FRCS Part 3

Centre:   Amman

   Date:    Dec 2012

Hi Friends ,

I am Dr Hari Karishan, working as consultant ophthalmologist in Taif, KSA. Basically from Karachi Pakistan. I have passed my FCPS(ophth) in 2003 and was away from the studies for 9 years. But by the grace of Almighty Allah, good support and prays of my family and my dears and nears, I got through, thanx to all. I read kanski thoroughly, oxford’s handbook, wong, wills eye manuals, American academy selectively( general Medicine, peads and strabismus, other selective topics), oxford’s emergency medicine(last 80-90pages). Above all thanx to professor Chua site for better guidance.

I am sharing my experience hope it will help for future candidates.

Day 1 Experience 3-12-2012

Neurology & General Medicine

Examiner 1: He was Pakistani with nice smile on the face, he started with scenario that 73 years old pt presented to you with mild to moderate ptosis, what is your D/D? I started with classification of the ptosis that neurological like 3^rd nerve palsy, horner’s syndrome, myogenic like myasthenia,myotonic dystrophy, Aponeurotic like postoperative &tranmatic then he interrupted , how will you differentiate b/w them ? I replied if 3^rd N palsy I will check EOM, horner’swili look for the iris & pupil and then he asked what will happen to pupil? My answer was miosis and heterochromia in iris. What is the reason for enophthalmos ? how will you confirm the horner? I answered by pharmacological test and investigations, then he explored everything in details, pharmacological test results, causes of central , pre-ganglionic & post-ganglionic and their investigations. Then he showed me a photograph of peripheral corneal ulcer to describe and D/D, I started with ocular and associated with systematic diseases. How will you treat? As the eye was angry looking so I told along with the local I will start the systemic immunosupsresants , what immuosupresants? After excluding C/I of steroids , I will start systemic steroids. Then he asked systemic S/E of steroids, my answer satisfied him.

Examinor 2: He was Jordanian , 80 years male pt with fever, headache and weight loss, he showed me the fundus photograph of the pt having swollen disc with splinter haemorrhages , what is the most likely diagnosis? I replied Giant cell arteritis  with AION, investigations and treatment he asked, which I answered well. Then he showed me another photograph of swollen disc and asked me D/D? my answer was I want to see the fundus of other eye, he replied more or less same picture, then I gave the D/D of papilloedema. Then he asked you are sitting in the clinic, outside in waiting area a 40 years old female developed seizures , how will you manage? I will call  emergency team meanwhile I will take care of her respiration, airways and circulation by putting airway, maintaining i/v line, giving 100% O2 by mask and to control seizures I will give her i/v lorazepam, then I will take the history if some relative is available. What will you ask in the history? Whether this is first time or recurrent? h/o space occupying lesion, diabetes, he asked why diabetes?  It can be a hypoglycemic ?h/0 hypertension, BIH, pregnancy, again he asked why? My answer was eclampsia, then bell rang.

OpthalmicMedicine:

Exaiminor 1: He was Egyptian, showed me photograph of cornea to describe, it was corneal stromal dystrophy but little confusing. It was thick ropes with dendritic fashion but whitish, crumb, sugar granuals, so I was confused b/w granular and lattice, so he asked how will you confirm? It will be confirmed on biopsy , he astonished “ will you do biopsy for diagnosis”? No sir !when we will do the keratoplasty then we can confirm it by staining, then he asked different stains and tell one diagnosis, I replied lattice, then clinical presentation and treatment. Then he showed me photograph of anterior segment with dilated pupil and psuedoexfoliatio, he asked where this material is deposited , I replied papillary margin, lens , zonnules and angle. What is called there in the angle, my answer was Sampoalesi’s line. Systemically where it is present which I could not answer. What are the worries during cataract surgery which I replied well. Then he showed me a photograph of two hands with long fingers and thin skin with prominent veins, asked D/D. I told Ehlerdanlossynd, Marfan’ssyn, oculr features , during answer I mixed some systemic features then he asked systemic features ,again I mixed some ocular features then he became irritated, tell me most common life threatening condition? I replied dissecting aneurysm of the aorta.Although thebell has rang long before but he continued.

Exaiminor 2: He was not having enough time to ask much , he showed me photograph of anterior segment, cornea with kps but the quality was not good so I took a little time that this is photograph of the cornea showing whitish deposits on the posterior surface,  he asked what it could be? The bell rang but during standing I replied it is fine nonpigmented kps.

Opthalmic Surgery and Pathology:

Exaiminor 1:He was British ,nice and very cooperative, showed me a photograph to describe  having limbaldermoid, why are you so confident? I told nothing can be other than this b/c I can see the hair on it, then he asked clinical presentation ,treatment and its indications. Simple excision will again cause the astigmatism so excision with lamellar graft. He also asked on which meridian will be the plus cylinder, which I have not replied confidently and he also ignored it, systemic associatios, my answer was golden har and Treachercolin’ssyndromes.

 2^nd photograph of scleral thinning with severe inflammation at 12’o clock, asked about D/D and Management, steroid c/I, what will you do before starting steroid? I replied confidently. Surgical treatment , I replied after controlling inflammation, we can do scleratic patch graft and amniotic membrane graft, next question how it works ,he was looking satisfied to my answer.

Exaiminor 2: He showed me photograph of acute dacriocystitis with abscess, give D/D? management? answerd well.2^ndphotograph of corneal endothelial dusting, mature cataract with posterior synechaesto describe? What is the diagnosis? I replied either it is chronic uveitis with mature catatract or mature cataract leading to phacolytic glaucoma. How will you differentiate? On history, clinical examination, difference of kps, iop.Management of the cataract? I answered after controlling iop, inflammation and doing B scan at my level I will go for ECCE+iol, which iol? Replied Heparin coated, then bell rang.

Day 2 Experience 4-12-2012

There were 4 examination rooms, each room has minimum of 2 and maximum of 3 patients and 2 examiners. We 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 may 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 may have chance of all 3 cases, this way you may get a chance to score more.

Station 1-Ocular Motility Disorder &Neuro-ophthalmology:

1st case was 9-10 years boy wearing glasses, task was squint examination, so I started with VA but they told leave it, I did Hirschberg , cover uncover and alternate cover test for far and near with accommodative target, with and without glasses, then ocular motility with torch, I asked for prism for angle measurement, they asked to quit it . In the last examiner asked me to summarize the findings and give diagnosis. I replied pt having esotropiaof  15degree roughly for near and almost orthophoric for far, with glasses orthophoric for far and near both, so diagnosis is accommodative esotropia. What will you do in this case? I will observe the case only.

2^nd case 20 year old young man, observe the pt without torch, he was having left exotropia, then asked me to check the pupil, I did direct ,indirect and swinging light test, he was having RAPD, what examination you would like to do? Optic nerve functions, fundus examination. What are the optic nerve functions? Then he asked to see with 90D, he was having posterior subcapsular cataract and optic atropy. What are causes of optic atrophy in this case? I replied looking at the age and Posterior sub-capsular cataract,  trauma is the most common cause, next glaucoma, then bell rang.

Station 2-Oculoplasty & Lid Disorders:

1^st case was 20 years old young man havingaxial proptosis with lid retraction, you are sitting in oculoplastic clinic examine this pt. I started with observation , there was axial proptosis with left lid retraction so I will do the proptosis examination then he discussed thyroid eye disease in detail i-e investigation , systemic presentation. If thyroid is normal what other diagnosis comes in your mind? IOID was my answer. If I allow you for one question to ask, what will you ask? I told I will ask about the pain. He smiled & bell rang.i missed here palpation of the orbital margin, retropulsion, dependent head posture and valsalvamanuovre.

2^nd case3years girl , observe the pt, the girl was having BE epicanthal folds , palpebralis type, what it can cause? Pseudoesotropia was the answer. How will you treat? I will do y-v plasty. She was also having BE dermoid cyst, he asked me D/D? BE dermoid cyst, dacryoadenitis ,sarcoidosis, lymphoid and leukemic infiltrations. Management? I replied ,will do x-ray and CT Scan to know the extention , he objected on x-ray, how will you take x-ray of this small girl? I replied by sedating her, I will go for excision biopsy.

Will you go for excision biopsy directly? As this is a benign condition I can keep her on observation, but the pt is a girl so cosmetically if the parents are worried then I can offer, totally depends upon the parents. Bell did’nt permit him for further questioning.

Station 3-Anterior segment:

Case 1: 55 years, male with psuedoexfoliation, slit lamp examination. He asked where the material is deposited, where it comes from? I replied it comes from the lens, he started making faces. He asked is there any relation b/w cataract and PEX material deposition? I replied no, this is related with glaucoma capsularis but he was not in mood of coming towards glaucoma so he asked difficulties during cataract surgery? Zonnulardehiscence , poor pupil dilatation, what will you do? I will try to dilate 2-3 before surgery with cyclopentolate&medipherine, if not then myricaineinj prior to surgery, as a last resource I will use iris hooks.

Case 2: 20 years old female with adherent leucoma, iris abscission temporally, vitreous strands infront of the lens temporally, lenticular changes. Question were simple like ,whatis adherent leucoma ? if there is no corneal opacity then what will you call it? If you were a surgeon , how would you have managed this case? In the last he asked before going to operate what will you see on the table? I answered I will look for extent of the wound and the bell rang.

Station 4- Posterior Segment:

Case 1: young female sitting on the slit lamp, he asked to look at anterior segment of left eye, it was prosthetic eye, now look anterior  segment of right eye, conjunctivalscarrig, on the cornea band keratopathy like deposition temporally only, deep anterior chamber, aphakic eye, he gave me hint anything in A/C then I looked for cells and flair, both were positive. Then he asked me to see the posterior fundus, he told I know this is the difficult case but you try to see, I started describing vitreous haze, disc is just visible, he guided look infero-temporally there were multiple hypopigmentedlesins. Then he asked me D/D? intermediate& posterior uveitis, old treated RD. then again he gave hint “what do you think what would have happened to her left eye”. Then I got the track, most probably left eye was enucleated b/c of trauma and now she developed sympathetic uveitis, he smiled and bell rang.

Case 2: young male around 22, posterior fundus with 90D, Disc was little hypraemic, vessel attenuated, severe choroidal sclerosis, macular scar in the right eye, bone spicule like pigmented lesions in the mid-periphry. He asked me D/D, Choroidemia&Retinitspigmentosa. What will you ask in history? Family history of nightblindness, history of glasses ,what will you find? Myopia is associated with RP &choroidermia. He showed me his glasses which were roughly 5-6D myopic. History of hearing loss , he asked why? Replied RP’s systemic association Usher &Refsume syndromes then he asked other systemic associations. How will you manage, as from the fundus examination it is obvious that pt has very poor vision so I will check his refraction and refer him for low vision aid. In the last he asked if I allow you for one blood investigation , what will you advise? My answer was “serum phytanic acid level”it was the end of examination.

My suggestions to the candidates:

Study thoroughly

Practice the clinical examinations routinely in your clinics

Discuss with colleagues

Make one book as the main book and other books for the references and add points on the main book, so that last one month for only revision and discussion

Examine the pt thoroughly & quickly, try to correlate the findings

ALL THE BEST TO ALL FUTURE CANDIDATES

Feel free to contact me on kirshandrhari@gmail.com&skype id hari454