|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
exam centre. Mine was at Sir Ganga Ram Hospital at Rajinder Nagar,
understand that's where the exam usually is. There are plenty of hotels
this hospital which are reasonably priced and offering reasonable creature
comforts. It takes a long time to cover distances in Delhi and you
enough things to worry about during the exam besides getting to your
Study advice: Get someone to practice examination techniques with you.
one area where most people who reach the clinicals lose out on. The
assess the 'slickness' with which you do your examination and if it
be slow and laboured, you might be in trouble. Get one of your colleagues
watch you objectively while you make your examination of different
ask him/her to give you a critical appraisal. Examination techniques
especially important for squint, motility disorders, neuro-ophthal.
your 90D and Indirect Ophthalmoscopy well, so that you don't waste
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
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
vivas the very next day. The 2nd batch had it one day later. Its better
finish your exam off first. Its waiting what makes one tense!
3 sessions here. 20 minutes each with two examiners who take 10-minute
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
Had one British and one Indian examiner. The British examiner began.
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
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
How do they work? Prevent pooling of blood.
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.
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.
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.
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.
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.
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
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
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?
Better to have your own protocol on these things. Related our hospital
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 clinical examination was one day after.
Carry occluders, your 90D (the ones provided are invariably not clean!),
40 minutes. Advised us to see at least 4 patients.
Had 2 Indian examiners.
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.
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.
demonstrate the cover tests.
Elderly gentleman. Do a 90 D on left eye only.
Temporal disc pallor, disc collaterals, occluded veins with sheathing,
Possibility? Old Venous occlusion.
Detailed discussion on venous occlusion. Investigations. Differences
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
How to manage? Prognosis?
Few questions about vitrectomy, endolaser.
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
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.