Final FRCS

Centre:    Delhi

   Date:    September2009

This was my first attempt at the FRCS (G) exam. My experience of this exam was good. It was conducted very well. There was a lot of stress after the clinical exam-waiting for the final result. It was a big relief to see my name on the list of passed candidates.

The Chua site cannot be thanked enough for providing free and extremely valuable input to FRCS candidates, especially those who haven’t trained in the UK/ had similar residencies. This is a fantastic selfless effort by Mr Chua, and I just am amazed that though so many have given these exams and faced difficulties, he alone has actually initiated something to help his juniors and peers. The site is full of very useful stuff for the exam and otherwise. Let me do my bit by sharing my experience.

Day 1: Essay Questions:

1.  A 34 yr old woman presents to the eye department with blurred vision in the left eye accompanied by floaters. She is a low myope but is not aware of any systemic problems. On examination, you notice a mild erythematous rash on her legs and feet. How would you manage this case and what systemic investigations may be important?

Wrote about intermediate uvetis, with a small mention about PVD/RD. divided floaters into inflammatory and hgic. Listed sarcoid, sle, behcets, syphilis, lyme’s, Henoch Schonlein purpura, etc with reasons and investigations (including OCT for macular edema). Treatment including that for macular edema.

2.  A 3 year old boy is brought to your clinic by his parents. They state that for the past few weeks he has been screwing up his left eye in bright light and complaining of some discomfort. The child is irritable but on examination, the left eye seems slightly injected and vision is reduced to 6/18 compared to 6/9 in the right eye. There is also a suggestion of a divergence in the left eye. What are the possible causes of the child’s symptoms and how would you manage the cause?

Was really running out of time as I wrote this one last - in less than 10 min. Gave spot diag-int exotropia decompensating. Mentioned possible organic pathologies that could be responsible in very brief and exam to exclude the same. Treatment-primarily surgical.

3.   A 67 yr old farmer has noticed reduced vision in his right eye for 6 months, but over the last week it has become painful and red. On examination, acuities are perception of light in right and 6/9 in left, with the right eye very injected. There was significant corneal edema in the right eye with a dilated unreactive pupil and engorged iris vessels and mature cataract. The IOP was 62 mm Hg in the right eye. What aspects of the history and examination are important in making the diagnosis in this case, and how should the patient be managed?

Very good question, but very difficult to answer succinctly. Issues discussed in the answer were- rubeotic glaucoma-IOP lowering, causative disease identification and cataract. Wrote different stems depending upon causative factors and visual prognosis.

Day 2: Free day

Day 3: Viva

General Medicine and Neurology (cardiologist and neuro?ophthalmologist)

What would you do if a 60 year old walked in with a 3th nerve palsy-asked about pupil involvement and systemic illness. Both negative. i’ll take BP in clinic and send for blood investigations and ask for urgent  imaging. How urgent-next week, few days, today? today. What would you think in a 20 year old with bilateral optic atrophy? Told him about inflammatory, neoplastic, hereditary, secondary to retinal problems - in that order. What would you do if patient waiting in your OPD complained of epigastric discomfort that has increased now, but was present earlier? Told I’ll examine and take history about nature of pain, systemic illness and medication. DD- acid peptic disease, esophagitis-reflux, inferior MI (that was what they were looking for). Gave me an ECG  to read saying that this is the patient’s ECG-inferior MI. asked me treatment- told that I’ll call cardiology team and begin emergency Rx. Bed rest in propped position, O2,  Morphine, Aspirin, B blocker, and send blood for investigations. What specific investigations? CBC, ESR, Sugar, Urea, Creat, CPK MB, Troponin T.  Cardiologist is unavailable or very delayed-what will you do? put on cardiac monitoring in ICU, Consider for thrombolysis-rule out contraindications-listed them. Names of thrombolytics. What endocrinological referrals do you get? Diabetes, Pituitary diseases, thyroid disorders, phaechromocytoma (malignant hypertension), Menopause-dry eye, etc.  What rheumatologic diseases affect the eye? Gave a list. In what situations do you use immunosuppressives? Scleritis, ulcerative keratitis, graft rejection, ant and post uveitis. What agents do you use? Methotrexate, azathioprine, cyclosporine, mycophenolate, cyclophosphamide. Asked dose, side effects and precautions prior to using cyclophosphamide. Was unsure about dose. Answered the rest. Told them that I haven’t had the need to use it as yet. Told that I will get a physician’s workup prior to starting any immunosuppressive. Was asked in detail about Wegener’s granulomatosis. Told about major features, but they asked about cause of death-I didn’t know it was renal.

Bell rang, Finally!

Ophthalmic Medicine: (Indian and English examiner)

1. Shown photo of dendrite- asked diagnosis and management, local measures.

2. Dry eye-Rose Bengal staining and grading. Asked 2008 definition of dry eye- did not know. Asked 4 components of definition-did not know. Asked clinical grading-told about old one according to schirmer’s unanesthetised value. Examiner wanted according to new definition, which I already said I didn’t know! Asked treatment of dry eye.

3. Severe Vernal catarrh. Features, treatment, corneal complications.

4. CRVO –what investigations? How to manage? When to do FFA?

5. Diabetic macular edema- treatment? How to manage ischemic macular edema?

6. Corneal opacity in young adult

7. Trachomatous follicles- SAFE strategy

Bell Rang.

Ophthalmic Surgery and Pathology: (Both Indian Examiners)

1. Topo of early keratoconus- a 20 yr old girl with just -3.0DSph OU and good corneal thickness. Rx –no lasik. Options- told other Rx options.

2. Hydrops treatment. Choice of keratoplasty-PK or LK

3. Phaco in PXF-  told in detail about IOP preop, pupil problems, Zonular dialysis, etc

4. Asked about phaco in grade 4 nucleus in PXF-  said I’ll prefer SICS. Why-  because I’m a VR guy n not the best person to do a phaco in such a situation. Still tell us what should be done-told theory-enough  visco use, sandwich visco, higher power, no pushing the nucleus while sculpting, horizontal chopping

5. Shallow AC after trab-What will you do?

6. Spatulated needle-design and uses in ophthalmology

7. Draw a Langerhans Giant cell. Where do you find it?

8. Rhabdomyosacroma pathology

9. Draw an epitheloid cell

10. Surgery for 40 PD freely alternating Esotropia in adult –amount of muscle recession/resection

Bell rang.

Clinical Examination- DAY 4

Cases-

1. Congenital Ptosis- History, Measurements, Important points in management, treatment.

2. High myope-90 D of discs-points to differentiate between glaucomatous and non glaucomatous-tests to do

3. Subluxed lenses-(missed subtle iridodonesis in one eye-after seeing the other eye, could demonstrate in the other eye)- DD, systemic features of Marfan’s, management

4. Accommodative esotropia- motility exam-limited abduction in one eye-cover-uncover test-did for distance and near and came to diag. Reason for lower vision in one eye. Treatment

5. Proliferative Diabetic Retinopathy-treatment, investigations.

Bell Rang

(have written about the med viva in detail, as candidates would already be familiar with answers to ophthal questions and cases)

My advice to future candidates:

ESSAY- 2-3 months before your exam, consider every patient that you see as an essay scenario. And refer immediately to your books to consider whether your line of thought and management is correct.

Do enroll for Muthusamy Virtual University of Post Graduate Ophthalmology (www.mvupgo.com). Dr Muthusamy’s free assistance to candidates is laudable. Very good for practice. I did a mistake of not practicing with time tabs-you do so. Found Wills Eye Manual and Decision Making in Ophthalmology (W A J van Heuven/ J Zwaan) useful for essays.

VIVA- Talk to 3-4 people who have cleared the exam to learn from their experience. Try arranging a mock viva or exam with experienced teachers. Let the viva be fast paced. Let yourself be asked many questions. This is the time to get the examiners attention and approval. Greatly helps the next day. Books found very helpful- Oxford handbook of Clinical Medicine, Oxford handbook of Clinical Ophthalmology, Moorfields Manual of Ophthalmology (discovered the book fairly late but found it extremely useful for viva), Kanski, Wills Eye Manual, Chua Manual, Macleod’s Clinical examination-chapter on Critically Ill Patients.

CLINICAL EXAMINATION- Whatever anybody says we all end up very tense-some of us before and some after the exam. Practice in the clinic and be polite and explaining to patients so that it comes naturally in the exam. Do write down and memorize instructions that you are going to give to patients before starting any test- especially useful for ptosis and confrontation fields. Practice on friends and in camera, if possible. When you view your tape, you’ll realize that you were making funny mistakes. And in the exam, just do the test correctly. Don’t stop doing a test midway even if you think that the finding isn’t making sense. Complete the test, stop for a while and think-if you can explain what you are thinking and why, you will make it through. Request the examiner if you want to repeat a doubtful test (I did). If examiner asks to summarize, or asks what is it-don’t jump to a diagnosis. Succinctly state the positive findings and give diff. diagnosis-gives you time to think. Usually 3-4 cases are fairly straightforward, and one or two may tax you a little.

Do download and print the experiences from CHUA website. Sit with them, imagine you are giving the exam, don’t look at the answers and answer aloud.

All the very best for your exam!