Final FRCS Date: March, 2006
|I am Dr Swadique. My email is email@example.com.
16 candidates passed out of 65.
This website and the books mentioned in this site helped me a lot. One thing I have noticed is that time is very precious in viva as well as clinicals, the more questions you get the better it is for you. So don't waste time on questions of which you don't know the answer. Admit that you don't know, quickly they will go to the next question. Nobody is expected to know everything. If you keep on trying to answer the things which you don't know, you are loosing your time.
Many highly prepared candidates failed in the problem solving written exam. Don't jump into writing the answer straight away. Take 10 minutes for thinking & formulating each answer before you start writing, and in next 30 minutes finish off writing that answer. ( ie. allow 40 minutes for each answer. Each word in the question is important, there may be many tricky points hidden, carefully read the question & underline the key points. Prof. Muthussamy's training was very helpful in problem solving. He can be contacted by e mail firstname.lastname@example.org or www.mvupgo.org (his web site).
Clinical case interpretations ( Problem Solving questions )
1. A 32 year old man has a 10 year history of ankylosing spondilitis and associated uncontrolled chronic anterior segment inflammation. He attends your clinic with vision reduced to 6/24 right & 6/36 left and he has developed secondary cataracts with band keratopathy in both eyes. The intra ocular pressure is raised in each eye and he is having difficulty continuing his work as a manager in a warehouse. Discuss the short and long term management of this patient.
2. A 15 year old boy presents with head ache and swelling of his left upper lid. His vision is reduced in the left eye and there is some restriction of eye movement. Discuss how you would manage him and how you would explain the conditions and risks to the parents.
3. A 70 year old lady presents with the recent onset of reduced vision
in both eyes. On examination visual acuities are counting fingers bilaterally
and the right eye has a disciform macular scar ( less than 2 disc
diameter in size ). On the left side there is a large sub macular haemorrhage.
The patient has heard that there may be surgery available for macular degeneration.
How would you advice and manage the patient ?
Surgery & Pathology
(2) S/L photo showing AC IOL & corneal odema. Possibilities ? endothelial decompensation due to AC IOL. How to manage ? Topical hyperosmotics / stromal puncture / Bandage CL / PKP. How do you do a PKP ? 0.25 mm larger donor corneal button, 4 cardinal sutures, fill in the quadrants with interrupted sutures. What are the advantages & disadvantages of continuous / interrupted sutures ? What are the other forms of keratoplasties ? LK / DLK / DSEK.
(3) S/L photo. Pseudo exfoliation material at pupillary border. What are the difficulties in cataract surgery ? Poor pupillary dilatation / Zonular dialysis. How to manage ? Endo capsular ring.
(4) S/L photo showing post op endophthalmitis. Treatment? Choice of
antibiotics, indications of vitrectomy. Is steroid indicated ? when ?
(2) What are the lasers used in Ophthalmology & its uses 532
Green laser PRP, grid & focal Red diode laser TTT YAG Iridotomy
/ capsulotomy PDT laser - CNVM
(3) Lap Top photo Color fundus picture choroidal melanoma. Pathology, cell types, prognosis, treatment modalities.
( 4) Lap top photo Large swelling in upper lid differential diagnosis, surgical options if you suspect malignancy excision with lid sharing procedures.
(5) BCC involving full length of lower lid management ? Excision with
3 mm clear margin, frozen section / Mohs micrographic surgery , Lid reconstruction
by Mustarde cheek rotation technique.
(2) Lap top FFA of LE showing BRVO. Findings on FFA ? Indications of Laser ? BRVO study.
(3) Lap top Colour fundus photo of CRVO. Findings ? DD ? How to differentiate ischemic & non ischemic CRVO clinically ? RAPD, profound visual loss, extensive cotton wool spots & hemorrhages in ischemic CRVO. FFA picture of CRVO describe the findings,? What are the indications of laser in CRVO ? CRVO study.
(4) Lap Top S/L photograph, fluorescein stained with blue filter few stained spots, possibility ? Dry eye syndrome. How to confirm ? Schirmers test, Tear film break up time, Lissamine Green. Treatment ? Artificial tear drops, punctum plugging, cyclosporine eye drops. Mechanism of action of cyclosporine ? T cell modulation.
(2) Which is the commonest cranial nerve palsy in the eye ? 6th nerve palsy. What are the common causes in old age ? Diabetes & HT. Commonest cause in young ? MS. How to diagnose MS ? MRI, periventricular plaques. Clinical investigation for MS ? LP
(3) What is immuno compromised status ? examples ? AIDS, Medically induced immuno compromisation after organ transplant. What are AIDS manifestations ? listed. Can chicken pox & HZO occur together ? never occur in individuals with normal immunity. But can occur in severely immuno compromised patients. Prognosis? Very poor
(4)What is primary Sjogrens syndrome ?
(5) Systemic effects of topical beta blockers.
General Medicine & Neurology
( 1) Sudden epistaxis causes ? Bleeding disorders, anti coagulant therapy heparin / warfarin, nose picking habit, hypertension. How to investigate ? PT , PTT . What emergency treatment ? pinching the nose, sitting with stooping forward position to avoid aspiration, Inj vitamin K, Platelet transfusion, blood transfusion
(2) Diabetes Mellitus What is the use of glycoselated Hb ? to assess long term bood sugar control. Normal range ? Complications of diabetes mellitus ? Neuropathy, Nephropathy, Retinopathy, Keto acidosis, Non ketotic hyperosmolar coma, Hypoglycemic coma. Classification of anti diabetic drugs.
(3) Old man had unconsciousness and loss of vision but recovered quickly, what could it be ? TIA. Difference between TIA & stroke ?
(4) Old lady in menoposal age group complains of body pain . cause ? Osteo porosis. Treatment ? Calcium & hormones,
(5) Complications of FFA ? Nausea & vomiting, extravasations of dye, Syncope, Anaphylaxis. Management of anaphylaxis ? Airway, O2, Adrenalin 0.5mg IM, IV line, Hydrocortisone 200 mg IV, Chlorpheneramine 10 mg IV, Call physician / Anesthetist, endotracheal intubation if needed.
(6) Patient with bitemporal hemi anopia cause ? Pitutary tumor, How to investigate ? MRI, CT.
(7) Steroid therapy Indications, Contra Indications, Complications.
(8) AIDS Definition, Systemic Manifestations, ocular manifestations, Treatment.
(9) Congenital eye infections- Toxoplasma, CMV, Herpes, Syphilis, HIV.
(10) Angina Symptoms, investigations & treatment. Tread mill test,
Unstable angina ?
(11) Bacterial endocarditis. Causes, Symptoms, signs, investigations,
Clinical Examination ( Southern General Hospital, Govan Road, Glasgow)
(1) Pigment Dispersion Syndrome (S/L) iris trans illumination defect & endothelial dusting present.
(2) AC IOL. What are the complications ? endothelial decompensation , pupillary block glaucoma.
(3) Thyroid Ophthalmopathy. Patient had exophthalmos, exotropia, diplopia, restricted elevation. What you will look for ? Exposure keratopathy, optic nerve compression ( vision, color vision, field , disc) , thyroid status ( pulse, warmth, tremor, bruit over thyroid, acropachy, pre tibial myxoedema ) Asked me to demonstrate the ocular motility examination. I did versions, convergence, saccades, cover test for near and 6 meter distance.
(4) RD Repaired with buckling. I was asked to do indirect with 20 D lens. There was cryo mark and buckle indentation.
(5) Fuchs Heterochromic Uveitis with Pseudophakia. S/L
(6) Choroidal Nevus. How to differentiate from choroidal melanoma ? elevation, surface, associated RD. What investigation you do ? B Scan, FFA, ICG.
(7) Plexiform Neurofibroma of upper lid (post surgery). Patient had
ptosis, scar on lid, Cafe au lait spot on hands, a few fibroma molluscum
on neck. Leisch nodules.
FRCS Ophthalmology Part B Sample Questions
1. In a patient who suddenly becomes unconscious:-
A Examination to determine the cause of the unconsciousness is the first
2. Nerve fibre bundle defect can occur in patients with:-
A Drusen in the optic nerve head
3. Dystrophia myotonica:-
A Is inherited as a recessive trait
4. The following are typical of Coat's disease:-
A Areas of capillary non-perfusion on fluoresce in angiography
5. Extracapsular cataract extraction is contraindicated in:-
A Subluxation of the crystalline lens
6. Neurology in relation to ophthalmology:-
A Bitemporal hemianopic field defects occur in the presence of normal
Problem Solving Paper
Please find below some past paper questions including for the final question a specimen answer:
1. A 17-year-old girl is referred to your clinic with a history of increasing prominence of her right eye. Her general health is good. Describe how you would investigate and manage this case.
2. An 80-year-old lady attends your clinic with a complaint of gradual vision reduction. She describes the problem as being greater for close vision rather than distance vision. She wishes to continue to drive. Describe how you would deal with this case.
3. A 42-year-old metal worker attends the clinic with a history of the recent awareness of substandard vision with his left eye. There is evidence of an afferent pupillary defect. How would you investigate and manage this case?
4. A 60-year-old lady complains of visual reduction for the last year. She works as a secretary and now has difficulty seeing her VDU screen. There is a history of myopia and she previously had successful surgery in both eyes for a retinal detachment 5 years before. On examination she appears to be developing cataracts in both eyes. Discuss the risks and benefits of treatment giving your preferred options and the reasons for your choice.
5. A 21-year-old apprentice decorator is assaulted and has a finger poked into his left eye. The following day he presents with slight epistaxis and dipopia on down gaze. Describe your management of this case.
6. You are asked to see a 35-year-old mother of two children who has
a history of ocular toxoplasmosis. On this occasion she is 20 weeks
pregnant and gives a history of distortion and blurring in the left eye.
Discuss the possible causes of her visual symptoms and how you would proceed
with the management.
Specimen Answer to Question 6
A. Differential Diagnosis: Most likely recurrent
History: nature of blurring, duration, onset, severity, intermittent or constant. Associated symptoms; pain, redness, photophobia, floaters, similar to previous episodes of toxoplasmosis. Systemic symptoms; general health, pregnancy, fever, weight loss, chest infection, renal problems.
Examination: VA in both eyes, Anterior segments for uveitis, conj injection, IOP, Pupils, lens, vitreous cells and debris, retinal appearance for active toxoplasmosis lesions or old scars, or any of the features mentioned in the D.Diagnosis, involvement of disc or macula and position of focus of inflammation.
Investigations: If toxo, probably need few investigations apart from baseline bloods (FBC, ESR, Glucose, U&E and LFTs). If other causes may need retinal photography and FA but caution as pregnant and some risk to foetus unless FA absolutely essential and diagnosis not possible with slit-lamp fundus exam. Perhaps orbital U/S if poor view of fundus to exclude detachment/solid lesion. Systemic investigations as indicated by history e.g.?CXR if chest infection, other sources of uveitis.
Treatment: decide if treatment is absolutely necessary for toxoplasmosis. Discuss the pros and cons of treatment or not of this condition in pregnant woman: if vision still not too bad and disc and macula not threatened then better not to treat. If vision likely to be permanently affected then need to discuss with obstetrician and pharmacist the best form of treatment.
Treatment: antibiotics; Azithromycin, pyrimethamine + vitamin supplements. Systemic steroids; again risk v benefit in pregnancy, probably safe to give in 2nd trimester if absolutely necessary, but discuss with obstetrician before starting. Topical steroids; safe to give but probably of little help unless anterior Uveitis
Follow-up: monitor closely till condition settles or until side effects with treatment require discontinuation, probably seeing every 1-2 weeks at clinic.
Other Conditions: Almost all of the other D.Diagnosiss should merely be monitored till baby delivered and then appropriate investigations performed and treatment instituted. Only exception would be retinal detachment, which would require surgery to repair more promptly.