My name is AHMED FOUAD MAHMOUD I passed FRCS exam in Tripoli, April 2009 (AL HAMD LELLAH). I'd like to thank my parents, my wife, my family and my friends for their kind support during these days before and during this examination
 

ESSAYS
1) A 65-year-old man attends your clinic with a one-month history of right-sided headache combined with complaints of drooping of the upper lid and some intermittent blurring of vision on his right eye. He has a history of heavy smoking with chronic bronchitis and chest infection. What is the possible diagnosis and how would go bout assessing and managing the case?

2) A 32-year-old man, who had previously spent time in prison for assault, is referred to you by his optician with raised pressure in one eye. On examination, acuities are 6/6 right and 6/12 left, with intraocular pressure of 18 mm/HG right and 34 mm/HG left. There is a left afferent pupillary defect. How would you manage this case?

3) A 22-years-old girl who has previously suffered from Steven Johnson Syndrome attends your clinic complaining of reduced vision. She has severe dry eye, with trichiasis and pannus, and her vision is 6/12 in the right eye and 6/18 in the left. There is some posterior Subcapsular Cataracts in both eyes. Indicate how would you manage this difficult case and explain the risks and complications of any intervention.

GENERAL MEDICINE AND NEUROOPHTHALMOGY
 

PATIENT IN THE WARD COMPLAINS OF DROSSINESS AND DETERIORATION OF CONSCIOUSNESS LEVEL 1 WEEK AGO
I think this patient is diabetic and he developed hyperglycemic ketoacidosis therefore I will asses the conscious level as the pt. in coma or not WHAT ARE THE SIGNS? Hyperglycemia, acetone bodies in urine and main complication is dehydration WHAT ARE THE SIGNS OF DEHYDRATION? Dry mouth, dry skin and oliguria YOU DO NOT PALPATE THE EYE?!!!!!!!!!!!! !!!!!!!!! !!(IOP) HOW WILL YOU TREAT? Insulin, fluids (saline 0.9% till blood glucose less than 300 then I can use glucose 5% WHAT ELSE? Potassium, heparin 5000 IU

PATIENT WAS ADIMITTED IN THE WARD COMPLAINS OF BREATHLESSNESS Call for help-check ABC, I asked preoperative or post operative (p. embolism) he said preoperative. Asthma, acute exacerbation of COPD, myocardial infarction and pulmonary embolism, If the pt. is diabetic I have to exclude MI (silent MI) HE SAID IT IS ASTHME HOW TO MANAGE? Upright position.O2 100% except if he has history of COPD HE SAID ASTHMA Morphine WHY? NO CHEST PAIN.WHAT THE RISK OF MORPHINE respirator centre depressant I will give Salbutamol 5 mg and ipratropium 0.5 mg the assess the improvement

SHOW FOR ME PHOTO OF LARGE CHOROIDAL MELANOMA HOW WILL YOU MANAGE AS it is large I will do enucleation, I will assess size. Site and metases WHERE? Liver. lung, bone I will do Chest X ray, bone scan, IF THERE IS LIVER METASES I will refer him to oncologist WHAT WILL HE DO I think chemotherapy or radiotherapy

70 YEARS MALE PATIENT COMPLAINS OF HEADACHE AND PAIN DURING EATING In this age I must exclude GCA WHAT IS THE PATHOLOGY occluded lumen, fragmentation of elastic lamina) HOW WILL YOU MANAGE history of scalp tenderness IT IS PRESENT c- reactive protein and ESR HIGH, I will do TAB ARRANGE AFTER 2 DAYS WHAT WILL YOU DO I begin systemic corticosteroids with correlation of physician WHAT IS THE DOSE AND COMPLICATIOS OF STERODS peptic ulcer, aseptic necrosis of femur TAB IS NEGATIVE I ensure I took long segment (skip lesion) YOU DID I will do TAB other side NEGATIVE, WHAT ABOUT STEROIDS i will stop it HOW ??????!!!!!! !!!!!Guided by C reactive protein and ESR HOW LONG I think 6 month OK

WHAT ABOUT STSTEMIC DISEASES AFFECTING THE EYE RA, SLE, Behcet, DM WHAT IS THE EFFECT OF DM Mainly diabetic retinopathy, change in refraction HOW hyperglycemia lead to increase osmolarity lead to myopia WHAT OTHER DISEASE AFFECTIG THE LENS Marfan. Homocystinuria, weil marchesani
 

OPHTHALMIC SURGERY AND PATHOLOGY
 

PICTURE OF UPPER LID MASS MEDIAL TO PUNCTUM FOR DD HOW WILL YOU MANAGEMENT Chalazion, sebaceous carcinoma, sq. cell carcinoma History of previous treatment. Surgery. Then we discuss how to manage and reconstruction BUT I DO NOT REMBER FULL DETAILS

CANALCULITIS caused by actin. Israeli HOW TO TREAT irrigation of tooth paste like material BY WHAT ANTISEPTIC OR ANTIBIOTIC both WHICH TYPE I don't know

PHOTO OF MARGINAL CORNEAL ULCER WITH POSTIVE FLUORECIN STAINING WITH CRESCENT SHAPE Marginal keratitis however no trichiasis or entropion, Morren"s ulcer however no characteristic edges HE ASKED ME NOTICE THE PLACE inferiorly (exposure keratitis) then I noticed lower lid ectropion WHAT THE CAUSE facial palsy UMNL OR LMNL I answered LMNL as eye is involved WHAT THE CAUSE OF FACIAL PLASY Idiopathic bells palsy, cerbropontine angle lesion according to other nerves affected as 6th or 8th what else!!!!!!!! !!!!!!!!! !!!!TRAUMA

HISTOPATHOLOGY I found intradermal keratin pearls (sq. c. c) GROSS PICTURE OF RT MASSIVE INFILTRATION, HOW WILL YOU MANAGE excision and reconstruction HOW!!!!!!!!! !!!!!!!IT IS MASSIVE my be radiotherapy and chemotherapy WHAT IS SENSETIVITY OF IT TO RADOTHERAPY I don't know

HISTOPATHOLOGY OF CORNEA SHOWING CYST THEN GROSS PICTURE OF IT WITH RING ABCESSES acanthameba keratitis GO BACH TO SLIDE IDENTIFY THE CYST AND TROPHZITE I did HOW TO TREAT neomycin, biguinied, chlorhexidine. brolene WHO ARE AT RISK soft CL wearer with bad hygiene like sleep or swimming HOW DO YOU DIAGNOSE stain with calciflour and culture I can not remember (non nutrient agar with E. coli) WHAT ABOUT CL I will take it and tell the patient it will be destroyed

HISTOPATHOLOGY SLIDE SHOW LARGE CLEAR SPACE SURROUNDED BY VACULOTED SPACES I asked about clinical picture UPPER LID SWELLING FOR DD I said it is chalazion WHAT IS IT giant cells WHAT TYPES OF GIANT CELL WHAT IS COMPLICATION OF CHALAZION mechanical ptosis HOW DO YOU MANAGE excision DEFIN ITION OF CHALAZION AND CAUSES

KERATOPLASTY (INDICATION AND TYPES) PROGNOSIS


OPHTHALMIC MEDICINE

PHOTO OF ANTEROR SEGMENT WITH MULTIPLE FLUROESIN STAININD SPOTS DESCRIBE THEN HE SAID NOTICE IT IS QUIET EYE I said this may be fuch"s heterchromic uveitis WHAT THE CHARACTER small, scattered, no synechia except after surgery. no steroids WHAT ELSE heterochromia

WHAT STAININD USED IN OPHTHALMOLOGY fluorescen, rose Bengal, trypan blue in staining capsule ROSE BENGAL USES

THEN ASKED ME ABOUT HERPES ZOSTER KERATITIS.WHAT THE ULCER CALLED, WHAT ABOUT IRIS
 

FEMALE PT COMPLAINS OF REDNESS GP DOCTOR GAVE HER CHLORAMPHENICOL BUT STILL REDNEES AND LACRIMATION. I will but DD of red eye IT IS CONJUNCTIVITIS it mAy be viral or chaylamidial NO I will check the compliance. Stop chloramphenicol and give oflox U DID AND STILL REDNESS I think he want to hear drug toxicity!!!! !!!!!!!!! !!!!

PHOTO OF CORNEAL ULCER WITH POSITIVE FLUORESCENCE STAINING Infective until prove otherwise WHAT ELSE exposure NOT AT THIS SITE

HOW DO YOU DIFFERNIATE BETWEEN INFECTIVE AND ABRASION Ciliary injection IN BOTH hypopyon EARLY abrasions more superficial YOU MEAN IN ULCER THERE IS INFILTRATION yes
 

THERE IS SURGERY DONE SUPEIORLY WHAT DO YOU THINK trabecuecltomy WHAT IS THE CAUSE OF THESE 2 CONDITION steroids (glaucoma and affect the healing) WHAT DRUG WE KNOW IT WILL CAUSE THAT BUT WE HAVE TO INJECT I don't know

PHOTO OF PCO WHAT IS IT PCO PATEINT DID SURGERY 4 WEEKS AGO AND COMPLAINS OF DIMINUTION OF VISION assess visual acuity and best corrected DID U NOTICE ANY THING I see irregular notch that suggest vitreous loss VISION IS REDUCED this is due to CME HOW TO TREAT topical and systemic NSAID he asked WHAT ELSE intravitreal injection of triamcinolone, IF THERE VITREOUS STRANDS IN AC cut it by YAG laser

PICTURE OF LENS WHAT IS IT Zeiss goniolens,4 mirror we do not have to rotate it, no coupling material used, handle WHY compress if there is any bleeding during laser procedure DURING EXAMINATION dynamic gonioscopy

OTHER LENS PICTURE It is small I WILL SHOW DIAGRAM ok it is laser suture lysis lens

PHOTO OF SMALL BABY WITH BILATERL CORNEAL OPACITY buphthalmous WHAT WILL YOU DO examination under general anesthesia…
 

CLINICALS
 

• SLE (SLIT-LAMP EXAMINATION) Old lady with Lt leucoma adherent +cataract Rt PKP + pseudophakia WHAT IS THE CAUSE- WHAT ABOUT LEUCOMA
   

• OCULAR MOTILITY Female patient with left esotropia with limited abduction for DD (6th nerve palsy-long standing esotropia-medial wall fracture) DO OCULAR MOTILITY Can I do cover –uncover test first OK. I checked VA which is poor in left eye. There is left esotropia HOW MANY DEGREE 30.IF YOU LOOK BEHIND THE OCCLUDE WHAT WILL YOU FIND phoria, As the patient has poor vision in left eye therefore I will not ask about diplopia. During examination patient closed her eyes WHY I do not know WHAT IS THE MUSCLES SEQUEL OF PARALYTIC SQUINT
   

• SLE old male has Left laser iridotomy - dilated pupil (mydriatic)- immature cataract CHECK FUNDUS hazy media OK EXAMINE OTHER EYE cupping 0.7
   

• SLE middle aged female: Bilateral macular lesions DESCRIBE I did DIAGNOSIS Bull's eye maculopathy CAUSES cone dystrophy, drugs as chloroquine however no sings suggested systemic disease
   

• INDIRECT OPHTHALMOSCOPE: Middle aged male with bilateral optic atrophy (primary –toxic) ASSES OPTIC NERVE FUNCTION (VA- pupil- color- contrast- brightness – field) DO CONFRONTATION, WOULD YOU LIKE TO EXAMINE ANTERIOR SEGMENT!!!!!!!!!!!!WHAT IS SYSTEMIC DISEASE CAN AFEECT THIS AGE Behcet with vasculitis
   

• SLE Old man with bilateral PKP: Left vascularized graft + Right graft rejection WHICH TYPE AND SIGNS
   

PREVIOUS EXPERIENCE
 

Tripoli 2007
 

GENERAL MEDICINE Hypoglycemic coma, Thyroid eye disease, Eye and GIT
 

PATHOLOGY AND SURGERY Histopathological slides, Management of dropped nucleus, Management of lattice degeneration
 

OPHTHALMIC MEDICINE Medical treatment of glaucoma and side effects in details, roth spot

Tripoli 2008

Ophthalmic medicine (7)

• Sturge weber CT brain tram track appearance

• Limbal dermoid goldenhar syndrome repair of lid coloboma HOW –WHEN

• Complications of cataract surgery PCO- endophthalmitis

• Flaffy iris syndrome

• Optic disc pit and CSR

• Disc edema with normal vision unilateral or bilateral

SURGERY (6)

• Choroidal rupture

• Blunt eye trauma

• Blind painful eye

• Bacterial endophthalmitis

• Thyroid eye disease restrictive myopathy (recession with adjustable sutures)

• Band keratopathy

• Painless diminution of vision

• After trauma eye appear smaller----- blow out fracture mechanism and management

GENERAL MEDICINE (5)

• Behcet disease

• Subarachnoid hemorrhage

• Myasthenic crisis

• Cholinergic crisis

• Treatment of pneumonia
   

Thanks a lot to ALLAH that I passed. It will give me much pleasure to provide the hand of help to any candidate for FRCS or any ophthalmological exam.

AHMED FOUAD – FRCS(Glasgow)
afmahmoud2003@ yahoo.com