FRCS PART 3 GLASGOW MUSCAT 2010

MY NAME IS AYMAN  MOHAMED RASHAD FROM ALEXANDRIA EGYPT AND WORKING NOW IN SULTANATE OF OMAN IBRA HOSPITAL . THANKS GOD ALHAMDOLLELAH I PASSED FINAL EXAMINATION FOR FRCS GLASGOW PART 3

I WOULD LIKE TO THANK ALL PEOPLE WHO SUPPORT ME AND WITHOUT WHOM THIS WOULDNOT COME TRUE. SPECIAL THANKS TO MY MOTHER WHO SACRIFY MANY THING FOR ME, ALSO MY WIFE ALYAA  AND MY SONS ZIAD AND MAZEN. MY BROTHER MOHAMED MOHAMED RASHAD WHO ISSUE ALL MY CERTIFICATE FOR MY SUBMISSION

ALSO WOULD LIKE TO THANK MY HOD IN MY HOSPITAL DR KISHAN KUMAR GUPTA  WHO ALWAYS SUPPORTED ME AND INSISTED ME TO APPEAR IN THIS EXAMINATION AND PROVIDED ME WITH MANY POINTS THAT COULD HELP ME TO PASS THIS EXAMINATION

ALSO MANY THANKS TO MY PROFESSOR DR SERRY SULIMAN  AGLAN CONSULTANT OPHTHALMOLOGY IN ALEXANDRIA WHO ALWAYS GIVING ME HOPE FOR THE FUTURE , MANY APPRECIATION TO DR KHALID MOUNIR AND DR OSAMA SABRY WHOM I WISH THEM ALL THE BEST.

CHUA WEB SITE WHICH IS THE MAZING SITE FOR ALL CANDIDATE WHO ARE PLANNING TO APPEAR  FRCS AND PERSONALLY  I GOT BENFIT FROM IT AND ESPECIALLY PATHOLOGY SLIDES AND PAST CANDIDATE EXPERIENCE AND MANY OTHER THINGS

MUTHUSAMY ON LINE COURSE A WOUNDERFUL SITE AND ITS VIRTUAL UNVERISITY WHICH WAS GUIDING US TO RIGHT WAY TO ANSWER QUESTIONS AND POWERFUL POINT IN THE EXAMINATION

MY READING SOURCES:

KANSKI, AMERICAN ACAEDEMY, WILLIS EYE MANUAL, OXFORD HAND BOOK OF OPHTHALMOLOGY AND THAT OF GP FOR EMERGENCY

ALSO REVIEW PATHOLOGY SLIDES FROM CHUA WEBSITE, AA AND LUCKLY I GOT ORGINAL YANOFF FOR PATHOLOGY

SURGEY RUBIN AND SMITH  ALSO I HAVE OTHER BOOKS  BUT DID NOT  WENT  DEEPLY THROUGH THEM LIKE WONG, OPHTHALMIC SECRETES

Viva examination: FRCS Glasgow part 3 Muscat 2010

First viva: neurology and medicine

First examiner:

Question: one patient in the waiting area in your clinic has got fit what you will do?

Answer: I will go in a hurry to the patient calling for help, isolate the patient from the surrounding to avoid self injury, rapid review for vital signs like pulse and BP, patient can be observed for few minutes as in most cases spontaneous recovery will occur _, but I have to insert airway inside mouth to avoid tongue biting, otherwise patient can be given IV valium 5 mg and dose can be repeated to 10 mg if not improved until arrival of the neurologist. The examiner told me that BP unnecessary as the patient is shivering that will hinder BP measurement.

Question: one patient 50 years old man presented with unilateral headache how you will manage?

Answer : I have to consider DD like refractive errors and eye strain, acute glaucoma, arteritic type of AION, intra cerebral causes like hemorrhage, SOL, sinus related like sinusitis , polyp.

I will take history of onset course , associated manifestation like blurring of vision, vomiting , tinnitus or change in consciousness, systemic disease like hypertension , SLE, migraine although the last one is common in females

Examination will include aided and unaided visual acuity and cycloplegic refraction, test ocular motility for any cranial nerve palsy, IOP measurement, test for RAPD for any compressive lesion on visual pathway, dilated fundus examination

Investigation like CT AND MRI especially if there is papilledema.

Question: one patient has got fainting what you will do?

Answer look for vitals and support for ABC, I gave differential diagnosis like vasovagal, hypo or hyperglycemia.

Ask me how to differentiate hypo and hyperglycemia, answer clinically by sweating and glaucotest, ask me if this test was not available he wanted to give IV glucose 25% any way in both condition as hypo is more serious  and that I realized later and told him the same

Other to be given is glucagon IV

Second examiner: 

He presented to me a color photo and asked me to describe what I see ?

Answer I could see right fundus with dot and blot hemorrhage, macular hard exudates area of retinal hemorrhage along inferotemporal arcade which could harbor neovessles, and old scar of PRP

Ask me what the management is.

Answer: history of systemic problem in addition to diabetes if he has hypertension, any renal disease or if the patient is female could be diabetic retinopathy with pregnancy

Control of systemic condition in cooperation with physician and gynecologist

Ocular examination include aided and unaided vision, anterior segment evaluation for iris neovessles or glaucoma, examination and evaluation of other eye

Coming to diagnosis is proliferative diabetic retinopathy

Investigation: FBS, RFT, FA to exclude neovessles and retinal ischemia 

He stopped me and  presented to me a color photo of optic nerve head swelling? What is your impression and if the other disc also swollen?

Answer:  bilateral disc swelling may be pseudopapilledema or true papilledema

Pseudopapilledema like hyperopic disc, optic disc drusen

True papilledema  is bilateral disc swelling due to increase intra cerebral pressure

DD pseudo tumor cerebri, neoplastic, vascular, inflammatory disease that affect intracranial cavity

Asked me how will you manage?

Answer: history, examination and investigation

Asked me what investigation?

Visual field, CT and MRI brain

Then he showed me automated perimetry both eyes of the same patient it was bitemporal hemianopia and I answer it is due to tumor at the chiasamal region

Asked me like what?

Answer pituitary adenoma

Ask me what is the function of pituitary gland?

Answer : anterior pituitary secretes hormones like GH, TSH, FSH and posterior pituitary secretes oxytocin and ADH

At the end I mentioned I have to make consultation with endocrinologist and neurologist

Second station: ophthalmic medicine

It was difficult to me initially but ends with good answer later

First examiner

Question: 30 years old man with night blindness what is your differential diagnosis

I gave retinitis pigmentosa and congenital stationery night blindness and high myopia

 Question: if he has retinitis pigmentosa how can you manage?

Answer : family history as it could be AD, AR or X-linked

Ocular examination vision aided and unaided, dilated fundus examination

He ask me what is ocular association ?

Answer: POAG, posterior sub capsular cataract, myopia, keratoconus

What is characteristic fundus finding?

Answer: salt and pepper pigmentation but he wanted, I think bone spicule fundus changes also I mentioned vascular attenuation and waxy pallor of optic disc

Investigation: ERG

He ask me how you can by ERG differentiate retinitis pigmentosa from CSNB?

I could not answer this question.

Then he presented to me color photo of patient 14 years old with conjunctivitis that has complaint of 3 weeks of discharge but has no history of previous allergic condition

I give differential diagnosis of trachoma and inclusion conjunctivitis and mention papillary conjunctivitis.

Ask me what is the management?

Answer eye hygiene, treatment of surrounding as trachoma is chronic endemic

Investigation like Conjunctival scrapping for intracytoplasmic inclusion bodies

Tetracycline and doxycicline

Ask me if associated with systemic problem

Answer: genitourinary infection

Second examiner:

What decongestant do you know?

Naphazoline….what else … getting blocked and couldn't mention others like mast cells stabilizer and antihistamine eye drops

Question:

35 years old female patient presented to you with unilateral protrusion of the eye globe, how you are going to manage this patient?

I start by the most common diagnosis is thyroid eye disease as it is the most common of unilateral or bilateral proptosis in middle age female but I have to exclude other causes of proptosis like vascular, neoplastic , inflammatory…

I will take history of the onset pain any visual disturbance

Asked me why vision can be affected in thyroid eye disease and what you will do?

Answer: vision can be affected due to severe proptosis and consequently exposure keratopathy, also may be due to compressive optic neuropathy which consider an urgent situation it is due to swollen orbital soft tissues and extra ocular muscles

Also choroidal folds can affect the vision

Management include history, measurement of proptosis and its progression, visual acuity monitoring, anterior segment and ocular motility, very important to test for RAPD and color vision

Investigation: B-scan ultrasound, CT and MRI which will show enlargement of EOM

Treatment include stop smoking , if there is signs of optic nerve compression systemic steroids can be given started with high dose of methyl prednisolone followed by oral prednisolone in a dose of 1 to 2 mg/kg and can be followed by radiotherapy

If no improvement or progressive optic neuropathy we can do orbital decompression

Question: classification of uveitis??

I said sun working group 2004

He Saied another classification? I said anatomical, pathological,

He wanted granulomatous and non granulomatous

Question: What is systemic disease associated with uveitis??

I mentioned many like ankylosing spondylitis, VKH disease, behcet disease, sarcoidosis, intermediate uveitis; syphilis, tuberculosis and discussion went into behcet disease  

What is sight threatening uveitis?

Answer: all uveitis that is complicated with corneal decompensation, secondary glaucoma, complicated cataract, cystoids macular edema, optic nerve affection and inflammation and retinal detachment that could end with phthisis bulbi.

Question what is the manifestation of behcet disease?

Ocular, systemic and neurological

Recurrent acute anterior uveitis, posterior segment affection like periarteritis

The disease is common in Japanese Middle East and midetranian sea area

He said behcet was a dermatologist

I said yes and patient has characteristics recurrent oral and genital ulcer, erythema nodosum

He said did you see any cases in this area?

I said yes I saw many cases of behcet disease in Middle East

What is the management?

I have to confirm the diagnosis by history, clinical examination is very important as the diagnosis mainly by clinical picture

Treatment:

Steroids can be given by all mean topical peri ocular, systemic by parentral or oral which may necessitate long term steroids therapy with its potential complications and even by intra ocular injection and implant

In case of complications or uncontrolled disease with steroids cytotoxic drugs can be given

Asked me like what?

Answer: methotrexate, azathioprine

Ask me what is the dose and complications of methotrexate?

7 to 10 mg per week and complication liver toxicity and bone marrow depression

Third station was surgery and pathology:

First examiner:

Question: a young lady come to you seeking advice for her lid retraction?

Answer: Muller muscle resection or mullerectomy

Levator muscle recession

Insertion of device in upper lid golden wt

I said sympatholytic eye drops but forgot to mention guanthidine drops as in kanski

He presented color photo and asked me to describe what I see?

It was pigmented peripapillary choroidal mass and breaking through Bruch's membrane in collar stud pattern and I diagnosed immediately choroidal melanoma.

Asked me how to manage this patient?

Discussion went into the prognosis and state of the other eye patient counseling and options of conservative treatment in case of only seeing eye and very old patient and the following can be given like external beam radiotherapy, radioactive plaque, TTT,

Or enucleating of the eye with pre operative radiotherapy

Question: what are the types of ectropion?

Congenital

Acquired:

Senile

Cicatrical

Paralytic

Question what are surgical options for ectropion?

Wedge resection

Lateral canthal sling

Z-Y plasty

Second examiner:

Question: what do you know about Fuchs endothelial dystrophy?

Abnormality in the descemets membrane with absent or abnormal function endothelial cells which affect corneal endothelial pump mechanism

What is this pump and for what?

Actually there is active pump ATP s sodium- potassium pump and passive diffusion of fluid across the endothelium from the aqueous humor to corneal stromal tissues it prevent over hydration and regulate nutrition and fluid to the corneal tissues but in Fuchs corneal dystrophy there will be excessive fluid passage to the cornea and manifested by recurrent corneal edema, pain and blurring of vision

What is the management?

Hypertonic saline, bandage contact lens

Pre operative precaution in cataract surgery

What investigation before surgery?

Corneal pachymetry and endothelial cell count, using excessive viscoelastic substance for protection of endothelial cell layer and low power of phaco ultrasound

She presented photo of epibulbar mass near the limbus 3x4 mm gray white with hair on the surface

I had described the lesion and asked me what is that?

Answer :dermoid cyst

Ask me hair is confirmatory or not

Answer :yes confirmatory with other skin appendage like sweat gland follicles on histopathology

Asked me what to do?

Answer excision in block under local anesthesia….. She interrupted me  but he is a child …. Correcting myself and said yes should be under general anesthesia.

Asked me what about refraction

Answer: very important for any astigmatic errors which will need correction to avoid amblyopia

Asked me what associations with dermoid

Answer: Goldenhar syndrome and facial hemiatrophy.

Question: A child with +4 diopter glass and has equal vision in both eyes, but still has esotropia, what to do?

Answer: surgical correction. Either mono ocular MR recession, LR resection or simultaneous both MR recession or both LR resection

Asked me what is the amount?

I said there is table for the amount of recession and resection.

Asked me on what basis?

Answer: each 1 mm recession MR correct 2 degree and each 1 mm LR resection correct 1 to 2 degree of squint.

Clinical examination: FRCS Glasgow part 3 Muscat 2010

First station was neuro ophthalmology

There were 2 female examiner and had given me 4 patient in this room

First patient is around 8 year's girl asked me to examine ocular motility

I did Hirschsburg test no deviation in primary position, but she interrupt me and told me  don’t use light for not to affect  accommodation

Ask  the examiner about glass told me  yes she has but doesn't matter

Cover test for far and near reveal exophoria more in far than near.

Second patient was a boy I noticed that left small palpebral fissure ptosis

I thought jaw winking, and test ocular motility but not sure mentioned superior oblique pals primary action of superior oblique

Third case girl 20 years with abduction defect and left narrow palpebral I mentioned diagnosis

 Duane syndrome type 1

Fourth case

Examiner asked me to examine the pupil in an old male patient

Patient had Left RAPD asked me the causes. It is due to unequal function of optic disc with more damage in the left side like glaucoma, optic atrophy, AION either arteritic or non arteritic, compressive optic neuropathy

.

Second station it was oculoplastic although expecting the worse but was the best to me very

 rapid diagnosis with  very frequent questions and spontaneous answering to all questions

First case 25 years old female patient with left congenital ptosis

Examiner asked me to sit in front of the patient and he started asking me

Describe what you see ? answered left eye drooping of the upper eyelid, with absent lid crease

What is your diagnosis, answered left congenital ptosis

How you can manage the case , answered history , clinical examination I put my finger on frontalis and measured levator function I said 4 to 5 mm , I measured MRD it was 0 to + 1 mm , ask what is the normal palpebral fissure answered 11 mm and normally upper lid cover 1 to 2 mm of upper limbus . Ask what else you will do... answer I will check for bells phenomena why? Answer to avoid post operative exposure keratitis if absent bells phenomena also I would like to check for superior rectus function as there is association between levator tendon and superior rectus that can affect surgery results

Could be horner syndrome? Answer I have to check for anisochoria and heterochromia and at the same time ptosis in horner would be mild around 1 to 2 mm of ptosis

What else could be the cause of ptosis? Answer jaw winking syndrome … what is that? Answer synchinesis between third nerve and nerve supplying jaw muscle

What surgery you will do

Answer levator resection either transcautaneous or transconjunctival

What amount of resection? Don’t know

Second case around 40 years male patient has right eye periorbital inferior bulging mass

What is the cause?

I gave differential diagnosis said it could be traumatic, inflammatory, neoplastic or vascular mass

What you will do

I will take history of onset, course, any pain decrease vision or any previous trauma

He asked if trauma? I said there will be bluish discoloration, emphysema …. He replied named hematoma. And asked me to examine the patient and tell me what you are doing?

I said by observation no proptosis , I palpate the mass no tenderness no hotness , it was soft mass , I test for retropulsion but it was normal ask me why you do retropulsion ?? answer to exclude retro bulbar or intra conal extension which can compress the optic nerve and I have to test for pupillary reaction and color vision if suspected any compressive optic neuropathy..

He said it is AV fistula.

Answer it can be closed by surgery or if patient refuse to report to ophthalmologist if any visual disturbance  

Third station was anterior segment station

First case Slit lamp examination for male patient 35 years old -

I described what I seen patient has  corneal scar at 12 o clock of previous phaco section, has deep AC, irregular reactive pupil with pupillary iris atrophy pseudophakia, posterior chamber IOL

Question: what is the etiology of cataract in this age group?

Answered : could be metabolic ,dm, chromosomal anomalies, traumatic…

Question : what is the most common cause of cataract in this age group? I got silent and he repeated the question twice more rapidly come to my mind traumatic…. He got happy and said yes it was traumatic and I continue especially patient has irregular pupil and traumatic iris atrophy.

- The second case was middle aged female  for slit lamp examination she has left eye limbal section, ac deep, peripheral iridectomy, posterior synechia 360 degree, and aphakia with organized lens opacity in the center, no red reflex

Examiner asked me to look at her face, she has exotropia and  there was a scar on the tip of the nose and above eye brow in the same  side, he asked me what was the scenario and why surgery was difficult ?  I suggested  may be scar of previous herpes zoster ophthalmicus and the patient has had uveitis, iris atrophy and complicated cataract and secondary glaucoma

Question : what you will do for her ?

Answer: she can be subjected for another surgery for synechiotomy, removal of after cataract and vitrectomy with scleral fixation IOL

Asked me you think vision will improve? Answered no sir as she might has amblyopia and posterior segment problem.

Fourth station was posterior segment, last one and the best to me as I was practicing well

 indirect ophthalmoscope and examination with + 90 and + 78 lenses

First patient examiner ask to examine with +78 d lens , there was vascular attenuation, mild pallor of optic disc and bone specule pigmentary changes and I give the diagnosis of Retinitis pigmentosa , he asked me about the macula I answered CME and I have to check for vision , ask what  is the treatment I said systemic acetazolamide                

Second patient was 12 years old boy ask me to examine the fundus. indirect ophthalmoscope and + 20 d lens was there, she ask the boy to lie down supine initially I diagnose mylinated nerve fiber which was peri papillary then ask me to see the periphery it was localized recurrent retinal detachment ask me it was pars plana or buckling I could found conjunctival scar of buckling and retinal indentation I said it could be a squelle of previous ROP or familial exudative vitreoretinopathy

Third patient on slit lamp he was aphakic with inferior peripheral iridectomy. asked me to examine the fundus with + 78 d lens there was macular scar with pigmentation and immediately come to my mind post pars plana vitrectomy with silicon oil inside the examiner was happy and asked me if the other eye has the same problem I said macular hole, myopia and pre retinal membrane this was my last patient and the end of my examination

Results were  announced after 15 December 2010 through internet but I reviewed  on 3^rd January 2011 and my number was  pre last number in pass list and I got so happy for this and prayed for Allah and also my wife got very happy

I wishes all the best to all candidate who are going to appear for this examination

 I will be very happy for any help , please send me mail to:

               ayman.rashad46@yahoo.co.uk

               ayman.mvupgo@gmail.com

More candidates' experience