Candidate 59                                                   Centre: Hyderabad
FRCS (Glasgow) Passed                                                     Date: February, 2005
I am Prakash Kumar Jain from Bangalore, India. I appeared in Feb 2005 for FRCS (Glasgow) in Hyderabad. I have cleared it by the grace of God and family prayers (little bit of my hard work too).
First day: clinical case interpretation (morning)
1.A 70 year old lady has priviuosly had complicated  cataract surgery to her right eye with an anteririor chamber implant and corneal decompensation .she now has a brunescent cataract in the left eye causing some shalowing of the anterior chamber and iridodonesis is noted. her vision in counting fingers in right and6/36 in left.she has moderate respiratory disease. What are  your management options and how would you advice the patient?
2. A 50 year old presents with sudden loss of vision in both eyes .He is an insulin dependent but rarely attends the hospital and on examination his visual acquities rae 6/24 right and counting fingers left.there are rubeosis iridis on both sides with some flares in AC and a vitrous haemorhage on the left.The IOOP are 20 mmHg in rt ang 37 in left.
How would you manage the case?
3. A 22 year old woman who has toric contact lenses for 10 years presents to her optician with a 2 month history of transient blurring of vision and headaches. On examination shows vision is good but VF shows enlargement of blind spots with a superotemporal defenc in the left eye. Fundoscopy demonstrates congenital tilting of discs. She is referred to you for an opinion. What are the possible causes of this woman;s symptoms and how would u manage her?
If you read casually the questionslooks easy but I found them to be demanding because time is short and you have to think and write too. Like in diabetic retinopathy care I forgot to mention about NVG and management like diode or cryopexy or glaucoma surgery like valve implant etc.
Another mistake was the question on scotoma (was in one eye) but  I read it as in both eye  so I wrote down refractive scotoma in my differential diagnosis.

Afternoon MCQ
Ophthalmology related questions were easy but medical MCQs were tough. Questions about  atrial fibrillation, Friedrichs ataxia, DM, thyrotoxicosis, pulmonary embolism, SLE, PAN etc.
I will advice reading the whole of Kanski but in particular the chapter on systemic diseases.  Harrison's Principle of medicine is also useful because some information may come in useful for the viva.
1 day break before viva
Ophthalmic Medicine

Indian examiner 
The viva began with a clinical scenario of  a patient with watering eye and photophobia secondary to corneal abrasion. He was treated with antibiotic ointment,cycloplegic and patching. 3 hours later the patient called up to say he has a severe pain in the treated eye. What may be the cause?
I answered probably developed infective  keratitis, he said that is too soon  and disagreed. The answer he was after which I gave was acute angle closure glaucoma caused by mydriatic.Questions on management (including the side-effects of timolol and mannitol)
Next question was about dry eye, questions on diagnosis. How to perform tear break up time and Schirmer's test.
British examiner
Shown picture, a case of clinically significant macular oedema in a diabeticc. Questions on treatment. Was asked what happens after laser and how oedema and hard exudates disapear. I mentioned phagocytosis by astrocyte or microglia.  I dont remember the exact mechanisms but he agreed and appeared happy.
Photo of central serous retinopathy. Asked about treatment. What are the findings on FFA and how you treat this? 

Photo showed retinitinis pigmentosa.
General Medicine

Indian examiner
Showed hand of rheumatoid arthritis. D/D  and what are the differences between arthritis of RA and SLE, investigations of RA, SLE (percentage of positive  titres).What is the histological diff between synovial fluid of RA and SLE ( Iwas getting more irritated than nervous) but i told coolly U dont know sir for the first time in this exam). Then ask to treat  RA , I mentioned that I  will refer to rheaumatologist, but the examiner insisted and wanted to mention 1st line,2nd line etc. Then about steroid dose, side post menopausal woman which complication you will look for osteoporosis, he gave a big smile and told exactly.
British examiner 
Began with a clinical case: During retrobulbar block the patinet suddenly became distressed , what might have happenen, I mentioned intracranial extention of anaesthesia leading to respiratory distrees. He was happy. How would you manage this patient. I mentioned shouting for help, CPR, and intubation. I also mentioned  respiratory stimulant like doxapram can be tried (by thier reaction i could guess they had no idea about doxapram).Both were very happy . Bell rang
Ophthalmic surgery and pathology
One eye 6/6 without cataract and another eye has poor vision with cataract. The refraction was -11.00D in each eye.  How would I advise the patient? I mentioned the use of contact lens, monovision etc. but he was not happy and the question went on for a long time. 
Entropion photo. Questions on management. What is double brace technique? I mentioned vertical incision of orbicularis oris and overlap themhorizontally. I was not sure if I got this right as there was no responses from him.


Clinical cases

Case 1
Bullous keratopathy with AC IOL-asked  possible mechanisms. 

Case 2
Atypical toxoplasmosis(active choroiditis involving macula). Investigations, toxoplasma titures and  HIV etc. Questions on medical management..
Case 3
90D lens. Very old man, uncoperative I could see thick hemorhage at macula, I gave a differential diagnosis of choroidal neovascular membrane. Questions on investigations with FFA, ICG, differences between classic and occult CNVM, PDT.
Case 4
Pupillary examination. I asked for the room to be darkened which the examiner did and passed  torch. There was no anisocoria but there is a RAPD. Fundoscopy revealed optic atrophy. Asked what I would do next, I mentioned checking the IOP and performs visual field. The examiner asked me to do the visual field, the patient was not able to fixate his eye but the examination revealed only temporal island of visual field. 

Case 5
Small girl running here and there not opening her eyes, she appeared to have hazy cornea., Asked about the diagnosis and I gave a list of D/D for hazy cornea. Asked about managemnet: EUA,systemic evaluation, surgery if  glaucoma etc etc.

Case 6
Bilateral obliteration of  the infeior fornix. Asked about diagnosis.I said I would like to take a history about drug use, asked for previous signs of Steven-Johnson's syndrome, look for signs associated with ocular cicatrical pemphigoid. i will take biopsy and mx accordingly.

Case 7
Last case:  perform cover uncover test. 
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