Candidate 194


FRCS Glasgow

Centre:   Hyderabad


Date:   Jan 2015


Salam. my name is Islam. Thank God, I have passed FRCS Glasgow this spring from the first attempt. I'd like to share my experience with you.

First: study materials

I studied Kanski, oxford hand book ophthalmology (great book) , Wong, emergency chapter in oxford hand book medicine, made easy ECG and this website ( irreplaceable significance especially the past candidates experience and the clinical multi-station exam). It took me one and a half month ( full time - unemployed) to study all of them just once however I greatly recommend to cover the website, Wong and oxford at least twice. Wills eye manual is a good book with a differential diagnosis for every topic but I didn't have time for it.


second: exam tips

1* it is an easy to pass, easy to fail exam! my exam included essentially straight forward basic info and skills, if you just concentrate enough you will definitely pass.


2* I had never been asked how to perform a surgical procedure or about refractive surgery . I don't know but that was my exam.


3* they do actually repeat questions and cases. I read past candidates experience in this web site starting from the most recent and found that my exam included many of them. so my advice is to cover at least the recent 40 candidates or so and search for the answer of every question mentioned.


4* practice, practice and practice is the key. share cases with your colleagues, discuss them and let somebody examine you. even while you're studying books do so in a loud voice so you can hear yourself and judge your thoughts and confidence.


5* if you are asked a question be systematic and start from the simplest part. many times I started to answer and was stopped just a few seconds later once they found that my answer is systematic. when asked how to approach or management always answer: history, physical, investigations and treatment.


6* each clinical case is given 6 minutes. from my experience 6 minutes is nothing and pass like a blink. you never know how time passes and suddenly you find your clinical exam ends when all what you remember is that you've just started. so concentrate 'heavily' in the clinical and practice examination in a very short time and practice observation as my clinical often depends on observation alone.


7* there was sterilium in every room to use between cases but to be honest I used them not in all my cases! Indeed, I forgot to do so.


8* when you enter the clinical, they ask you to remove any jewelry except a wedding ring and to cuff your shirt up to the elbow and neither to introduce yourself to the patients nor to take permission for the examination.


9* you are not expected to be perfect and answer all the questions correctly, no one will ever be! so just relax and try to do your best and forgive yourself for a few mistakes and don't let them change your confidence during the exam.

10* I found that all the examiners are good, supportive and helping. many times you can tell that your answer is true or wrong from the facial expressions of the examiner! when you are taking the right way of answering they are always encouraging. They also like spontaneity a lot, I frequently didn't wait for the next question and  mentioned the required points when following a systematic way in answering.

Third: my exam:



* posterior segment:

1-SLE of middle aged female, examine fundus of the right eye that showed large hypo and hyper pigmented macular scar involving fovea with fine surface gliosis that extends to the optic disc, clear vitreous.

Q: - describe: I answered: the vitreous is clear, the vessels are ok, the disc has surface fine sheet of gliosis and the macula had a scar that.. - are you sure the vitreous is clear?  yes. - is there any other lesions? I returned back and examined again; there were none. -differential? -trauma, if bilateral I'll think of macular dystrophy. - what type of macular dystrophy can lead to such a scar?  best disease. -if I tell you that this patient had this condition since childhood and she went to the UK at that time for treatment, what could be the condition? retinoblastoma. ( he said right).  -management?  I answered: history, physical including other eye, he stopped me.


2- they appeared impressed from my first case so they told me to come and have a quick look with indirect ophthalmoscope to a boy with ?? inferotemporal retinal dialysis. I told them there is a retinal elevation inferotemporally - what's that? I said retinal detachment vs retinoschisis. It appeared obviously that I didn't pick it up, so they said ok, forget about it and come and see case 3.


3- (indirect ophthalmoscoe) examine right eye in a middle aged female: large subRPE discoid hemorrhage with central barely identified macroaneurysm with another small hemorrhage away from it. vessels were sclerosed and attenuated (HTN retinopathy).

Q:- describe: - I can see a homogeneously darkly pigmented 4 disc diameter lesion straddling the inferiotemporal arcade not involving fovea, minimally elevated, well demarcated, the disc is normal with cup disc ratio 0.2, the vessels are significantly attenuated. there is another one disc diameter sickle shaped flat lesion inferonasally.  -differential diagnosis? I stupidly said : melanoma, CHRPE, he stopped me: is that a melanoma? is it elevated? - no sir! what could it be? I wondered desperately but couldn't pick it up! the other examiner said: could you see any other hemorrhages ( yes they always try to help you) I again stupidly answered: no there is no other hemorrhages! - what could it be? again I didn't reached it! - the other examiner another time tried to help and said: you've just said the vessels are attenuated, how could this be related? - no answer!

- investigations? I said B scan. - it is flat on B scan, what else? no answer! ( I should have mentioned FFA but I don't know what was happening to me! ) then the bill rang..

I was totally depressed after this case and I really thought of running away from the whole exam as my devil told me "you will never pass after this case" but hey my devil, I did it!


* orbit and oculoplastic:

1- observe and describe: middle aged female with right lower motor neuron 7 CN palsy with poor blinking, marked lagophthalmous and a white material on the lower lid ( the patient was wearing a scarf, I missed to observe behind ear and around the parotid).   -why do you say it is lower motor? because the upper facial muscles are involved. - what do think is the white material? eye ointment -why? because of lagophthalmous.  -differential causes of 7 CN palsy. I said: starting from the facial nucleus at Pons, it could be a lesion at Pons, cerebellopontine angle, parotid..- how could you differentiate?  what other associated lesions are present and the taste in the anterior 2/3 of tongue. -what if I tell you that she also has 8 CN palsy, where is the lesion? I said: at the cerebellopontine angle. - like what? I said tumors like acoustic neuroma, .. but he seemed unconvinced and searching for a specific entity, ( some other candidate told me that it was a case of gardingo syndrome).


2- observe and describe: young dysmorphic adult with bilateral symmetrical proptosis, shallow orbits and talengectatic vessels in the inferior half of conj.

-spot diagnosis ? carotid cavernous fistula (?) - no it is not, what if I tell you that this patient had this condition stable for a very long time? I said: I don't know sir! ( till this moment I don't know what it is).


3- observe and describe: a child with unilateral severe ptosis,  defective blinking, brow suspension scar ( it was a very fine scar and the boy had a long anterior lock of hair that I didn't elevate so I missed the scar!)

-management? history physical and surgery - do you want to do something before surgey? oh, ya vision and refraction. then he gave me his glasses to test, I use the floor blocks ( myopia with astigmatism ).


* neuro and squint:

1- observe and describe: a young man with nystagmus, I said: I can see a young man with bilateral conjugate horizontal uniplanar low frequency  moderate amplitude pendular nystagmus. -continue exam? I performed cover/uncover, EOM, saccadic and convergence, I commented: jerky in side gaze, not affected with covering one eye or convergence. ( I learned nystagmus exam from oxford, very nice neat six pages about it- highly recommended). -type of nystagmus? pendular. then been asked about sensory, motor imbalance, up and down beat nystagmus.


2- examine alignment and EOM: young very very very uncooperative child with glasses.

Q:-findings? first I observed her and found that she had bilateral eso but I didn't comment as I was thinking could that be possible? then I performed cover/uncover, alternate cover, prism/cover with and without glasses then EOM. she was extremely uncooperative and not fixating and barely could I observe limitation in abduction bilaterally, eso was around 20 for far and 15 for near as I remember but there was also hypotropia?? that measured 8. I mentioned all that and when asked about my diagnosis I said bilateral 6 CN palsy but need to retest her when she is not tired. From this case I recommend that if you face an uncooperative patient don't panic, just perform your exam fully, comment on whatever you find and mention that you'd rather re examine later at a better condition, as an uncooperative tired patient is highly expected in such an exam.

 -management? history including congenital vs acquired, physical including vision and refraction and treatment including surgery depending on the patient complaint ( I forget to mention temporary measures like prisms).


* anterior segment:

1- examine on SLE: child with right valve and left failed trab ( fibrosed bleb) , I definitely would miss them if I didn't elevate the upper lids. they asked me to comment while examining so I started from the lids, conj ...

-type of glaucoma? I looked at the patient, she was around 12 years, so I said it could be congenital vs juvenile glaucoma. - is the left trab functioning? no sir because it is fibrosed, - if IOP is still high what surgery would you perform? either augmented trab or tube. -which one would you choose? tube. - why? what are the complications of valve in this particular age group? as the eye is small I will expect the plate to interfere with ocular motility and .. he stopped me and said true. - how would you manage a baby that came to you as a suspected congenital glaucoma? beside taking history I will examine him under general anesthesia preferably ketamine and measure IOP, corneal diameter, optic disc.. he stopped me and said ok, that's fine.


2- examine on SLE: middle aged undilated man with right IOL, clear cornea and PXF. left central faint subepithelial haze, PXF and cataract. same thing they asked me to comment while examining so again I started from lids, conj ..

- if the patient is complaining of his left vision, what will be your treatment? I should address both the cataract and the corneal scar. - ok, how would you treat the corneal scar? I don't know may be PTK ( I should mentioned the need to know the cause of the scar, duration, corneal OCT to determine the level then decide) - ok, never mind, let's talk about the cataract what precautions to take? I would expect zonular weakness and poor dilation, so I will intensely dilate him preop - what will you give him? ( it would be better to mention the drugs right away rather than just saying intensive dilating eye drops).


ORAL: ( all the questions are preselected from the college with each examiner supposed to ask you about a couple of cases with an answer sheet that should be ticked for every true answer, so try to mention any thing that come into your mind as there is predetermined specific answers you need to mention to gain points and wrong answers don't count! ).


* general medicine:

1-the examiner gave me a scenario f middle aged man with unilateral granulomatous ant uveitis:

-differential diagnosis? infective, non infective and masqurade. - like what? infective like herpetic, toxoplasma - and what? TB ( he was looking for it) -non infective? sarcoid, VKH, sympathetic ophthalmia   -sarcoidosis clinical manifestations? I answered: ocular and systemic : ocular starting from skin: sarcoid granuloma, lupus pernio and.. he stopped me and systemic? lung involvement that is classified into 4 stages first stage.. again stopped me - ok, how would you treat him systematically? I would send him to an internal medicine physician - ok, what do you think he will give him? systemic steroid and azathioprine ( it is not true methotroxate is the right answer) - ok, what will you check before starting steroids what are  steroids contraindications? I said: peptic ulcer disease, active systemic infection - like what? TB, sir ( again he was looking for it) .

2- scenario of 62 yo female, unilateral headache and loss of vision - I don't know why when I looked at this examiner I feared him and lost my concentration though I don't know him and never saw him before!

- spot diagnosis? GCA -differential diagnosis? It was a long pause that ended me saying I don't know sir, total mind block! -ok, GCA what other things in the history? jaw claudication -other? - I can't remember! ( he was looking for polymyalgia symptoms) - ok, physical? - loss or decreased pulsation of the superficial temporal artery, ocular movement defects. ok, investigations? CBC, ESR, CRP and temporal artery biopsy. treatment? systemic steroids. -which steroid will you start her? oral prednisolone 1mg/kg ( he surprised) - is there any other faster option? oh, ya IV methylprednisolone 1g daily for 3 days then oral. - (again) what will you check before starting steroids? peptic ulcer disease, TB, - and at this age? osteoporosis -how will you do that? DEXA scan -(surprised) will you do dexa right away? what will you need to do before? Ca and Po level - supposedly normal, what else? history of hormonal replacement therapy - (surprised) do you expect her to be on HRT? no sir, I am sorry, history of recurrent fractures - yes, now you're right ( and put a tick on the answer sheet) .


3- he then gave me a scenario of 75 yo female at the day of cataract surgery, she co indigestion the nurse informed you and done an ECG, he handed me an ECG that has no name or date, it showed ST elevation on most of the chest leads.

Q: - what does this ECG show? ST elevation suggestive of acute MI ( I should have told him that pericarditis is also a differential) - how will you manage her? I'll put her on high flow O2, chewed aspirin, sublingual NTG and IV morphine in addition to taking blood samples for CBC, U & E, troponins, CBK MB. ( I think it will be better if I mentioned taking detailed history and risk factors at the beginning). - suppose this woman had been treated for her condition, when will you perform the surgery?  not before 6 months (I don't have a solid info about the earliest time but I read it from one past candidates answers! though during my exam the examiners appeared unconvinced by my answer and the other examiner asked what if she have a retinal detachment? I said to escape answering: it depends whether macula sparing or involving. - macula involving? I said desperately pneumatic retinopexy!).


4- then given a picture of CRVO in 50 yo HTN male

Q: describe? a few hemorrhages with mild disc swelling, I need to examine under slit lamp to determine if there is edema or not. -spot diagnosis? CRVO, mostly nonischemic. -difference between ischemic and non ischemic? I answered: history, physical including, vision, RAPD, fundus changes, investigations.- what investigations will you order for this patient? FFA and OCT. - management? systemic and ocular, systemic investigations like CBC, BP, lipid profile, U & E, FBS and referral to an internist. ocular depending on vision, FFA and OCT findings.

5- 25 yo female co headache , bilateral disc swelling

Q: spot diagnosis? idiopathic intracranial Hypertension... time is out. 


* ophthalmic medicine:


1- picture of herpetic lesion.

Q: describe? large central dendretic multiply branching lesion but no obvious terminal end bulbs.   -differential diagnosis? herpetic, healing traumatic, acanthameobic.  -which herpes? mostly simplex. -diagnosis using: history, physical and investigations? history: of skin lesions, recurrent corneal disease, physical: other corneal manifestations but most importantly decreased corneal sensations (he greatly stressed on this sign), investigations: PCR and cell culture.  -treatment? topical acyclovir. -duration? about two weeks but the rule is at least three days after the lesion disappear. -other types of topical antiherpetic drugs? I  mentioned idoxuridine but couldn't remember any other. -types of herpetic corneal diseases? desciform, stromal, metaherpetic, geographic. -when to use oral antivirals in corneal disaese? he said there is a strong indication, I mentioned the prophylactic one but he seemed unconvinced.


2- 7 yo child with right upper lid swelling and redness of 24 hours:

Q: differential diagnosis? orbital, preseptal cellulitis, allergy, trauma ( he seemed happy when I mentioned the latter two) and the remote possibility of embryonal sarcoma. - about orbital cellulitis: how to proceed? histoty including history of trauma, sinusitis, fever, physical including EOM, RAPD, pain with eye movement, fundus exam, then I will order CBC and orbital CT and ask for ENT consultation. - what to look for in the CT? distinction between orbital and preseptal, sinusitis, orbital complications like abscess. -cause of orbital air fluid level?? I said anaerobic infection but it appeared it is not the right answer. then they skip it and asked about the treatment?  intravenous antibiotics  (they didn't asked which ones). -what if CT showed maxillary sinus collection? I will ask the ENT team for sinus drainage.


3- picture of an optic disc with temporal B zone, CDR 0.4 vertical and 0.3 horizontal.

Q: describe? clinical approach? I will examine other eye then take intraocular pressure. -what's the differential if bilateral symmetrical? I said glaucoma, myopia and idopathic. -how to differentiate? other myopic fundus findings, IOP, refraction, visual field and optic disc OCT.


4- picture of CHPPE with partial depigmentation.

Q: spot diagnosis? clinical significance? the typical type is clinically insignificant but the atypical is associated with familial polyposis coli and related syndromes. -which doctor you will consult? gastroenterologist.


5- picture of keratitis with history of agricultural trauma 5 days ago

Q: describe? abscess ( ?? descematocele). -approach in history? age, other risk factors, progression, pain. -physical? I will take a swab from the discharge and scrape the cornea. -how will you do that? with blade 15 taking part from the base and the leading edge starting from the normal towards the infected cornea. -culture?  blood and chocolate agar, sabourud dextrose for fungi. treatment? I will start him on fortified vancomycin and ceftazidime with close daily follow up and add antifungal if no improvement within 48 hours. ( I think I must also have mentioned admitting the patient)


* surgery and pathology:


1-hazy picture of fundus with three white retinal lesions

Q: spot diagnosis? ( candida retinitis ). risk factors? IV drug abusers, IV dwelling catheters, immunosupressed, diabetics and malignancy patients. treatment? IV amphotricin B. -mention other antifungals? azoles like variconazole, ketokenazole, itrakenazole . natamycin and flucytocin.


2- picture of Avelino dystrophy

Q: describe? spot diagnosis? inheritance pattern? autosomal dominant. -presentation? either decreased vision or recurrent erosions. -management? depending on the patient complaint and remainder of eye exam but the cornea can be treated by PTK, anterior stromal puncture or lamellar keratoplasty.

3- a boy with blunt trauma with a stone that caused zonular dialysis at one side.

approach: history? time, complaint, previous ocular disease. -physical findings in blunt trauma? I mentioned them all starting from orbit to retina. -management of this patient? vision, refraction, if cataractous lens then surgery.


4- picture of dacryocystitis.

Q: -describe: erythematous raised medial canthal lesion. -diagnosis? to be honest I first thought it was a skin mass and gave a diagnosis of basal vs. squamous cell lesion but as I caught up the examiner's dissatisfaction I thought again I found it was an obvious picture! -management? warm compressors, oral coamoxiclav, later DCR. -what if the patient come back two days later not much improving and the abscess is pointing? I will open up the abscess at the maximally tender point keeping in mind the risk of iatrogenic fistula formation. ( I was taught that it is forbidden to open up a lacrimal sac abscess, I told him that but he disagreed!) .


5- a rupture globe patient is on the operation table, what do you want to look for?

time is out and I left the examination room feeling that I am going to fly finishing the exam since I dedicated my whole time for many days for studying and studying neglecting my home, highly supportive husband and my nice cute baby. Finally I am free!


I wish that anyone who read this summary will benefit from it. Good luck!




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