|My name is Dr. Khalifa
Mohamed Ali and I am from Libya. I passed the FRCS (Glasgow) part B examination
held in September 2006 (New Delhi). I like to thank my family especially
my family and wife for their support. The examiners were helpful
and asked logical questions. I found this web site to be extremely
useful for preparation. Last but not least I like to thank Dr. Hussin Soilam
VERY MUCH for his valuable assistance.
Here is my experience of the examination
Viva 1: Ophthalmic Medicine
( Professor Mohan + a British Examiner)
Question 1 ( Professor Mohan)
I was given a visual field and asked to
comment on it? I looked at the reliability indices which were reliable
and told him it was a reliable Humphrey visual field of the left eye using
the central 24-2 threshold test. The field showed paracentral scotoma with
a median deviation of 28 (severe reduction in the retinal sensitivity).
He asked why I thought the field was reliable. and asked the upper limit
of the percentage of fixation loss, of false positive as well as
of false negative in deciding the field relaibility? I answered it should
not exceeds 20%, 33%, 33%. Then asked about the differential diagnoses
of this field ie. paracentral scotoma.
Question 2 (Professor
Coloured photos of one eye + FFA of proliferative
retinopathy with tractional RD and laser marks. Asked to comment on the
picture and give a differential diagnosis. He asked about management so
I said I like to find out how the other eye was like. He said the other
eye has proliferative changes but no traction. I said I will perform laser
(PRP) to the contralateral eye. As the eye he showed me had TRD (tractional
retinal detachment) involving the macula I will counsel the patient about
undergoing par plana vitrectomy and the prognosis. He gave me a paper and
asked me to show him how I would perform laser photocoagulation. This was
followed by discussions of complications associated with laser photocoagulation.
He asked how I would perform the laser to ensure that this patient does
not have visual field defect which may interfere with his driving.
I said I will leave spaces on the horizontal meridian (do not laser),
toward the nasal region (nasal to the optic disc) as well as temporal region
(over all more than 120 degree on the horizontal meridian) and 20 degree
up and down. Finally asked about the classification of diabetic retinopathy.
Question 3 (The British Professor)
A mother brings a 6-month old child to
your out-patient clinic and is concerned that the baby cannot see. How
would I proceed? I started with the history: beginning with
pregnancy like rashes to exclude maternal infection, diabetes mellitus
or drug use during pregnancy. History of prematurity and normal development
and growth. Then examination; look for nystagmus, ability to fixate on
an object with each eye separately. He asked me how to examine visual
acuity to this child. He asked me in details about every test (How to do).
Then I said torch examination of the ant segment for corneal opacity, cong
cataract, pupil reaction. Aniridia or microphthalmus (PHPV). Fundus exam
to exclude ROP, optic nerve atrophy or hypoplasia, leber cong amaurosis
(+ ERG). Cycloplegic refraction to exclude extreme refractive error. CT
scan or MRI of brain in cases of optic atrophy to rule out brain tumors
and evidence of trauma or hydrocephalus. If every thing is normal it might
be delayed maturation of the visual system takes up to 12 months.
Question 4 (The British Professor)
Coloured photographs of two eyes and FFAs
showing ARMD of the wet type in both eyes. Asked about differential
diagnosis? What are the latest modality of treatment of wet age-related
macular degeneration. I mentioned intravitreal
injections of nnti-vascular endothelial growth factor (Anti-VEGF such as
a vastin, macugen). The professor asked about the mechanism
of action of photodynamic therapy and the precautions when giving it.
Photos of two eyes and FFAs of 30 year-old male patient showing a right
subfoveal CNV with dysplastic optic disc. Left multiple parafoveal chorioretinal
scars. However, there were no myopic changes in the fundus.Asked about
the diagnosis; I started with histoplasmosis, the examiner said the patient
is not an American. Then I said PIC (puntacte inner choriodopathy) but
qualified it by saying that the patient is commoner in myopic females.
Then I mentioned AMPPPE. The examiner was not happy with my answers and
I was not happy either.
Then he asked about management. I said
I will repeat the FFA and then I will treat the right eye accordingly depedning
if the CNV is subfoveal, juxta or extrafoveal.
Then what I was looking for the bell rang
VIVA 2: General Medicine and Neurology
Scottish Professor and an Indian Professor)
1 (The Scottish Professor)
picture of 50 year-old male whose forehead had red lesions. The examiner
gave me the history of headache and sudden visual loss. I answered giant
cell arteritis (GCA) and the reasons of either AION or CRAO. Then
showed the picture of the optic disc which was typical of AION with oedematous
optic disc with splinter haemorrhages. Asked about management and how long
would I give steroid for? I mentioned the treatment will be dependenet
on the level of ESR and usually takes one to two years. I also mentioned
that I would perform steroid work up prior to starting steroid? Asked how
I would do this. Asked about management of osteoporosis: I mentioned calcium
supplement. Asked about peptic ulcer: H2 blocker. (ranitidine).
Other complications associated with steroids Asked why you give mega dose?
I said in order to protect the other eye and not for the treatment of the
Question 2 (
The Scottish Professor)
a picture of a pale optic disc (primary optic atrophy). Given the history:
the disc belonged to a 30 year-old female and the other eye is perfectly
normal. I said primary ON atrophy either due to optic neuritis, compressive
lesions or nutritional causes. Asked what I know about nutritional
causes of optic atrophy? Then how to exclude compressive lesion. I said
ultrasound, CT and MRI of the orbit. Then shown CT scan of axial
section of the brain and orbit. I looked at the picture which was tricky.
A very small meningioma of the optic nerve in the orbit (tram track sign).
Followed by management.
3 ( The Scottish Professor)
young patient in the post-operative period complained of breathlessness.
What are the possibilities? Discussion went into management of acute severe
asthma and pulmonary embolism (including clinical signs and findings on
investigations and management in details).
Question 4 (Indian professor)
Given a scenario. You were on call and
the physician in the medical department called you to see a 50 year-old
patient presents with severe headache, dilated pupil, ptosis and out ward
deviation of the right eye. What conditions can you think of? Mentioned
third nerve palsy and most likely a cerebral aneurysm. Discussion went
into diagnosis and treatment. Then asked about the latest modality of treatment.
I mentioned intervention radiology with catheter and coils. The examiner
was happy. Then what I was looking for the bell rang
VIVA 3: Ophthalmic Surgery &
(The English professor and an Indian professor)
a picture of of flat bleb with positive Seidle's test. The patient was
second day post-trabeculectomy. Asked about detailed management of this
condition.This was followed by a picture of blebitis. Asked about maangement
including organisms and belb-related endophthalmitis.
What are the factors that lead to involutional
entropion. How would I manage a case of involutional entropion. Given a
paper to illustrate how I would perform a lateral tarsal strip procedure.
Asked to describe in details how to carry
a dacryocystorhinostomy (DCR).
scenario. A patient with pseudoexofliation presented with phacodonesis
and cataract and poor pupil dilatation. What would I approach the case.
I began with vision assessment, IOP measurement, try to dilate with tropicamide
and phenylephrine in order to assess the amount of subluxation. The examiner
interrupted me and said the pupil does not dilate. I said I would counsel
the patient about the operation and we might do phaco with or without tension
ring or ICCE + AC IOL depending on the amount of subluxation after inserting
iris hooks. Asked precautions during phacoemulsification of this
precautions you should consider in patients with sickle cell anaemia
and retinal detachment. I mentioned I would perform vitrectomy because
of chances of getting anterior segment ischemia after buckling. Also hypoxia
is dangerous during and immediately after the surgery, give oxygen and
the anaesthetist informed in advance.
of primary vitrectomy in rhegmatogenous retinal detachment. Indication
for subretinal fluid drainage. Asked about different types of temponades
ie. silicone oil, gas etc and their durations and complications
Then happy moment I was looking for: THE
Mohan and a British Professor)
Slit lamp examination of a middle aged
female with vacularised leukoma adherent to the right iris. I was questioned
about the possible causes and management. This was conducted by Profssor
Slit lamp examination of a 16 year-old
girl with phthisical bulbi of one eye with band keratopathy and iridodialysis.
Questions on possible causes and management.
Again conducted by Professor Mohan.
A 14 year-old bespectacled boy. Professor
Mohan asked me to perform cover test
and ocular motility.
The boy was orthophoric for near and far
with glasses but had alternating exotropia of about 15 degree for far without
glasses. The ocular motility was normal. My diagnosis was alternating exotropia
of about 15 degree caused by divergence excess that is correctable with
glasses. Asked about the management of this patient. I said glasses as
the tropia was controlled with them.
The British professor asked me to look
at the fundus of a young girl with bilateral secondary optic atrophy and
a left exotropia measuring 45 degrees.
Asked why did I say secondary and not
primary optic atrophy. I answered, and then he asked what are the causes
and management of each one.
Indirect slit lamp biomicroscopy examination
(+90 D) of a middle aged man without a history of diabetes mellitus. The
right eye showed proliferative retinopathy with equatorial neovascularisations
and vitreous haemorrhage. The left fundus was perfectly normal. I described
every single detail seen. The British professor asked about the diagnosis.
I said this might be CRVO of the ischemic type or sickle cell anaemia or
even sacrcodosis. He asked me about the causes of CRVO taking into account
the age of this patient and how to manage the condition. The British professor
was not happy with my answers and I was not too happy either after this
Indirect ophthalmoscopy of a young girl
that showed a huge left posterior coloboma involving the whole nasal retina
up to the ora serrata. Questions about systemic associationsand aslo questions
on precaution with regard to the retina. I mentioned prophylactic laser
to areas surrounding the coloboma to prevent retinal detachment.
A young boy of about 15 year-old with
left complete ptosis. The Professor asked me to perform eyelid examination.
There were complete ptosis, dilated pupil and exotropia with intact intorsion.
I diagnosed isolated surgical third nerve palsy. The examiner was happy
and so was I as the bell rang at the same time.
My e-mail is: firstname.lastname@example.org.
Please contact me if you require any help.