My name is Chinmaya Sahu. I am a Vitreo-Retina consultant at L.V Prasad Eye Institute, Hyderabad. I had appeared for the FRCS Part 3 in New Delhi and passed. I wanted to share my experience with others.

Day 1

Ophthalmic surgery

Examiner 1 (Indian male)

1. A patient for whom you have done Cataract surgery, comes to you a month later with IOP of 32 mm Hg.

1. What are the possible causes of raised IOP?

Steroid induced glaucoma, Secondary to post operative inflammation, Glaucoma missed in the pre operative phase (wanted this)

2. What is the mechanism of steroid induced glaucoma?

      Secondary to deposition of Glycosaminoglycans in the trabecular meshwork. 

     (Happy, immediately moved to next question)

3. How will you manage this patient

Started saying after evaluating the patient………..stopped me sayin remember you have already evaluated him in the pre operative phase……….I said will start with anti glaucoma medications like……………stopped me saying won’t you do something before that…………I said……..Will stop the steroids if he is still using them 

2. What are the causes of flat Anterior chamber following Glaucoma surgery?

Mentioned about bleb leakage and scleral flap leakage. Examiner went into details of how to differentiate between the two and how to manage them.

Then asked me what are the other causes. I mentioned with raised IOP, pupillary block glaucoma, malignant glaucoma and hemorrhagic choroidal detachment

Went into management of Choroidal detachment. Mentioned topical and oral steroids. Kept looking at me……..Then I said if IOP is very high or retino retinal adhesion is occurring, will consider choroidal drainage (happy)

 Examiner 2 (UK, female)

1. Gave me a scenario of a  60 year old person coming to you with a  lower lid mass. Mostly Basal cell carcinoma.

1. What are the clinical findings suggestive of Basal cell carcinoma?
2. What are the H/P findings?
3. How will you manage it? (Went into details with the surgical techniques and reconstruction methods)
4. (Happy till now) She asked me, If the tumour was medially and involving the Nasolacrimal duct, how will you manage? (Said will excise the tumour and do a DCT…….but also told her that I wasn’t sure……..She said that’s fine

2. Showed me a picture of an Epibulbar dermoid and asked me the diagnosis

I said, this is an Epibulbar dermoid

1. How will you manage this patient……….. I described in details…….
2. What are the sites of dermoid cysts in the eye?
3. What will you be worried of when you are doing an excision of a dermoid which is in the superotemporal part of the orbit? (I said, rupture of cyst leading to severe inflammatory reaction,,,,,, she said fine,,,,,,,,what else (she wanted intra cranial extension).

 Pathology

Examiner 1

      Gave me a situation of a 4 month boy presenting with a mass in the superotemporal 

      part of the orbit……What are your differentials?

a.       Dermoid, dacryops, hemangioma………then was at a loss of words, when he said

      why can’t you think of a common thing like a chalazion?

b.      Went into details of management of Capillary hemangioma.

Examiner 2

     Showed me a fundus picture with hyperemic disc and what looked like an area of

     Retinitis…….I started describing, when I said Retinits, she asked me am I sure??

     I looked carefully again. I realized that the lesion was out of focus and told her that it

     could possibly be in the pre retinal area, she became happy, said that’s right, so what

     do you thing it is?

     I said most likely it is Fungal infections. She then went into details of types of fungi,

     ocular affection and management of Fungal endophthalmitis

General medicine and NeuroOphthalmology

Examiner 1 (UK, male)

1.Gave me a scenario. There is a patient who has come to you with sudden onset ptosis and oculomotor nerve palsy. What is the most important thing you will rule out………….I said Aneurysm. He asked me where is the site. I said in the area near the posterior communicating artery. He then asked me the importance of papillary examination.

2.  He asked me how will you examine for the action of superior oblique in

this patient? I said I will assess intorsion? How will you do that?

I answered 1. On S/L identify a prominent vessel and then check for the                        movement. On fundus examination assess the relation of the fovea to the disc.  (Seemed happy)

3.    He showed me a clinical photograph of the Optic disc. One eye looked normal and the other eye disc looked paler. I started describing the abnormal looking disc (Did not have a clue, as the disc was looking slightly pale sectorally was thinking along the lines of Resolved NAION. He said I will give a clue, this patient has this condition since childhood. I hesitatingly answered, Optic disc hypoplasia. He immediately approved (though I wasn’t convinced myself). He asked me regarding the systemic associations. I answered DeMorisier’s syndrome, agenesis of Corpus Callosum………..He kept waiting……..Then said, Won’t any gland be affected. I said yes, Pituitary gland.

4. Gave me another scenario…………A 50 year old male patient comes to you with unilateral severe headache……………..What are your differentials………..I started with In order of severity………..Temporal arteritis. Was very displeased. Asked me, will you get Temporal arteritis in a 50 year old patient? I said generally is seen after 60 years age, though can be seen earlier…………….He said what else? Something more common……..I said uncorrected Refractive error……….Again was unhappy……….Will you get a unilateral headache in uncorrected refractive error? By this time I was feeling flustered, the examiner was very aggressive …………He said some structure around the eye that can cause headache?? I said sinusitis………….Satisfied. Asked how will you manage? Answered…………What are other causes…………I said Migraine, Trigeminal neuralgia………….Asked me how will you manage trigeminal neuralgia? I said Medically with drugs like Carbamazepine, injection of alcohol in the region of the ganglion……….He asked any other………..I said ……….Not aware of any other way.

(Had a very bad feeling after this Viva, had started well but midway started going downhill!)

Examiner 2 (Indian, male)

1. Indian examiner, grim faced. Gives a scenario. You are in your OPD. Sister comes to you and says a patient in the waiting area is complaining of chest pain, what will you do?? I said, will shout the Emergency code prevailing in our hospital so that the Emergency response team can arrive, meanwhile I will start rushing to the site……….He said, the patient is stable and conscious, so what will go across your mind?  

I said, I will think of the possible causes and started giving the differentials saying will rule out the life threatening causes like Myocardial infarction, Aortic aneurysm rupture, Pulmonary embolism, Tension Pneumothorax…………He asks……..How do you think the patient will be sitting…………(Didn’t understand the question) I said he will be clutching his chest and bending forward………………He said fine, now what will you do…………I said, I will enquire regarding the history and based on the history……….will ask for the ECG machine…………He said before that………I said will check the BP and pulse…………(Satisfied) He asked me the different type of pulse that I am likely to encounter………………….Then he asked me what position will you want to give the patient…………I started saying depending on the situation…………If the patient was also breathless and possibility of heart failure was present………….will give propped up position…………..if signs of patient going into shock were present….will give leg raise position…………How will you manage if this is MI? I started with the management, when I mentioned IV Morphine………He appeared startled………….Asked me do you know what is the side effect…….I said there can be a sudden drop of blood pressure………..He smiled, then said, so do you want to give IV morphine………..I fumbled (At this point, he intervened and moved to the next question)

2. Another scenario. Patient is at the FFA table and collapses, the minute dye is injected…….What are your differentials…………..I said Anaphylactic reaction, Hypoglycemia, Syncope………..What is the definition of syncope? What is TIA?

What are the signs of Anaphylactic reaction? How will you manage? I started answering. He heard me out………..then smiled and said Thank you

3. Asked me regarding the ocular manifestations of Rheumatoid arthritis.

(Heaved a sigh of relief, the Emergency medicine viva had gone off better than expected)

Ophthalmic medicine

Examiner 1 (Indian male)

1. Showed me a fundus photograph with the disc in focus………..NVD was present but the rest of the Retina was not seen. So, described it…………..Then gave the possible causes……….Examiner kept smiling, as he was not asking any question…………I started with the management in a systematic manner, right from examination to investigation…………………(I am a Vitreo-Retinal surgeon, so this part was really cool) He seemed impressed and did not intervene………..I went on with management…….Then I started with the Pan Retinal Photocoagulation………..At this point, he asked me what will be your parameters……….I said it depends on the system……If it is the Zeiss ………….If it is PASCAL………….Then he asked what will you tell the patient about the possible side effects……………Explained in detail………(Examiner was very happy and realized that retina is my forte, so moved to Glaucoma

2. Asked me, how will you manage a young patient who walks into your OPD and on recording his IOP is found to be high………..

I said, will recheck the IOP, examine the IOP of the other eye…………..On fundus examination look out for the disc changes of Glaucoma (explained in details)………Then will ask for Central corneal thickness and Automated perimetry……..Smiled and said, If I said his IOP is 23 and CCT is 580, what will be his corrected IOP……………I said for every 16 microns change in thickness, a 1 mm hg correction is required………..So assuming 520 micron as the average corneal thickness………….his corrected IOP should be around 19 mm Hg…………He was happy…………Said very good…………..

Examiner 2 (UK female)

1. Showed me again a Disc photograph with a whitish fibrous tissue originating from the disc…….I was stumped……………I thought, it’s not possible that again they will show me a NVD………..But ventured with that as my first DD…………she kept a blank face…………I noticed that there were ILM folds temporal to the disc, so got distracted and went into possible causes of hypotony and ILM folds………She said, focus on the disc…………..I was blank………….She said do you want to give up?? I said no and asked if I could get some idea about the age of the patient………..She said a 10 year old boy…………….Then it struck me and I answered Bergmeister’s papillae………….She smiled

2. She then asked me regarding the causes of sudden painless loss of vision in one eye. I started with CRAO, Optic neuritis, CRVO, RD…………….and went on……I stopped after I thought I had exhausted my list……………….she kept looking at me and said what else……………I was stumped…………I thought I had covered everything, then finally said Panuveitis………….she was satisfied…………….

Asked me, about the clinical presentation of Optic neuritis, how to differentiate it from NAION. When, I told about field defects, she asked me, do I know the reason for altitudinal defect following NAION? I didn’t know but told about the ONH circulation……she kept looking………I said I don’t know correctly……………….Then she asked me about the management of Optic neuritis………….I started with Oral steroids………..She asked me regarding the duration of treatment…………I said, I will slowly taper the oral steroids over 3 months to a dose of 10 mg and then continue at that dose for at least a year and monitor for response……………….She said what are the exact ONTT recommendations……….I said this is what I am aware about………She said do you know of any other studies………..I quickly mentioned CHAMPS, ETOM, CHAMPION………She asked me about CHAMPS……….I told her promptly…………Became happy. 

Overall, had a mixed feeling at the end of the viva…………..

Day 2

Anterior segment

Case 1 (UK, Male examiner)

A patient sitting on S/L. I first cleaned my hands, asked whether I could observe the patient’s external features. Was asked to proceed to slit lamp examination. I examined the oculars, adjusted the magnification, started with diffuse examination………….Kept explaining what I was doing at each step……………patient had microcornea, iris coloboma……………………..The discussion then went on what further examination, management (was smooth) Said, will dilate and examine the lens and fundus. Likely to have Retinochoroidal coloboma……….Based on refraction, lens status and fundus findings, will decide further management……(Examiner satisfied)

Case 2 (Indian, male)

Patient appeared to have a Diffue corneal opacity in the Right eye……….Before I could start examining on the S/L……….Examiner asked to examine the other eye………I noticed there was a whitish tuft on the papillary margin inferiorly, presence of pigments on the anterior surface of the lens………….I found few KP’s on the endothelium……….So, the examiner asked me……..What do you think you are dealing with ………….I said, it is a case of resolved uveitis………..Asked me what else will you like to examine………….I was blank………………The patient was a 25 year old male………..Examiner said will give you a clue…………The disease started in childhood…………………………Initially could not put the pieces together, then it struck, the other was actually a BSK………….I said, Juvenile RA………..He smiled……..I talked about the types………..(Examiners seemed happy)

Posterior segment

Case 1 (Nigerian, Male)

Asked me to so s/l biomicroscopy………..I noticed there were hard exudates macular thickening, and sectoral photocoagulation scars……….I described and said Moderate NPDR with CSME with Lasered resolved ITBRVO…………He said are you sure……I said ‘Yes’ I said I will like to examine the other eye………..Had similar findings………….He said now do you want to revise the diagnosis………….I said, I will like to perform Indirect Ophthalmoscopy to scan the other quadrants for NVE………….I could not find any…………….I said, another possibility is that the patient has PDR and has undergone 1 sitting of laser…………He said how will you know for sure, I said, I will like to FFA………..

Case 2 (UK, Male)

Examine the patient with Indirect Ophthalmoscopy. Old lady, when I started asked me to be gentle…………….I saw STBRVO (Resolved)………….I described the findings and said STBRVO……………Does it look fresh or resolved…………..I said resolved………….Asked me how will I distinguish………Answered in detail…………Asked me what are the sight threatening complications…………I said Macular edema, Vitreous hemorrhage and Glaucoma……..(Examiner happy)

Case 3 (Nigerian, male)

Slit lamp biomicroscopy………….Patient had presence of Disc pallor, pigment corpuscles, arteriolar attenuation………….I said I will like to examine the other eye………Had similar findings…………..I said Retinitis Pigmentosa……..What tests will you like to do? What are the systemic associations

Examiners appeared happy, said well done!

Ocular motility and Strabismus

Case 1 (UK, Female)

Asked me to examine pupil………….i asked for room light to be dimmed. Asked another person to throw light with a torch from distance. Use pencil torch and started moving the torch from one eye to the other rapidly………Noticed presence of RAPD…….

Examiner asked me to examine the field of the other eye……………I started………..Asked the patient to occlude the other eye…………Asked if he could see my entire face……….At this point the examiner interrupted, would you like to do something……………I realized that I was not at the same height as the patient………….I said ‘Yes’, I will like to lower the chair height ………..She smiled……….Then I continued uninterrupted with my examination……………

She asked me how will you check for central field…………I showed………..Happy

Case 2 (UK, Female)

Asked to observe the patient from a distance and described. Noticed that the left eye had Ptosis, frontalis overaction……….I did ocular motility, there was a widening of the palpebral fissure on abduction with slight restriction of abduction………….I said, I have 2 differentials…………..1. Aberrant regeneration of the 3 oculomotor nerve and other is Duane restriction syndrome, however Ptosis more in favour of the first……(Examiner happy)

Case 3 (Both examiners)

Quickly have a look on S/L biomicroscopy and tell us the finding, you have exactly 10 secs…………I saw it was Tilted optic disc with hypoplasia……..(Examiners very happy)

Oculoplastic

He said, you will be given 2 cases and 5 minutes each, imagine this is your clinic and do what you will normally do.

Case 1 (UK, Male)

Case with bilateral Ptosis. …………..I went about examining the patient and describing each step………(I wasn’t interrupted) At the beginning in differentials had mentioned Involutional and Myasthenia Gravis)………….Ended my examination with ocular motility………Examiner seemed satisfied. Asked how will you manage……….Described in details. Examiner satisfied

Case 2  (Saudi, Female)

Bilateral proptosis…….I started examining. Asked for Hertel’s Luede……..Said to bypass that step………………….Examined for Thyroid goiter………..Did ocular motility and noticed Lid lag (Described it) Examiner asked about other signs….Described all signs with name in details (Examiner very happy) Asked management…………Again started from beginning in systematic manner. Wasn’t interrupted. When I finished……………Was told ‘Very good’

The clinical stations went off very well……………….My hopes revived…………

The results were out in a matter of 4 days. A pleasant surprise and passing was the icing on the cake.

I hope my experience will help others while preparing. I felt that there were a lot of questions asking Causes of headache, sudden visual loss….etc and it seemed that the examiners had a list of differentials and until all the causes were enlisted, they kept persisiting………So, my suggestion is that you should revise the commonest causes of various symptoms and situations in details…………Also, practice examining as many cases as possible and if possible keep discussing with a colleague………..