FRCS Part 3

Centre:   New Dehli

   Date:    September 2012

Hi Friends,

My name is Dr Sabyasachi Sengupta. I am a vitreoretina fellow at Sankara Nethralaya, Chennai, India. I have passed the FRCS part 3 examination in 1^st attempt held in Delhi in September 2012 thanks to the support from my wife, blessings from my parents, wishes from my dear friends and above all, god’s grace. I am sharing my experience and hope this will be useful for future candidates

Follow the link for my suggestions for reading from various sources including preferred books and online resources – http://www.eophtha.com/eophtha/f2f1.html. The link is designed for preparation for an Indian exam but is applicable for FRCS and other exams as well.

Day 1 experience – 25.9.2012

Ophthalmic Pathology and Surgery – OSCE

1.      You have operated trabeculectomy yesterday and on post-op day 1 there is a flat AC. How will you proceed? After being satisfied with all the differentials, I was then asked specifically about management of suprachoroidal hemorrhage

2.      A 65 year old lady complains of visual distortion since past few months? D/d and questions on FTMH – stage 2

3.      ECCE with IOL (uncomplicated) – 1 month post-op has refractive surprise of – 3.50DSph. What are the causes and how will you manage? I managed quite well – said regarding wrong IOL formula chosen, Wrong IOL implanted, oil filled eye, post LASIK eye etc. Also said regarding Contact lens, monovision, refractive surgery and IOL Exchange in management

4.      Photograph of a large fleshy pterygium encroaching onto the center of the cornea. What is the pathology of pterygium and what layers of conjunctiva and cornea are involved histologically? How will you surgically dissect? What are the 2 things you will tell the patient? How will you reconstruct the conjunctival defect? What is the pterygium belt of the world

5.      Avellino corneal dystrophy – features, management, origin of the name of the dystrophy? DALK – Anwar Big bubble technique

General medicine and Neurology (Tricky)

1.      Photograph of a large anterior staphyloma – I said it was due to trabeculectomy with MMC. Examiner gave hint and I managed to utter scleromalacia. Asked DDs for staphyloma, systemic associations of scleritis, management of Wegner’s granulomatosis, scleral patch graft, use of immunosuppressants

2.      21 year old obese lady with headaches and papilledema. One diagnostic modality of choice – what would that be? How will u manage? Wanted weigh.t reduction as 1^st answer and wanted MRI with MRV as investigative modality of choice

3.      Gave a scenario – 24 year old lady with rash on the face and involvement of small joints of hand – what are the DDs – I asked for ANA and ANCA results, was told that ANA was positive, then I said will do ds-DNA – said it was positive too; I confirmed SLE. What other organs are affected? Lupus nephritis – what tests will you do for confirming lupus nephritis? What are the ophthalmic manifestations of SLE and which is the commonest – I said dry eye – seemed happy

4.      Scenario – 45 year old lady detected to have irregularly irregular pulse on routine preoperative examination. How will u proceed? I said that Atrial Fibrillation is the most likely cause. Asked causes – I said Valuvular disorders like MS, MVP, MR etc. Asked any other non cardiac causes - I said Thyrotoxicosis – asked how will u confirm – said T3, T4, TSH. Asked how is Atrial fibrillation treated – I said Digoxin – seemed happy and asked regarding any newer drug – I said adenosine, didn’t seem happy. Then asked what the ophthalmic complications of A.Fib are? I said CRAO – asked management of CRAO. Then asked what other complication can occur? Gave hint and I answered embolic stroke – asked which region – answered MCA territory causing hemiplegia – seemed happy

Ophthalmic Medicine – OSCE

1.      Gave me a color fundus photo of pseudohypopyon stage of juvenile Best’s disease. Asked what are the stages of Best disease, what investigations will you do – wanted EOG and Genetic analysis

2.      Clinical scenario – 7 year old boy with progressively worsening erythematous lid edema over 24 hours – what are the DDs – work up of orbital cellulitis and its management

3.      Aniridia – ocular associations? Management, systemic evaluation, surgical intervention, genetic testing

4.      Showed a photo of marginal keratitis, DDs from PUK and Mooren’s ulcer, pathogenesis of marginal keratitis, management with role of steroids, complications – perforation etc. Asked how staphylococcus looks on grams stain? Asked whether I know the steps of Grams stain – I said I don’t do it often myself so I don’t remember it

5.      Showed photo of Giant papillary conjunctivitis – asked about contact lens associated GPC, its management. Asked what will you do if the patient refuses to wear glasses and insists continuing his CL wear?

Day 2 Experience – 27.9.12

There are 4 examination rooms you are supposed to attend. Each room has minimum of 2 and maximum of 3 patients and 2 examiners. You have 12 minutes in each room and are expected to quickly examine a minimum of 2 patients in each room (6 minutes each). If time permits, you get to examine the 3^rd patient as well. The trick is to examine quickly and answer as many questions as possible so that you can take a shot of all 3 cases. This gives you the best chance of scoring adequately.

Room 1: Posterior Segment cases:

Case 1: Use 78D lens - Classical retinitis pigmentosa. All routine questions asked. Investigations – ERG, Visual field analysis and what do you see in each. What are the atypical variants of RP, what are the systemic associations of RP, what is pseudoRP, ocular associations of RP etc

Case 2: Indirect Ophthalmoscopy - Central retinal vein occlusion – lead the examiner into differences between ischemic and non-ischemic variety of CRVO, role of FFA, management of macular edema with intravitreal pharmacotherapeutics, role of prophylactic laser, risk of NVG, need for systemic work up. This part of my VIVA was flawless and I cracked everything including CVOS, CRUISE, GENEVA and COPERNICUS trials for CRVO

Case 3: Quickly examine the ONH – was markedly cupped. No more time for any more questions on this

Room 2: Neuro-ophthalmology and ocular motility disorders

Case 1: a middle aged lady with right sided ptosis, elevation restriction and abduction restriction – looked like incomplete 3^rd nerve palsy + 6^th nerve palsy (rare combination). I said that this combination can occur only in a cavernous sinus lesion as these 2 nerves meet only at the cavernous sinus level. No proptosis, No anisocoria (Pupil sparing 3^rd nerve). Asked all possible etiologies of cavernous sinus – inflammatory (Tolosa Hunt), infectious, Neoplastic, vascullitis etc..Asked what Neuro-imaging you will perform and why? I said MRI with contrast and MRV – didn’t seem entirely convinced

Case 2: Young girl with alternate Exotropia (freely alternating) – asked to examine thoroughly with Cover, uncover, alternate cover test and Prisms. Asked how will you manage? I said Resect+Recess in one eye or B/l LR recession. Asked to commit on one surgery – I said Resect+ Recess in one eye – seemed happy

Case 3 (most tricky case): A young boy with nystagmus and alternating esotropia (alternating esptropia is exceedingly rare I believed until I saw this patient). May have also had V-pattern strabismus along with esotropia but I couldn’t tell due to too much nystagmus. Every examination including cover, uncover etc was tough due to associated nystagmus. Didn’t do too well in this case but was fortunate enough to attempt most basic questions in the previous 2

Room 3: Oculoplasty and Lid disorders

Case 1: Young boy (3 year old) with right mild congenital ptosis, was very subtle and not easy to identify, looked almost normal at first glance to me. I also examined the pupils in dim light and EOM. Was asked why I wanted to examine the pupils so much. I said that pupil and EOM evaluation is a must and part of conventional teaching with every case of ptosis irrespective of cause. Also said that I wanted to rule out Horner’s syndrome especially as the child had very minimal ptosis. Examiner seemed impressed and asked few questions on congenital and acquired Horner’s syndrome. Then he asked “Is this Horner’s?”. I said No. Then asked what is it then? I said I wanted to rule out Marcus Gunn Jaw winking phenomenon before labeling it as simple congenital ptosis. The MGJW was negative.

Then asked how I would like to treat. I said that this is a very minimal ptosis and would thus like to observe only. Indications of surgical correction are stimulus deprivation amblyopia or cosmetically unacceptable ptosis appreciated by the child. I also mentioned that congenital ptosis is a non-progressive condition and hence surgical intervention may be delayed till Primary school going age (6 years) especially if the child or parents complain of cosmetic appearance. There is no chance of amblyopia developing in this child at all.

Final question of the case was what other tests you would like to do before putting the child under the knife. I said I would check the Bells phenomenon (asked to demonstrate), check whether upper lid of other eye drops when the affected ptotic lid is lifted passively. What else – I could not answer – was told you must check corneal sensations as well.

Case 2: Straight forward case of Myesthenia Grevis. Everything was positive for myesthenia. Patient was an elderly gentleman (around 60) with severe ptosis (fatigued LPS from repeated examinations by other candidates), minimal EOM restriction, prominent eye balls but no proptosis, Positive Cogan lid twitch sign. Asked differentials – I said CPEO if EOM restriction is present, Eaton – Lambert syndrome especially if the patient is a smoker

Asked what other tests you will do to confirm Myesthenia grevis? I said I will enquire regarding systemic fatiguability, dysphagia, Ice pack test, Single muscle fiber EMG in orbicularis (decremental response expected), circulating Anti – cholinesterase Antibody titre estimation, and pharmacological testing with Tensilon / Neostigmine. Also rule out thymoma (HRCT Chest) and red cell aplasia and other systemic associations.

Asked how will you treat? I said Pyridostigmine, Oral steroids, Crutch spectacles for the ptosis. Asked what else is available for the ptosis. I could not answer but said that surgery is not indicated.

Case 3: Case of Phthisis Bulbi – asked what can you do. I said Evisceration and Ball implant followed by an artificial prosthesis for cosmetic correction. I specifically mention evisceration gives cosmetically better results compared to enucleation with implant, asked why, I answered, Then asked what Ball implant materials do you know? I said Bio-integrable and non bio-integrable. The bell rang and It was over

Room 4: Anterior segment examination

Case 1: Middle aged gentleman with small (3mm) para-axial nebular corneal opacity in his left eye located in the anterior stromal region. Epithelium and endothelium were in excellent shape. Asked what level and what type of opacity it is. Patient also had some ghost vessels in the cornea traversing from the limbus and going upto the opacity. Was asked whether the opacity will cause visual loss? I said “No it will Not”.

I also commented in the other structures – AC quiet, iris normal, Lens – NS2, was asked to look at the nasal conjunctiva – I discovered a very small pterygium as well – examiner was happy.

Then was asked regarding different filters on the slit lamp and their utilities – was able to answer. Then I was asked to demonstrate scleral scatter on slit lamp. I demonstrated it but the examiner wanted the slit to be off axis which I duly performed

Case 2: Given Torch light only, no slit lamp. Was asked to observe a young 7 year old girl from head to toe and asked whether there were any defects noted. I noted a long Beak shaped nose and spider fingers but said that I wasn’t sure.

Then was asked to use the torch light alone and see what the defect in the eye was. It was again very subtle but the child had bilateral superonasal subluxated clear lenses. Wasn’t easy to pick on torch light alone as the pupil was not well dilated and child was not very co-operative.

Was asked again to examine the child – I found high arched palate, gave hint to look at the chest (of whatever was visible above the dress). I thought of pectus excavatum but nothing was visible to commit to that. Said may be Marfans syndrome, Ehler – Danlos or homocysteinuria. Said I would surely take a pediatrician consult for this.

Asked how will you manage? – I said that definitive management is by Lensectomy + Vitrectomy + Scleral fixated IOL. However, if refractive correction is feasible, then would delay the surgery till as late in life as possible. Asked Why? I said that prolene suture related complications occur with 7-10 years of SFIOL and may cause decentration, suture breakage, loosening etc. The life of the prolene suture is finite. Hence delay the surgery as far as possible. The Bell rang and time was up.

Tips for Cases – SPEED is essential while examining. Try and examine the routine cases in your own OPD as quickly as possible and keep a time limit on yourself on a daily basis while examining patients. Answer quickly and do not ask too many questions to the examiners, you may ask a few relevant questions though.

Finally, remember that what you do on a daily basis over the course of your residency determines your outcome in the FRCS – part 3 exam. If you are able to examine patients within 6 minutes and not miss findings by the end of your residency then no one can stop you from passing FRCS. All the best

Please feel free to interact with me on drsunny1980@gmail.com