My name is Khalid Ghaith; I passed the exam in Muscat, December 2008 from the first time (Thanks GOD). I'd like to thank my Family, my friends for their kind support during these days before and during this examination, I'd also like to express my deepest appreciation for consultant Dr. Ahmed Reda who organized my knowledge and give me the most important tips during the different stages of the exam.


First Day: Written exam 30/11/2008, 9:30-11:30 am

1. A 40 year old lady is seen in your clinic with a history of intermittent pain, redness and watering of the left eye for 60months, occurring particularly night. During the last attack 5 days ago, the vision in the eye had become blurred and she had been aware of colored haloes. On examination acuities were 6/6 with refraction and both eyes were quiet with normal intraocular pressures.

What are the possible differential diagnoses and how would you investigate and treat this patient?

2. A 25-year-old female patient is myopic and has always had reduced vision in the left eye. Her best corrected vision is 6/6 right with -4.00 DS and 6/60 left with -7.50 DS. She usually only wears a soft contact lens in her right eye. Two days before her wedding she is referred to your clinic with pain and redness in her right eye and an obvious corneal opacity.

How would investigate and manage this case?

3. A 75-year-old lady who is carer for her invalid husband presents with sudden loss of vision in the right eye with the left having been poor for many years. On examination acuities are counting fingers left and 6/60 right and she has a macular branch retinal vein occlusion in the right eye. On the left side there is a dense cataract.

What are the possible treatment options for this patient and how should she be managed?


Answers:

Most of the candidates managed the first case as intermittent ACG, DD are those causing haloes, pain and watering. The investigations should be aimed for systemic associations, gonioscopy, and field of vision. In the management we should consider the other eye, use of miotics and counseling the patient about YAG PI in both eyes.


The second case most of us considered as ocular emergency (contact lens related corneal ulcer) and talked about admission because she is nearly single eyed, sexual history (in any young patient), history of the corneal opacity, C&S of the corneal scrapings and for both the contact lens and its case, fortified drops, systemic antibiotics, Postpone her wedding, search for any correctable cause of drop of vision in the other eye and treat.


The third case it is a straight forward case BRVO in one eye (best seeing) and old standing cataract in the other eye. The patient can't afford long hospital stay because she is the only carer of her disabled husband. If she is to have cataract we should asses her posterior segment condition and the visual potentials of this eye. Consider topical and local anesthesia. it can be done during the follow up of the vein occlusion. Search and treat any systemic cause of the BRVO, consult internal medicine and anesthesiologist treat the vein occlusion according to the BRVOS. I forgot to mention low vision aids if the macula is ischemic and the other eye have low visual potentials.


Second Day: Viva exam 1/12/2008, 9:00-4:30 pm

Pathology and Ophthalmic surgery:

1st examiner:
After introduction the first question was a surprise for me (pathogenesis of diabetic cataract) I hesitated for a few seconds then I remembered Dr. Ahmed Reda advice about starting with an introduction. I said DM causes a hyperglycemic state and excessive glucose in the lens will activate the aldose reductase enzyme transforming it to something toxic (the examiner said sugar alcohol) then asked me, what does this cause to lens? I said transform soluble lens proteins to insoluble proteins, he asked me what else? I said osmotic damage by increasing intra-lenticular water, then he asked about how to manage diabetic cataract and what possible problems you may face (here we are back to ophthalmology where anyone who had experience can do well) he continued about how to manage each problem intraoperative and postoperative management of this patient.

2nd examiner:
He started by showing me an anterior segment photo with posterior synaechia asked me about causes of this condition, chronic uveitis, post traumatic, post AACG, how would you manage? I mentioned ECCE, preoperative dilatation, with all means, intraoperative by viscodilatation, mechanical and sphincterotomies. He said is it good idea I told him this is last resort and may increase postoperative uveitis, I told him if a senior consultant will do he might use iris hooks. He asked about PCO after cataract surgery. I mentioned YAG capsulotomy, he asked how, I mentioned we should counsel the patient first, he forgot the YAG and asked about counseling and post YAG macular edema and its management. He also presented a post cataract refraction of +2 DS/+2 DS×180, and the non operated eye +1 DS/+1 DC×180 and asked what to do, I started by selective stitch removal, then remembered the other eye and said it is correctable with glasses also. Also asked if it is preoperative astigmatism, I said we will plan the incision in the steepest meridian. The bell ringing does not protect you from answering, if you have important answer tell it if you don't KEEP silent.


General medicine and Neurology:

1st examiner:
Dr. Madi (Arabic examiner) he started by asking me what is bad headache, It was strange start also, I mentioned it may awake patient from sleep, has neurological signs or symptoms, signs of menengism, loss of conscious, and fever. He asked DD of severe headache, I mentioned subarachinoid he, SOL, infection. He asked also about patient with bacterial meningitis. I answered it is an emergency we should call neurologist and admit the patient, secure IV line and start antibiotics, support patient vital signs if he is comatosed. He asked what type of antibiotics, I mentioned cefroxime 1.5 gm IV /8 hrs. He asked what the use of Beta-blockers is and I mentioned hypertension, arrhythmias and thyroid and the bell ring. The examiner kept silent after each question and gave no clues or hints to enrich the disscusion.

2nd examiner:
Professor: Gobta he started by asking me do you use beta-blockers in thyroid ophthalmopathy, I said no it is for cardiac manifestations. Then he asked about cause of optic disc swelling, I asked unilateral or bilateral, he said bilateral, I asked about any age preference he told me, give DD, I started by GCA in old, demilination in young and then other causes, he asked how to differentiate and we started a discussion about each cause and it differentiating signs, symptoms and investigations, he said what about CRVO, and I mentioned that edema and hges will extend outside the disc, he also asked about drusen and I mentioned its signs and symptoms and field changes, he told me what about calcifications in X-ray I told him yes it cause this. He asked the mood of inheritance of Leber's optic atrophy. I mentioned mitochondrial DNA. Really it was very objective station and Professor Gobta has a very good experience in managing the discussion.

Ophthalmic medicine:
1st examiner:
She was an English lady. She started by showing me slit lamp photography of 34 years old patient with paracentral corneal epithelial defect 4 mm diameter and stained by rose Bengal, and mentioned that the patient has sore eye for 3 weeks. I mentioned we will treat as bacterial ulcer. She said can 3 weeks corneal ulcer look like that. I asked about medical history, it was free, ocular history, sore eye one year ago. I shifted to viral corneal ulcer HSV or HZV. She said OK what are corneal manifestations of HZV, and I mentioned it, except neurotrophic keratitis. She continued to ask what happened after HZV heals (here it came to my mined by Gods well) just before the ring. She was searching for Neurotrophic Ulcer. She was very helpful. All this 10 minutes I was telling my self why I mentioned Zoster in the DD and at the end it was the required answer.

2nd examiner:
Dr. Khalid Sharif. Jordanian Consultant. He started by asking what other ocular manifestations of HZV, I mentioned uveitis, scleritis, PORN, ARN. He asked about what is the characteristic feature of uveitis, I mentioned sectorial iris atrophy, and he then asked about secondary Glaucoma, I answered. Then asked about rubiosis irides and its causes, management of diabetic rubiosis, cataract with rubiosis and rubiotic glaucoma. He asked for the DD of 34 years old female with unilateral proptosis, I said the most common is TED, vascular, neoplastic, he asked about ON meningioma and I answered in details. He asked me just before the ring about the DD of a baby with bilateral opaque corneas, I said birth trauma, MPS, then the ring then I said Buphthalmus. He was very objective and managed the discussion very well.



Third Day: clinical exam 3/12/2008, 9:00-4:30 pm

1st case:
The English examiner showed me a case of posterior segment to examine by the I/O. I asked if I could talk to patients in Arabic. He said OK but explain what is going on. It was a case of mild Diabetic retinopathy in one eye and BRVO in the other eye which had a large C/D ratio (same as the last case in the written exam but here I mentioned low vision Aids if the macula ischemic), he asked about the management.

2nd case:
Female doctor from Oman she was very decent and objective. She showed me a case on the slit lamp with UL cicatricial entropion trichiasis with corneal opacities, LL ectropion, asked about possible causes and the mechanism of senile entropion. What are the manifestations of trachoma in the eye? , what are Herbert's pits I said degenerated limbal follicles, she asked about the sign of old trachoma and I said healed pannus.

3rd case:
5 years old boy with left congenital severe ptosis, left head tilt, and facial asymmetry on the left side. Asked me to examine ptosis and explain every thing I do, I mentioned the previous data in inspection, then I did the measures comparing both eyes, then I but my finger on the patient forehead to measure the levator function he asked me why I put my finger on the forehead I said to stop frontalis effect. He asked me what is this I mentioned this is severe congenital ptosis with poor levator function, but I like to examine ocular motility, he said OK go on, I examined the motility and told him he has also congenital right fourth nerve palsy, he asked about the left eye is there any thing in it, I asked to examine again and did so, I said he has left hypotropia. He asked about what is the most important thing to ask in history I said the duration of ptosis, and in the examination I mentioned VA. He told me what if he had poor vision in the ptotic eye, I said we should correct any error of refraction and treat amblyopia, he asked how I mentioned patching of the right eye.

4th case:
Young male patient with bilateral corneal dystrophy, the discussion went with the female examiner about level of opacity, it was in all layers, with clear zone from the limbus, asked me to demonstrate sclerotic scatter and specular reflection, and she asked me what kind of dystrophy, I said it might be granular, she said is this how granular looks like, I said I didn't see this much dystrophies to differentiate. The English professor said OK. Let's move on.

5th case:
Middle age male in his fifties. Asked me to examine left anterior segment and tell what I see. He had a circular corneal opacification and I said it is post refractive surgery complications and I said mostly LASIK, he asked why do you think he had low vision after the surgery, I said he had dense cataract, he said apart from cataract, I said interface dense opacification. The time was up.

For any information or help, please don't hesitate to contact me Khalozo73@yahoo.co.uk
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