Candidate 51                                                         Centre: New Dehli
FRCS Glasgow(Passed)                                                          Date: September, 2004
My name is Sebastian Mathew and I am from Kerala, India. I took Part B of FRCS
Glasgow from New Delhi in September 2004. This was my first attempt and I am
glad to say that I passed.

First, some general advice.
If you are taking the exam in Delhi, try and take up your accomodation near your
exam centre. Mine was at Sir Ganga Ram Hospital at Rajinder Nagar, and I
understand that's where the exam usually is. There are plenty of hotels around
this hospital which are reasonably priced and offering reasonable creature
comforts. It takes a long time to cover distances in Delhi and you will have
enough things to worry about during the exam besides getting to your centre on
Study advice: Get someone to practice examination techniques with you. This is
one area where most people who reach the clinicals lose out on. The examiners
assess the 'slickness' with which you do your examination and if it appears to
be slow and laboured, you might be in trouble. Get one of your colleagues to
watch you objectively while you make your examination of different systems and
ask him/her to give you a critical appraisal. Examination techniques are
especially important for squint, motility disorders, neuro-ophthal. Practise
your 90D and Indirect Ophthalmoscopy well, so that you don't waste time during
your examination.

The first day - Written exams

Two sessions with an hour's gap in between.

The first session was the problem solving one. Essay type answers are not expected. You have about 40 minutes for each question, so plan out your answer well and try to make it like a flowchart. Give practical solutions tailored to the problem and taking into consideration the patients visual requirements.

The questions were:

1. A 20-yr old woman has attended the clinic for some time with atopic conjunctivitis. She has been treated with topical steroid drops but had to discontinue these because of a steroid induced intraocular pressure rise. On this occassion she presents with reduced vision of 6/36 right and 6/18 left and seems to have developed keratoconus. Discuss how you would manage this case and describe the difficulties and risks involved.

2. A 75-yr old retired professional man presents to you with sudden loss of vision in his right eye. On examination acuities are Counting fingers right and 6/18 left, reading N8. He has a full thickness macular hole in the right eye with a moderate cataract on the left. Explain how you would manage this patient and discuss the risks and benefits involved.

3. The parents of a 6-month old baby girl tell you that there has been a swelling in her left upper lid since birth which has gradually enlarged. On examination the left upper lid is swollen and covering the pupillary axis. You also notice a small capillary hemangioma on the back of her head. Give a differential diagnosis and describe how you would investigate and manage this patient.

One hour later the MCQ exam began.

60 questions with 5 stems requiring True/false responses for each. There is negative marking here on a 1:1 ratio, so be very careful here. A good strategy would be to answer only the ones you are 100% sure of in the first round. If you get around 180 in the first round, that should be sufficient and you are better off not guessing. I covered 196 in my first round, then answered a few more that I was reasonably sure of in the 2nd round. Totally answered around 210. There were quite a number of general medicine/neurology questions. Eg. About parkinsonism, features of UMN lesions etc. But generally the questions were straightforward.

The 2nd day -Orals

We were divided into 2 batches. I belonged to the first batch and so had my
vivas the very next day. The 2nd batch had it one day later. Its better to
finish your exam off first. Its waiting what makes one tense!

3 sessions here. 20 minutes each with two examiners who take 10-minute segments
each while the other examiner makes notes.

First session was General Medicine/Neurology
Medicine is usually emergency situations only unless you happen to lead the examiner into some dark alley! Neurology too is generally ophthalmic related.

Had one British and one Indian examiner. The British examiner began.

First Question
Patient had surgery under GA few days previously and now has breathlessness.What are the possibilities that run through your mind? Said pulmonary embolism. pneumonia and if chest pain also MI....Ok, so how do you assess the patient.  Talked of clinical examination, respiratory rate, cyanosis (where will you look for? the tongue.. ok why? peripheral cyanosis may be due to cold..ok), bloodgas, pulse oximetry, chest xray (what will you find in PE? increased vascular markings, wedge shaped shadow.. And in ECG? usually normal or sinus
tachycardia.. ok)
How will you manage this patient if its PE?
Recited the management from OHCS (emergencies). READ THE OHCS EMERGENCIES, very, very important!!
How will you prevent a PE?
Assess Risk factors. Which are..? Said the list from OHCS again.
How will you minimise risks? Alter modifiable risk factors. Elastic stockings.
How do they work? Prevent pooling of blood.

Second Question
Ok, lets change topics. You must've seen a lot of arteritic ischemic optic neuropathies. Yes (Glad discussion is turning to ophthalmology!). They often require long term steroids, so what are the problems of long term steroids? This is commonly asked and it would be good if you learn it well. I think I answered it reasonably well. Halfway through the bell rang and it was the turn of the neurologist.

Third Question
Young man comes to you with 2 month history of headache and you find bilateral disc swellings. What are the possibilities? There was a pretty detailed discussion about papilledema, differential diagnosis and investigations. Discussion finally went into idiopathic intracranial hypertension, its management, when surgery indicated. Surgical modalities. When I said about ventricular shunt, he smiled and asked me the types. Didn't have a clue! Asked about field defects in papilledema and then the bell rang.

There are a few hot topics that you should know. Eg. HIV disease, Thyroid disorders, Hypertension, MS, Emergencies, Pituitary tumours, Other ICSOLs, Demyelinating disorders, GCA, Parkinsonism etc.

The next oral was 1 hour 20 minutes later

The 2nd viva was Ophthalmic surgery and pathology
2 Indian examiners here. Not very friendly and both looked quite irritated. 

Question 1
Started off asking about entropion (Grade 4 entropion, how will you manage?) Muddled through it somehow, because I hadn't done Gr 4 entropions. Asked in detail surgical procedures. 

Question 2
40 year old comes with Fuch's dystrophy and cataract, how will you manage? Management depends on which more severe. Methods of assessing endothelium? Specular microscopy, Ok count below 800 with cataract how will you manage? Combined PK with cataract surgery. Other than PK, modalities? Discussion went up to DLEK (Deep lamellar endothelial keratoplasty) . Have you seen it being done? No,never!  Discussion then went into instruments. Some where straight forward, Kuglen hooks, lens glide, bulldog clamp, different muscle hooks, irrigating vectis, couldnt identify a cannula, didnt look familiar at all! Asked a couple of questions regarding sutures.. then the other examiner took over.

Question 3
Showed a slit lamp photograph of a posterior polar cataract (extremely poor quality!) What are the problems in surgery/symptoms? How will you manage a posterior capsule rupture? Precautions in a ppc? Careful hydro etc. Few questions about anterior vitrectomy. Then, tell me uses of YAG laser in Ophthalmology. Capsulotomy, Iridectomy, Anterior vitreolysis. Detailed questions about PI.
Bell rang and it was over.

Third viva again 1 hour 20 mins later.

1 Brit/1 Indian combination. Ophthalmic medicine.

Question 1
Showed a lot of fundus photographs and FFAs and few questions on each. 1st picture was a hemicentral venous occlusion and pretty detailed discussion on risk factors, risk factors in young patients, management. FFAs were pretty straighforward papilledema, proliferative retinopathy, pre-retinal h'ge etc.

Question 2
30 year old woman comes with increasing prominence of both eyes and some congestion. What would you think of? Said commonest possibility in my practice thyroid ophthalmopathy. Discussion went into systemic manifestations of hyperthyroidism! Hello! General Medicine viva over! Halfway through that the bell rang

Question 3
Other examiner. 30 year old woman comes with redness of one eye and some blurring of vision.(Why this obsession with 30 yr old women?)  Possibilities? In my practice, commonest would be a viral keratitis. Discussed clinical distinguishing features, went into uveitis. Then again showed  few fundus photographs. Macular choroiditis scar. Hypopyon
corneal ulcer. How would you manage? Scrapings/Culture. which media? Drugs used.
Better to have your own protocol on these things. Related our hospital protocol
which is pretty standard. Time was over by then.

Results were out within 10 minutes of the last person's viva. It was pretty good. Only 5 people had failed to make it to the clinicals from my batch.

My clinical examination was one day after.


Carry occluders, your 90D (the ones provided are invariably not clean!), fixation target.

40 minutes. Advised us to see at least 4 patients.
Had 2 Indian examiners.

First Case
An elderly gentleman on the s/l with congested left eye, with corneal edema, deep vascularisation, very hazy view of the iris. ?Was there an AC-IOL? Cornea too hazy to be sure. Could I see the other eye. Clear cornea. Areas of Iris atrophy, pupil irreg, PC-IOL with pitting, Posterior Capsulotomy done. Disscussion went into Bullous keratopathy, PK.

Second case
15 year old boy. On general inspection of anterior segment what do you see? Left esodeviation, apparent enophthalmos, smaller diameter cornea. Can I do squint/motility
No, do slit-lamp first which showed an inferonasal iris defect -  coloboma, zonules also absent there, ant cortical opacity. No phacodonesis. How do you know its coloboma? Site, scarring/atrophy absent
Do a 90 D. Inferonasal retinochoroidal coloboma with dysplastic disc. Ok..
demonstrate the cover tests.

Third case
Elderly gentleman. Do a 90 D on left eye only.
Temporal disc pallor, disc collaterals, occluded veins with sheathing, pigmentary changes.
Possibility? Old Venous occlusion.
Detailed discussion on venous occlusion. Investigations. Differences between

Fourth Case
Middle aged gentleman.
Do an indirect ophthalmoscopy on the left eye.
Fibrovascular membrane from disc to macula, NV adjacent to disc, PRP scars, scattered haemorrhages.
Can I see the other eye? No need, its the same findings.
Proliferative retinopathy. Diabetic. Other possibilities, mentioned a few.
How to manage? Prognosis?
Few questions about vitrectomy, endolaser.

Fifth case
Middle aged lady. Do 90 D of both eyes.
Not a very co-operative patient. Kept blinking and moving her head. Examiners also realised this and told her repeatedly to keep still. Could just see blurred disc margins in both eyes. I think examiners were satisfied with that and asked  about papilledema/pseudopapilledema and benign intracranial hypertension.
Bell rang, my time was up.

The results were put up in the evening and I had passed. Overall the results were pretty good. 22 out of 54 had passed. Its very important to stay cool. The examiners are generally very friendly. The most important fact I think is to practise for the examination both for the
vivas and the clinicals. In the viva, learn how to describe a particular slide or a photograph before jumping into the diagnosis. Practise your examination techniques again and again. All the very best.

Do mail me if you need more info/help.
Dr. Sebastian Mathew.

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