Candidate 193


FRCS Glasgow

Centre:   Hyderabad


Date:   Jan 2015


Hi, I'm Dr Chinmay Nakhwa. I recently cleared my FRCS 3 in the first attampt. Exam was held at Hyderabad. 

Day 1 ( 30th Jan 2015) -  Orals

Table 1 - Ophthalmic Surgery and pathology

Examiner 1 -

Showed a slide of a lateral canthal large ulcerative lesion ( i thought there was evidence of discharge too)- a bit confusing because of poor picture quality. Gave d/d of subcutaneous cellulitis / neoplasms. questions on types of neoplasm, plan of management. definition of exenteration etc. Types of biopsies.

second slide he showed was of a nodule at limbus/ asked d/d in a six y/o child, additional tests , what vision problems can it cause.


Examiner 2 -

Showed a classic picture of pseudoexfoliation. What is true XF, differences between true and pxf. How will you evaluate patient before surgery? What are the difficulties and complications you will expect during surgery?Questions about rhexis size / modifications made to this pt.

What are the long term complications expected in this pt. What is PXF syndrome.A bit on pathology of PXF.


Table 2 - General Medicine and Neurology

Examiner 1-

Showed a picture of neovascularization of the iris with ectropion uvea. Asked to describe the findings. What are the clinical conditions which can cause such a picture? What are the investigations and management which you would do for this patient in your OPD? Discussions went on crvo, pdr, role of glycemic control in PDR. What is glycosylated Hb? Role of lasers, intravitreal Anti VEGF agents.Whats your choice? Showed a second picture with retinal hemorrhages with retinal whitening. Asked for d/d.


Examiner 2 -

Gave a clinical scenario- A senior gentleman walks into your room for a cataract surgery evaluation and on history he complains that he has been feeling uneasy in his chest with pain for the last 1 week. Asked for d/d. What is the 1 inv that you would do for this patient? ( ECG). Gave an ecg which showed STEMI Ant wall. Asked for the blood supply of ant wall. How will you manage the patient? what is the role of Aspirin? what are its side effects? What is the mechanism of action of GTN. What are is most common side effects? When would you eventually do a cataract surgery for this patient? What would you do about the Aspirin before cataract surgery?


What are the causes of papilledema. What are the causes of papilledema in the young girl?

what are the investigations you would do.


Table 3 - Ophthalmic medicine


Examiner 1 -

Give a scenario of a young mother who has noticed a white pupillary reflex in the eyes of her young child. What are your differentials ( please do not answer in abbreviations..mention full names like retinopathy of prematurity instead of ROP!). So if this is Retinoblastoma how would you investigate and manage? He wanted everything in great detail starting from the history to investigations and technique of examination. enumerate the treatment options.A few questions about the histopathology of retinoblastoma. What information will you get which will help you in prognosis. ( He probably wanted well differentiated vs poorly differentiated- but it didn't come to me till the end!)

Showed a picture which looked like diffuse KPs. Asked for the conditions which can cause diffuse KPs.

Picture of Giant papillary options. What are the long term complications of management. ( wanted glaucoma and cataract due to steroid use)

Examiner 2-

What are the systemic side effects of Acetazolamide? What are the other CAIs you know of.How would you treat parasthesiaoccuring due to acetazolamide?

How does diabetes affect the macula. What is CSME. What are the ETDRS guidelines. What are the outcomes of ETDRS.How do you treat macular edema? What intravitreal anti VEGF agents are available? doses? ( Mentioned everything from Avastin, Lucentis, Aflibercept, IVTA, Dexamethasone implants) . Which newer intravitreal steroid implant is available in Europe but not in India, lasts for 3 years! ( mentionedfluocinolone but couldn't remember Iluvien!)


Day 2 ( 2nd FEB 2015) - Clinicals

Station 1 - Anterior segment

  1. A case of unilateral stromal and endothelial scarring with central corneal thinning. diagnosed it as K’conus with Hydrops. Examiner wanted d/d- can it be post infective?

            management options- glasses, CL, Dalk, PKP

    2.     Slit lamp of a case of sutured corneal wound with infiridodialysis with uveal tissue incarcerated in the wound. Asked to describe the wound. What additional tests would you do.( i would do dilated fundus exam to look for iofb, retinal breaks, tears, detachments) where would you expect the retinal tears to happen. What other manifestations in the posterior segment? Imaging for IOFB. Would you do gonio in this patient.( yes to look for angle FB, angle recession. ) . Would you do a gonioscopy in this eye ( no, the wound looks freshly sutured). How long would you wait? ( until the wound heals, six weeks). can you comment on the visual status based on the sutured wound and a/s findings? ( Pt probably has a high astigmatism as there are dm folds due to a tightly sutured wound)

3. A young man with left eye exodeviated. Asked to describe the appearance of the patient. Asked to check the pupillary reflexes ( gave me a direct ophthalmoscope!) light was too low so he gave me an IDO. checked the pupillary reflexes, pt had a left APD. Checked direct consensual and near reflex too. Asked to examine the fundus- pt has a Primary optic atrophy( total cup, looked GOA). What is the probable vision in that eye.( poor because there is optic atrophy and the eye is exodeviated due to sensory exotropia). What would you do for this pt. Examine the other eye for treatable lesions/ IOP.CNS imaging after systemic examination.


Station 2 - Posterior Segment -

  1. Examine a patient however you want - I asked for IDO and reported as i examined that the patient had a inferotemporal branch retinal vein occlusion with macular edema. Q- is this the best way to examine macular edema. ( No sir, id like to do a s/l biomicroscopy) Did that and repeated the findings. What else would you look for on s/l ( NVD, NVE, ERM, TRD) questions on BVOS, BRAVO. How would you treat? ( laser, i/vit pharmacotherapy)

  2. Examine with IDO- patient with Typical retinitis pigmentosa. Questions on causes of vision loss, modes of inheritance.How much do you think the vision is in this patient.  management options ( refraction, Cat sx, LVA, family screening)\

  3. Examine the peripheries in this patient ( did a gross exam and everything seemed normal!) . patients are sitting in the exam room so doing a good ido can be challenging! Bot i managed to see a lasered lattice pre equatorially in one eye!. Questions on indications for treatment of lattice degeneration/ peripheral degenerations.

  4. 78d examination  of a young male with aphakia with a GDD and inf PI. Retina looked attached with peripheral CRA. Was a little confused until the examiner hinted whether this could be post operative. Yes could have undergone a retinal detachment repair with secondary glaucoma for which a GDD was implanted. Describe the ant seg findings ( ptaphakic, gdd tube in situ, infiridectomy) questions on the purpose of infiridectomy. What retinal surgery do you think was done ( rd repair with silicone oil)

  5. A young man with perimacularh’ges. Could not discuss this case as the bell rang.


Station 3 - Ocular motility and neuro-ophthalmology.

  1. A young girl with left eye exodeviated with a face turn. Asked to examine the extraocular movements which i did using a torch light.( the examiner was a little irritated that i didn't do cover uncover, didn't ask for diplopia while checking EOMs- so be careful. do not panic while examination!). Pt had DRS type 1. discussions on management.

  2. Given a torch and asked to examine a young 10 year old boy. started with observation of habitus, facial asymmetry, hirschberg, pupillary actions ( everything was normal till here!) Checked EOM which were restricted in all gazes and then i noticed a distinct lid twitch! Boy also had compensatory frontalisoveraction. and a normal looking lid crease.  Asked for diagnosis - MG, CPEO. How do you differentiate between the two.causes of frontalisoveraction. ice pack tests. few questions on CPEO, age of onset, characteristic features.

  3. A young male with evidence of forehead trauma and complete ptosis on the same side. Asked to examine the EOM! Checked versions and ductions. the eye was exodeviated with restriction in all gazes except depression. Asked for possible etiology- traumatic 3rd nerve palsy. Site of injury? Pupillary involvement? ( pt had a fixed dilated pupil) No time for further questions.


Station 4 - Lid and Oculoplasty

  1. Young male with rt ptosis with compensatory chin elevation. Asked to describe the appearance. Do complete examination for ptosis with all measurements, EOM ( elevation was restricted in affected eye, lid lag on downgaze) , summarise your findings. Diagnosis? ( Rt Severe congentital ptosis with good levator function with compensatory chin elevation ) plan of management.What surgery will you do if indicated. What do you think is the visual potential for that eye.  ( Eye is orthophoric with normal pupillary actions with chin elevation- so vision potential seems good!)

  2. An old man with bull gore injury to the left eye with complete ptosis. Eye looked enophthalmic with restriction of movements in all gazes. there was medial canthal tendon laxity with ectropion. Was asked about the attachments of the medial canthal tendons. what all structures could have been injured in him? What is your plan of management.

  3. An old lady with bilateral staring look with periocular puffiness. Was asked to describe the ocular findings on examination whichi did. Also mentioned the absence of any neck swelling or scar. What do you think is the diagnosis ( TED). other differentials. ( High Myopia, Shallow orbits, NSOI). Bell rang . No time for further questions.

The trick is to remain calm and think on your feet. You should be able to justify your management. Discussing with colleagues while preparing for the exam is very useful.

All the best to future candidates.


Dr. ChinmayNakhwa


Vitreo-Retina Consultant

AdityaJyot Eye Hospital Private Ltd.



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