usually no diplopia but if asymmetrical then may have. Systemically can have heart block, cerebellar ataxia, deafness, diabetes and failure to thrive. Investigations include skin biopsy for ragged muscle fibers, ECG for cardiac conduction defects and peripheral blood for mitochondrial DNA analysis. Treatment is usually unsatisfactory.

Types include
a. CPEO alone
b. CPEO plus (Kearns Sayre syndrome) because it is mitochondrial cytopathy with mitochondrial DNA deletions).
c. MELAS syndrome
d. Oculopharyngeal dystrophy

After this the bell rang and I went to the third segment i.e. oculoplasty and orbit which is my favourite sub speciality .

C). Oculoplasty and orbit

The examiners greeted me and took me to their first case to examine with a torch.
(i) My first case was bilateral lower lid involutionalectropion with punctal eversion. The examiners said demonstrate us all signs of involutionalectropion? I demonstrated to them.
- Punctual Eversion which were positive
- Horizontal lid laxity
- Medical canthal tendon laxity
- Lateral canthal tendon laxity- which was absent

The examiners said, How you manage. I said I have a number of options. They said, “Can you describe to us these options. I said, “OK”. I narrated to them steps of following procedures.
• Retro punctual cautery
• Tarsoconjunctival wedge excision
• Lazy-T procedure
• KuhntZsymanuski procedure
• Lateral tarsal sling
They were speechless when they listened my discussion.

ii. My second case was again an eyelid case. A 70 year male with redundant skin and no other abnormality. I said the patient has bilateral dermatochalasis. They said OK would you like to examine the patient again? I realized I have missed some thing. Probably ptosis. I re-examine the patient and to my expectation turned out be bilateral 1 mm aponeurotic ptosis with lipodermoid cyst. When I narrated these findings to the examiners they were delighted. They said “Brilliant” How you manage? I said will discuss the issue with the patient because it is mild dermotochalasis and aponeurotic ptosis - one option is conservative and the other surgical. Surgical options include blepharoplasty with levator resection.

The examiners said, “Have you ever done this procedure in your life? I said, “Yes They said “ Can you give us the steps of this procedure? I said, “yes”. The examiners said “proceed” I gave them a detailed description of the procedure. They became astonished. One of the examiner said, what you want to do with lipodermoid” I said I am not offering surgery for this” They said “why” I said Surgery will create more problems like dry eyes, motility problems, irregular ocular surface and damage to palpebral lobe of lacrimal gland. The examiners said “OK” Then they enquired from me functions of different parts of lachrymal gland. I initially become puzzled but then recover to give them a detailed answer.

The examiners were literally bowled by my answers and seemed very satisfied and impressed. I said any more cases? They said “No” it’s enough. The bell rang and I went for posterior segment cases.

D. Posterior segment

i. The examiners welcomed me and guide me towards my first case in posterior segment.

I started examining the case with slit lamp and gave them a running commentary. I said, Sir, would you like to come as both pupils are severely miosed and difficult to comment on fundus. The examiners said, “ Don’t worry, just gave us your findings. I said, “Ok”. Both anterior segment shows coloboma of iris, lenticular colobomas. They said, Ok what’s in fundus? I tried again to see through the pin point pupils and luckily got the findings. I said colobomas of choroid above the optic disc as well as involvement of the discs. They said anything else? I said, “No” The examiners seemed satisfied with my answer. They enquired from me differences between colobomas and staphylomas and iris coloboma and traumatic iris rupture which I answered them.

ii. My second case in posterior segment was again an un-dilated pupil. I took my 78 D lens to
examine the fundi. One of the examiner stopped me and said, “Take my 90 D lens and examine
fundus as 90 D lens is best for seeing fundi in constricted pupil. I said “OK” but cursed the examiner in my mind that why on earth they failed to dilate the pupil. Any how I started examining fundi. I said the patient has bilateral nucleosclerosis, the discs appears pale, but the vessels are normal looking. There are scars of PRPC in both eyes involving macula. I said my impression is that the patient is diabetic and underwent PRPC for his proliferative DR. The examiners didn’t agree to my answer. They said would you like to re-examine fundi and comment on vasculature and vessels. I said, “OK” I re-examined fundi and said that the vasculature is in normal limits and there is no attenuation, there are old photocoagulation scars but no bone spicules. The examiners said, “Whats your final diagnosis”? I said, “Diabetes Mellitis” but the examiners thought that the patient had Retinitis pigmentosa. The examiners said, “How you proceed? I said, “well ask patient whether he is suffering from diabetes or laser therapy in eyes in the past. The examiners then enquired from the patient the patient said that he is diabetic and had laser in eyes in the past. The examiners were stunned and clean bowled. They were speechless. I was delighted and in high spirits as I have conquered the whole world. The examiners were convinced that their so called bone spicules were actually old photo coagulation scars and pale discs were due to extensive PRPC and not waxy pallor of the disc due to retinitis pigmentosa. They apologize from me because of their failure to dilate the pupil and to make correct diagnosis. The examiners acquired from me differences between photocoagulation scars and bone spicules and the treatment of diabetic macular oedema which was my favourite topic. The bell rang and I was satisfied with my performance.

Table viva

A. Ophthalmic pathology and surgery.
The table viva was due on 5thJune, 2014 at RCOPSG. The viva started half hour late. There were two examiners at each segment - usually one Indian and the other English.

1st Examiner

(i) Corneal ulcer with hypopyon
The examiner greeted me and asked me to let us know if you need something. One of the examiner started viva by showing me a slide of corneal ulcer with hypopyon. I narrated my findings and said that it’s corneal ulcer with hypopyon. The examiner said”. How you investigate, I said with
1. History
2. Swab for culture and sensitivity for bacteria and fungi.

The examiner said how you take swab for culture and sensitivity, I explained the whole method Then he enquired from me different media for culture and sensitivity.

ii. Corneal laceration with iris in wound.
I narrated him the findings. The examiners said,”How you manage. “I said” “I will start with a

• History – asking about history of trauma,blunt or penetrating + IOFB auto-immune disorders.
• Investigations – for culture and sensitivity
• Treatment

As AC was shallow I said during surgery reformation of AC, separation of iris from wound with viscoelastic,
If corneal laceration small 2mm—cyano acrylate glue, will work
If wound large ( more than 2 mm)- tectonic or therapeutic Keratoplasty will be required

iii. Corneal graft failure
The examiner showed me his third slide. I said, the picture shows full thickness keratoplasty with separate 10/0 nylon suture. The graft was central and thick but there were no KPs. I said in practicel life I will examine the patient on slit lamp for anterior chamber reaction to differentiate between graft rejection and failure. He said, “whats your impression”? I said corneal graft failure. Then the examiner enquired from me complications of full thickness keratoplasty, differences between graft failure and rejection and treatment of both forms

2nd Examiner

i. Rubeosisiridis

The second examiner showed me his first slide. I said, “there is extensive rubeosisiridis. He said “OK” Anything else”? Suddenly it clicked that I have missed some obvious finding. When I saw it again I said, “ I am sorry, there is also ectropionuveae. The examiner was stunned with my findings. He then enquired from me pathogenesis of ectropionuveae and causes of rubeosisiridis. I said, I will like to check IOP for neovascular glaucoma and B-Scan for posterior segment evaluation. The discussion went into stages and treatment options for NVG. I said”. Different options depending upon cause, complications and visual potential in the eye. It may include:

• Trabeculectomy with Inj. MMC
• Anterior trabeculectomy
• Glaucoma shunts
• Retro bulbar alcohol
• Enucleation

ii. Flat anterior chamber

My second slide was flat anterior chamber. The examiner said, “ How much flat”? I said, “grade 3,”. In the 1st grade there is peripheral angle touch, grade 2 - there is central iris touch to endothelium and in grade 3 there is central corneal touch. No details were visible. I said, “ it seems post trabeculectomy flatness of AC. He then enquired from me causes of shallow AC and their management. I divided the causes into- shallow AC – with low IOP and shallow AC- with high IOP.

I said, I will check IOP, pupil block and fundoscopy for choroidal detachment and hypotonic maculopathy. The discussion went into shallow AC with high IOP like pupil block and malignant glaucoma. The examiner said”. How you treat malignant glaucoma. I divided the management into:-
• Medical therapy with mydriatics and IV mannitol
• Laser therapy with Nd YAG laser and cyclodiode
• Surgical therapy with pars planavitrectomy

The examiner even told me that you are right as this patient does had malignant glaucoma.

iii. Chemical injury

My 3rdslide was anterior segment showing lacerations / burns of lid, conjunctiva and cornea. The cornea showed epithelial defects and inferior half of limbal ischemia. I said” It’s chemical or sodium bicarbonate injury. The examiner then enquired from me management plan for chemical injury.

I gave him the Roper Hall Classification of chemical injury into various stages and correspondingly its management which included:-

• Lubricants, cycloplegics
• Topical steroids
• Ascorbicacid- topical / systemic
• Tetracyclines
• Lysis of developing symblepharon
• AMT, limbal stem cell transplantation
• Keratoplasty
• Kerato prosthesis

(iv) Endogenous Endophthalmitis

My fourth slide was that of a clear cornea with hypopyon and occluded pupil. I gave him differential diagnosis of hypopyon without involvement of cornea. The examiner said, “Elaborate” I said, “OK”.

• Hypopyon Uveitis e.g. Ankylosing spondylitis, Behcet disease, spill over from posterior
segment- like vitritis, intermediate uveitis, choroiditis, retinitis and panuveitis
• Hypopyon with endophthalmitis.

The examiner said, ‘OK” what will be your diagnosis if the patient give history of catheterization in the last 2 weeks. I said “endogenous endophthalmitis”. The examiner smiled and said”. How you manage such a case? I said “, will examine the patient in detail, which may include:-
History – for catheterization sore throat, pneumonia, fever, sub acute bacterial endocarditis etc.

Examination – Ocularly & systemically

Investigations - vitreous tap, blood culture, urine culture, ECG, Echo.

Treatment -
Ocular – Intensive antibiotics and steroids from all routes - topical, systemic, intravitreal, subconjunctival

Systemic - Treatment of cause e.g. sub acute bacterial endocarditis, pneumonia, osteomyelitis

As the discussion was going on the bell rang and the examiners shake hands with me and said “good bye” with smile on their faces. I was sure that they must have given me maximum marks as no single question was dropped.

2. General medicine and emergency medicine related to Ophthalmology

I was greeted by the examiners.

1st Examiner

i. AlON.
The examiner showed me a fundus photograph. I started describing the photograph – and said that the optic disc shows secondary optic atrophy as the disc is pale, raised and irregular margins. I enquired from the examiner “Sir, can I ask you one question? He said, “Yes” I said, What’s the age of this patient”? he said, 7’0 years”. I said “Then it’s AlON- the examiner was literally yorked with my answer and he said” Great, how you manage? I said, “there are two types

- Nonarteritic
- Arteritic

The examiner said, “How you manage arteritis AION. I elaborated on both systemic and ocular features of giant cell arteritis like jaw claudication, fever, polymyalgia rheumatica, anterior or posterior Ischemic optic neuropathy, CRAO, BRAO, Ophthalmic artery occlusion etc. Investigations include ESR, platelets count and temporal artery biopsy. The examiner interrupted and said, “ What’s if biopsy comes out negative”? I said, “we have to keep in mind the phenomenon of skip lesions. He said “ what will you do then”? I said “ I will then take biopsy from the other side. What if that biopsy is also negative’? I said if the suspicion of GCA is high negative biopsy does not rule out GCA. The examiner was amazed by my answer. He then said, “How you manage GCA? I said, “with systemic steroids. The examiner then said, “ How you give systemic steroids” I said, “ I will first take history of hypertension, Diabetes, peptic ulcer. I will start therapy with IV methylprednisolone 1g / day for 3 days, then oral prednisone 1—2 mg / kg / day. After 3 days then oral dose is, reduced to 60 mg and then 50 mg each for one week. The daily dose then reduced by 5 mg weekly until 10 mg is reached. The examiner said “ what factors govern tapering of steroids”? I said, patient’s clinical features, ESR and C-reactive protein. The examiner was question less.

(ii). 6 D myope with vitreous hemorrhage

The examiner said, “ Suppose a 6 D myope presents to you with vitreous hemorrhage, how you manage”? I elaborated all causes of vitreous hemorrhage especially in a high myope - from a retinal tear or PVD or CNV or RD.

I said,” I will examine the patient with slit lamp and indirect ophthalmoscope. If there is no view I will do B- Scan to rule out R/D. So if the retina is flat I will admit the patient for periodic review. If the vitreous hemorrhage is absorbing, I will observe the patient. If not absorbing or B- Scan shows retinal detachment, I will go for PPV. The examiner said “How long you will wait for the vitreous hemorrhage to absorb? I said there are two schools of thought- depending on experience. Some surgeons go for early vitrectomy and other wait for 4—6 weeks before going in. The examiner said “What will you do? I said, “ I will wait for at least 4—6 weeks for PPV. The examiner said “ Do youi know late vitrectomy can increase the risk of RD. I said “Yes, but I have seen all complications of PPV including corneal erosions, re-detachment and endophthalmitis. It is not an innocent surgery. The examiner said, “ what if patient turned out to be your mother-in-law? I said “ yes” I will wait at least for one month before intervening. The examiner laughed and smiled at my reply.

(iii). 16 D myope with cataract

As there was some time the 1st examiner gave me another scenario— “A 16 D myope with a cataract. How you manage”? I replied, “ We can handle this case at three levels.

Preoperatively –Biometry with IOL Master.

Assessment of eye for retinal tears, RD and predisposing factors. Avoid peribulbaranaesthesia and give topical anaestheisa to prevent globe penetration in case of posterior staphyloma.

Operatively – Phaco is the safest procedure. As AC is very deep one should be very careful during sculpting. There is increased risk of PC rupture because of stressed posterior capsule and chopping seems to be a safe technique as compared to divide and conqueror. Hydrophilic acrylic IOL seems to a best choice.
My answer was still incomplete but the bell rang and I was through to the second examiner.

2nd Examiner

(i). Myocardial infarction.The 2ndexaminer was a middle age English lady asking questions in emergency medicine. She gave me a scenario and said that there is an elderly lady for phaco surgery tomorrow. In the evening a sister phoned you that the lady has developed indigestion. The examiner gave me her ECG and wanted my opinion. I said”, No problem, whether you want me to give detailed account of this ECG or just positive findings. The examiner said, “ Give me just positive findings. I said, “OK”. There were typical signs of ST Segment and T waves’ elevation in chest leads. I said, “ The patient has myocardial infarction. The examiner said”, You mean her indigestion is due to myocardial infarction. I said “Yes”. Hearing this she become delighted. “Is this acute or chronic MI”? I re-examine the ECG but failed to answer. She said”, It’s ok probably it’s too much for an ophthalmologist to answer. Later on I came to know that T wave inversion signifies chronic MI. The examiner then asked one how would you handle this case? I said that I will follow good medical practice guidelines. The examiner said what are they? I said that in such scenario I will postpone phaco surgery for 6 months and will refer the patient for cardiologist’s opinion. She said. How will you convince the patient that surgery is not safe for her at this stage? I said I will reassure the patient about two facts. There is a high risk for fatal arrhythmias after infarction if surgery is carried out within 6 months of MI and acute MI requires emergency treatment in form of injections like streptokinase, O2, Aspirin and others very early, which is only possible if phaco surgery is postponed.
She said, “Great we will now move to 2nd scenario. I said OK”.
ii. Drug induced hemoptysis and shock. My 2nd scenario was an elderly lady admitted in eye ward for some eye problem suddenly present with hemoptysis.She has osteoarthritis. The examiner said, The patient has thready pulse and BP of 100 systolic, what will you do? I said, The cause of bleeding may be gastric or duodenal ulcer, gastritis, Mallory Weis syndrome, bleeding from portal hypertension due to cirrhosis liver and drug induced gastropathy. I will follow the ABCDE guidelines which includes clear airways, chest movements and respiratory rate and maintenance of two wide-bored I/V lines as the patient is in shock I will raise foot end of the patient and will give I/V dextrose saline one to two liters fast to revive her circulation. If there is severe hemoptysis. I will take blood for cross- matching and ABO compatibility. The examiner said”, Anything else you want to do? I said, Yes, I will call for gastroenterologist to do endoscopy for the patient. She said “what do you think is the cause of hemoptysis”? I said, It may be peptic ulcer or drug- induced because the patient may have taken some NSAID for her osteoarthritis. The examiner said, That’s great.

iii. The examiner said as there is some time we will take a 3rd scenario. I said. “OK” She said that there is an elderly patient with initial abduction limitation but suddenly developed medial rectus limitation. Give me one diagnosis? I said, “Myasthenia Gravis” She said, It could be. The bell rang. The examiners seems very impressed with my performance and said good bye to me.

(3). Ophthalmic medicine

1st Examiner
(i) Choroidal mass (melanoma)
My 1st slide was that of a fundus photograph with a large choroidal mass invading vitreous. I gave my findings and said that it’s choroidal melanoma. The examiner was delighted over such a quick response and said, “Can you give the differential diagnosis”. I said the differentials include choroidal nevus, choroidal detachment, choroidalhemangioma etc. But only one differential diagnosis in this case. The examiner then enquired from me clinical features, investigations and treatment options for such a lesion. The discussion then went into complications of charged particle irradiation such as protons including cataract, papillopathy,maculopathy,loss of lashes, eyelid de-pigmentation and keratitis.

(ii) Thyroid related orbitopathy
The examiner said suppose a patient comes with bilateral proptosis, how you manage such a case? What comes into your mind? I said Thyroid Related Ophthalmopathy. He then enquired from me all ocular and systemic features of TRO, its investigations and its treatment options including:-

• Lubricants
• Systemic steroids
• Radioactive iodine
• Orbital decompression

(iii) Conjunctival nodule
The examiner showed me a slide of a conjunctivalthicking / nodule. I said, it may be sclertis or episcleritis or phyctenolosis. The viva then went into features and treatment of scleritis with options like systemic steroids and immuno modulator therapy.
(iv) Fourth slide
The examiner then showed me a fundus photograph. On first look I couldn’t find any pathology. Luckily the bell rang & I moved to the second examiner.

2nd examiner
i. Kerato conjunctivitis sicca. My first slide was that of an irregular corneal surface with filaments. The examiner said”, give me most important cause? I said, kerato conjunctivitis sicca due to dry eyes. The discussion went into investigations like BUT, Shirmer test, fluorescein stain, Rose bengal dye and treatment with lubricants, collagen plugs and mucolytic agents like acetyl cysteine 5 % drops for filamentary keratitis.
ii.Myastheria Gravis.
The examiner said, “A patient has presented to you with easy fatigability. I said, “Its Myasthenia Gravis”. The examiner was interested in the clinical signs and investigations of Myasthenia Gravis which I elaborated indetail.

iii. Marcus Gunn Jaw Winking ptosis
The examiner said a mother has brought a 5 months old child with droopy left eyelid. she says that when my child takes milk there is retraction of left eyelid. What’s your diagnosis? I said, “It’s Marcus Gunn Jaw Winking Ptosis”. He said, how you manage such a case? I said that in MGJWP there is anomalous connection between levatoraponeurosis and medial pterygoid muscle and is usually unilated. I said there are a number of treatment options depending on grade of wink amount of ptosis and associated syndromes.

In mild winking- we have just to do levater resection ignoring winking.

In moderate to severe winking-Bilateral. levatordisinsertion followed by brow suspension with fascia lata or any other suspension material (preferred procedure to have a symmetrical result).

Unilateral levatordisinsertion followed by brow suspension.

Unilateral levatordisinsertion followed by frontalis flap.
The examiner said, Have you done frontalis flap procedure in your life? I said “Yes”. He then enquired from me the steps of frontals flap procedure.
(iv). Angioid streaks. As there was some time the examiner took the same fundus photograph which I couldn’t diagnose with the 1st examiner. When I saw the same fundus photograph, I thought that the examiner has clean bowled me because I knew nothing about the slide. Then suddenly I pick up the diagnosis and started describing the findings. There were subtle grey or dark red linear lesions radiating from the disk. I said, “Sir, the photograph shows angioid streaks. The examiner was literally stunned when he heard my diagnosis as it was missed by all previous candidates. He then enquired from me about the pathogenesis of angioid streaks (cracks like dehiscences in the Bruch’s membrane) causes (PEPSI- Idiopathic, sickle cell disease, Pagets disease, Ehlers Danlos syndrome pseudoxanthomaelasticum, acromegaly and Marfan syndrome), and complications (streak involving fovea and SRNVM and choroidal rupture).

As the discussion was going on the bell rang and the game was over. The examiners were so impressed that they shake hands with me and said good bye.
After the exam I was hopeful that I will pass the FRCS Exam but I was unsure about my anterior segment viva. On 18thJune, 2014 my friend called me that result is out. When I gave my roll number he congratulated me on my success. This was the happiest day of my life.
Any ophthalmologist interested in getting tips of passing any portion of FRCS Glasgow Ophthalmology Exam my services are available. Just e-mail me at
I will be glad to help.

Dr. Tariq Farooq Babar



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