Written exam:

1. A 13-year-old girl was brought to your clinic by her mother complaining of        reduced vision. Visual acuities are 6/18 in both eyes, reading N8 unaided. Her parents have just been divorced. How would you manage this patient and what investigations may be appropriate? 

My answer plan was:
 (1)Hysterical, but I should exclude other causes of diminution of visual acuity in children as (2) Gross ocular abnormality e.g. cataract, glaucoma (3)Normal looking eye without nystagmus e.g. ametropia (4)Normal looking eye with nystagmus e.g. optic nerve or macular hypoplasia, macular or photoreceptor diseases.

2. A 55-year-old man who works as an engineer has attended the eye clinic previously with latent angle closure glaucoma and has bilateral peripheral iridotomies performed. His refraction is +7.5DS in the right eye and +8.00DS in the left. On this occasion vision is reduced to 6/12 in each eye because of cataract. What potential risks would you perceive with this patient and how would you manage this cataract?

My answer paln was:
We have two problems which should be managed simultaneously according to severity of each one, through detailed history and examination then discussing with the patients the ways of managements.
Problems of dilatation, Iol calculating, shallow AC?

3.      A 33-vear-old woman has been aware of a degree of left-sided proptosis for several months. She presents to your clinic with a 1-week history of pain and redness in the left eve. Reduced vision and an apparent corneal ulcer. 
Explain the possible causes of this patient's symptoms and  how you would manage her? 

My answer plan  was:
The corneal ulcer may be related to the proptosis (Exposure) or not (most dangerous is infectious or most common is traumatic).
The most common cause of proptosis here is thyroid eye disease and the most dangerous is malignant tumor infiltration of the orbit. But you have to mention other differential diagnosis of proptosis.
 

General medicine: 

The first professor asked me about 70 years old male patient in the word, got a surgery 2 days ago, complaining of chest pain (How do u manage this patient?), my answer was that, I'll call for help and check ABC then I have to exclude life threatening conditions pulmonary embolism and myocardial infarction, by rapid history, examination (do not forget to look for DVT at lower leg) and ECG. Then he asked me about criteria of the pain of pulmonary embolism (pleuretic) and myocardial infarction (retrosternal radiating to left shoulder). Then he asked what the changes of ECG in acute myocardial infarction are? (Raised ST segment). Can you know which part of the heart affected by the ECG? (If V1, 2, 3 anteroseptal, if V1-6 extensive inferior……) So if u diagnosed pulmonary embolism and the physician is not available what will u do? (IV morphine 10mg, 5000 u IV bolus heparin).
Then he changed to another question: While a patient was taking IV …. Got loss of consciousness after injection, how do u manage? (Call for help then I'll check the carotid pulse rapidly if no pulse I'll start CPR if there is pulse: Most probably it is anaphylactic shock so I'll check ABC…………
Then he asked me; what are the ocular features of diabetic retinopathy? …………

The second professor: You  have a 60 years old patient in your clinic complaining of diplopia so what will u ask him to know the cause of diplopia ?(uniocular or binocular, if binocular: horizontal or vertical, more for near or for far. At which direction it increases) Then he gave me a Hess chart of and asked me what this is? What is your diagnosis? (………Superior oblique palsy. What are the possible causes of superior oblique palsy in this patient? (Mediacal causes e.g. DM, hypertension, GCA). IF you suspect GCA how do u manage? (I answered in detail). Then he asked how u can differentiate between congenital and acquired superior oblique palsy?..................   If the patient is diabetic how do u investigate for diabetes in your clinic with a simple rapid test? (………..He wanted to hear urine analysis!).
 

Ophthalmic Surgery: 

The first professor: drew a picture of a pterygium reaching near to the papillary border and asked me about the management? (I have to individualize the patient: age, VA, BCVA, visual needs of the patient, if cosmetically annoying the patient, then I'll manage accordingly……………..) Then he asked me how u will close the bare area? (In our center we use amniotic membrane transplantation) Do you know other methods to prevent requrrences? (Bare area technique with suturing of the edges, conjunctival graft, beta radiation, laser, mitomycin). What is the dose and time of aplication of mitomycin? What is the mechanism and precaution with applications? (Answer in detail).

Then he showed me on his laptop, a color photograph of a large upper temporal tear, associated with subclinical RD and asked me how do u manage? (Should be managed prophylatically without delay as it may progress to clinical RD with involvement of the macula, so I'll send him to our vitreoretinal consultant for photocoagulation or cryotherapy)

Then he gave me a refraction (0 / + 4.0 * 60) this patient asks for refractive surgery? (LASIK)  Another method? (I don't know).

If you got posterior capsule rupture while you arte doing extracapsular cataract extraction, how do u manage? (Answer in detail).

The second professor: showed me a photo of 2 months old baby with upper eye lid defect and asked what this is? (Upper eye lid coloboma).  How do you manage? (Repair of the lid defect in detail).

Then showed me a photo of an eye with rejected graft of PKP. Why this patient got a PKP surgery? (The iris picture was suggestive of trauma so most probably leucoma). What are other indications for PKP? (Answer in detail). The graft was closed with interrupted sutures, he asked me why do u think the surgeon use these interrupted sutures? (Better control of astigmatism, easier for him). When the surgeon can remove the sutures? (9-12 months). 
What is the cause of this graft failure? (Endothelial rejection as there is Khodadoust lines; it was obvious in the picture,).

He showed me also a photograph of patient with lower eyelid involutional enteropion.  What is the pathogenesis of involutional enteropion? (Answer in detail). How do you treat this patient? (Weiss procedure). What is Weiss procedure? (Just the idea of this procedure).
Picture of whitish raised subretinal mass. What is this? (I'll consider this amelanotic melanoma until proved otherwise). How do manage this case? (Answer in detail).
 

Ophthalmic medicine

The first professor:  First question was a surprise to me: What are the diseases of RPE? (…………, Best disease), Tell me what do u know about Best disease? (Stages are…... EOG is subnormal during all stages but ERG is normal). How do u do EOG & ERG? What is the Arden ratio?!. What is the inheritance of Best disease? (AD).

What is retinitis Pigmentosa? (It is diffuse retinal dystrophy mainly affecting rods). What are the stages of RP? (Arteriolar attenuation, RP sin pigmento, Retinitis punctata albescens, bone specules,waxy disc)what is the pathology of bone specules?! Can RP be treatable? (Yes), how come? (As in Refsume disease: plasmapharesis and phytanic acid free diet. And in Bassen-Korenezweig: with vitamin E).Tell me about the pathology of one of systemic association of RP? (Kearn-Sayre: Red Ragged muscles).

You are in the clinic and a child came to you complaining of arthritis without ocular complaint. What do you expect to see in his eye? (He is most probably JIA and has anterior uveitis). If you find flare and cells but the patient doesn't complain, are you going to treat him? (Yes) Why? (For fear of complication e.g. glaucoma).
Then he showed me a picture of hand with Rheumatoid arthritis and the bell rang.

The second professor: showed me a photo of a hand with to nodules, and asked me what do u think that this patient has in his eye? (Glaucomatous uveities). What are these nodules could be? (Sarcoidosis, when he showed me the face of the patient so I said rapidly it is neurofibromatosis). So what could be the ocular features of this patient? (Answer in detail……. Till said choroidal nevus) then he asked why this disease is associated with the choroidal nevus? (Cause it is phacomatosis). What is the mechanism of glaucoma in this disease? (Answer in detail).
Then he showed me a photo of young patient about 20 years old with left proptosis and dystopia to the left, with conjunctival chemosis, and asked me what your differential diagnosis is? (Answer in detail).
Then he showed me a photo with old female patient with skin rash in the forehead, what is your possible diagnosis? (Herpes zoster ophthalmicus), then the discussion run with the treatment of this disease.
 

The clinical exam:  (two English examiners)

In this examination do what you use to do in your practice and let the examiner feel that you are practising as  in your clinic and not just for the examination.
I asked the examiners to introduce myself to the patients and asked their permission for examination, he said that they already agreed. He asked me to translate the conversation between me and the patients as he ddidn't speak Arabic.

Case 1 
Examination of posterior segment with 78 D lens of an old patient. He had only myopic fundus, he asked me about the periphery (the pupil was mid dilated, so can't see the periphery well) what do you expect (lattice, may be holes). What are complications of cataract surgery with this patient (including anisometropia)?

Case 2 
Cover and uncover of young patient. I started with examination of  VA in the right eye he couldn't see my fingers, so I could not do it, then the examiner asked me to do it with pen torch, then when I asked he patient can youu see the light he said no ( it was a surprise to me) so I can't do it even with pen torch.
Then he asked me to examine the fundus with an indirect ophthalmoscope: right eye had a pigmentary retinopathy but left was normal. Then the discussion runs with possible causes of unilateral pigmentary retinopathy of his patient.

Case 3 
Cover and uncover, then ocular motility, then papillary reflex of a 10-year-old boy, at the end of examination he had right congenital superior oblique palsy and left sensory exotropia.

Case 4
Anterior segment examination of a patient, had right keratoconus with central opacity, and left PKP with AC IOL. I asked the examiner to evert the lid and examine the fundus, he asked me why but did not let me do it. Then the discussion runs with the cause of AC IOL implantation of this patient, and cause of central opacity in the other eye (including acute hydropes).

Case 5
Examine this patient; she had bilateral irregular posterior lid margin, crocodile shagreen, nuclear cataract grade III, diabetic retinopathy…..

Case 6 
Examine fundus of about 25 years old female; she had bilateral cone dystrophy. The examiner asked me about my differential diagnosis, what investigation I'd like to do.

Case 7
Patient with unilateral central leucoma non-adherent. In about 60 years old male. What are the possible causes in this patient? And how do u differentiate by your examination?
Then the bill rang while he 8th case is sitting down.

Thanks a lot to ALLAH that I passed from the first attempt. It will give me much pleasure to provide the hand of help to any candidate for FRCS or any ophthalmological exam. My email address is tageldin1973@yahoo.com