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I am Dr Muhammad Naeem awan from Lahore Pakistan, I appeared
for FRCS ophthalmology Glasgow in april 2014 ,at Amman Jordan.It was
my first attempt and with grace of almighty Allah I passed.
When I was preparing for my exam CHUA Eye Page was my favourite , I
used to read previous candidates experience,exercises ,viva etc. So it
gave me confidence for exam and helped my a lot in my self assessment.
The books , as all people know are Kanski , Will s Eye Manual ,
Examination Review ( Wong) , oxford hand book of medicine.These are
must and other books can also be read.
I am highly obliged and thankful to Chua Eye Page for my preparation
of FRCS 3 and also Prof Muthu ,who guided me during my preparation of
FRCS 2.
This exam is two days exam.
Day 1 , clinical cases , comprising of four clinical stations with 8
examiners.
Day 2 , Three table viva with six examiners.
Day 1, 29 April 2014 Tuesday
, Lasik Center , King Hussein Medical Center , Amman Jordan
Our reporting time was 10 to 10:30 am.Pre exam briefing was given by
Ms. Hilary Dunk and DR Arvind Singh.He said if you examine lot of
patients in your practice and make right decisions ..here you will
pass.Our aim of examing you is that how safe you are , while
practicing as ophthalmologist
Our batch consisted four candidates and exam started on10:56 am .
12 minutes on each station and two min gap for shift over
Station 1 Lids & Oculoplastics
One female 60 years , sitting on couch , command was to observe and
examine lids,both examiners were side by side.On observation ,
significant finding was dermatochalasis both eyelids.I told examiner
this is a case of dermatochalasis .He said what do you want to examine
further.I said I want to see lid laxity , and it looks to be
pseudoptosis ,so I want to examine regarding that.He said ok,how you
will treat patient, I said blepharo-plasty . He asked procedure, then
asked indications of blephroplasty , complications of blephroplasty.We
discussed lid lag, exposure keratopathy and management.
Then he asked what are causes of lid edema.? I told him ocular
causes.He then asked systemic causes of perorbital edema.I told
cardiac failure ,renal failure then he said what about thyroid
disease. I said yes there is lid and periorbital edema , then we
discussed thyroid eye disease signs, symptoms,classification,risk
factors etc
Second examiner showed me , a young man looks to be 25 year old with
right facial palsy.Command was to observe and examine this patient.I
said this is case of right facial palsy.He asked UMNL or LMNL.I said
LMNL.he asked what tests you want to perform.I told and performed test
for VII nerve palsy, we discussed about bells phenomenon,then exposure
keratopathy,management and surgical options for paralytic
ectropion.Then he asked if patient presents to you like this how will
you proceed..i said I will ask detailed history, then examination…we
discussed briefly all cranial nerve examination to know any associated
cranial nerve involvement, then I told him I will do investigations
like CT scan or MRI to rule out any space occupying lesion or any
effect of trauma…Bell rang
Station 2 Anterior Segment
I was asked to examine and comment the anterior segment of patient
sitting at slit lamp. On examination , Right eye showed there was
corneal graft with edema ,very hazy view of anterior chamber with
white debris on endothelium..difficult to decide patient phakic,pseudophakic,or
aphakic.I asked examiner I want to examine left eye to know
possibility why penetrating keratoplasty was performed.He said sure.
On examination in left eye cornea was clear , pupil updrawn with
subluxated IOL. I told all findings to examiner,he said ok what is it
? I said failed corneal graft . He said how will you manage , I
answred ,second corneal graft,but I am not sure this patient s lens
status due to hazy view.Examiner said this patient is aphakic then I
said I will plan corneal graft with Scleral fixation PCIOL but I want
to know status of posterior segment of this patient.He said Posterior
segment is ok. Then he asked what are complications of Scleral
fixation IOL.Then he asked what can be cause of left eye subluxated
IOL. I told eventful surgery, trauma .He then asked management.
Examiner was satisfied..we had a good discussion
Second examiner asked to examine a 16 year old girl at slit lamp.On
first look I noted she is having large corneas,then on slit lamp I
noted cornea was large but very deep anterior chamber , I became
little confused but scenerio cleared when I asked patient to look down
there was a big bleb then I searched for iridectomy,,,,so there it was
..it was small iridectomy ..so I made my diagnosis. I asked examiner
can I see left eye he said ok..there were same findings in left
eye.Examiner asked me what is your diagnosis.i said Congenital
Glaucoma , with trabeculectomy done.He asked is this bleb working, i
said yes and he asked how do you classify congenital glaucoma,then he
asked secondary associations of congenital glaucoma.He asked Axenfeld
reiger anomaly signs and cause of glaucoma.He asked treatment options
for congenital glaucoma.Then he asked do you perform trabeculectomy ,I
said yes. I told him whole procedure of trabeculectomy.He asked any
antifibrotic agents you use,I told preferably MMC.we discussed
possible complications of trabeculectomy and their management like
patient came after 7 days with raised IOP and well formed anterior
chamber.what to do?
Station 3 Posterior segment
60 year female sitting at slit lamp, and command for me was to examine
posterior segment and comment your findings simultaneously,I started
my examination with a quick look on iris and lens. Pupil was
mid-dilated with no neovessels on iris, but there was cortical plus
posterior sub capsular cataract , I told examiner he said I know but
you have to see posterior segment. View was a little bit hazy I told
him optic disc is normal and there are exudates in posterior pole and
macular area,there are haemorrhages in all quadrants but I have not
seen any neovessel. Then he said ok examine other eye,it was
psuedophakic eye and view was better,optic disc pale , with vascular
changes , this fundus had multiple chorio retinal atrophic patches
also, The examiner said what is your diagnosis now, I asked is she
diabetic ,examiner said yes,then I told him this is case of NPDR with
Maculopathy.He became a little bit angry and asked what you said and
what does it mean NPDR, I said sorry sir it is Non Proliferative
diabetic retinopathy , with maculopathy. He asked how you will treat
this patient, I said I want to take detailed history regarding ocular
and systemic problems, examination,investigations like FFA ,OCT and I
will strictly manage systemic problems like DM, and hypertension, on
FFA I want to see any leakage , Examiner said do you expect leakage in
this case..? I said yes because there are exudates in posterior pole
area.Then I have two options focal laser for leaking aneursms and we
can use ANTI-VEGF to treat macular edema.
He did not look satisfied.So I was disturbed after this patient
Next patient 50 year female sitting on couch ,examiner handed over to
me Indirect ophthalmoscope(IDO) and said examine posterior segment of
right eye and also told me this IDO has dim light but manage to see
with this.I tried to fix head band on my head ,it was loose then I
tried to get my binocularity, it also became difficult for me to do
that..so my time wasted on IDO, with loose head band and improper
binocularity I examined patient,suddenly light gone..i was disturbed
what is happening ,I searched,wire was disconnected.Ok , then I saw
patient and just had look of posterior pole and inferior quadrant,
patient was uncooperative , she refused for examination and even not
following commands to look straight , look up and look down.One arabic
speaking Doctor was there but patient was very un-cooperative. Then
examiner said to me ok tell me your finding , I told him ,disc is
normal and there are pigmentary changes in inferior quadrant,other
part of posterior segment I was unable to examine.Then he asked what
can be the possibilities,I said may be patches of healed choroiditis.
In the mean time he called a young patient , and said to examine this
boy,I put on IDO, started examining but pupil was un-dilated..bell
rang
I was very annoyed and disappointed on this station
Station 4 Ocular Motility and Neuro-ophthalmology
16 year old girl sitting on chair,command was to perform extra-ocular
movements in this girl. I asked examiner should I perform cover/
uncover test ? He said OK you should, then he he came very near to me
and said how do you perform cover/uncover test show me.He observed my
methods very keenly,then asked what are findings.I said eyes
orthophoric. He said ok perform ocular movements ,I found left
abduction defect and retraction of globe in adduction . I told him
this is a case of duane s syndrome.He said what other findings I said
inferior oblique overaction,then he asked how do you check inferior
oblique action show me. I performed ,he had some objection then I told
him that inferior oblique elevates and abducts eye. We had discussion
on actions of inferior oblique muscle. Then he asked what surgery you
will perform to this patient..will you are not.? I was telling him
this is a complicated surgery , we have to tell the patient that……….
Next examiner called me,come here and check pupils of this
patient.This was a 70 year old man, I performed all steps with light
off and on, patient was having anisocoria due to left eventful
surgery. I told examiner all my findings ,he then asked did you check
for RAPD ,I said yes.He said do it again.I performed he then objected
why you are putting light from front. I said sorry sir, then I brought
light from sides and performed swinging flash test.He said ok. No RAPD
was there.
Then he showed other case and said this youg girl has left esotropia
,how you will measure ? I said alternate prism cover test.He said ok
perform test . Prism was there on table. I performed for both distance
and near .Examiner had objection on my cover by occluder but I
performed test completely ,he asked what are findings. Then he
suddenly said check temporal visual field of an old man….bell rang
In this station attitude of both examiners was very aggressive.
Day 2, May 1 ,Thursday 2014,
Hotel sheraton Al Nabeel Amman Jordan
Our reporting time was 10 30 to 11 am and exam started at 11:30 am
Station 1 Ophthalmic Medicine
Examiner 1
Photograph showing mild corneal staining, mid dilated pupil with
atrophic patches on iris ,lens opacities. What is diagnosis.? I did
not noted corneal lesion in first view bc it was very mild staining
.He asked what it can be I said post acute congestive glaucoma, post
viral uveitis.he said ok how do you treat acute congestive
glaucoma,then he pointed to corneal lesion and said if this patient is
having HSV epithelial keratits and viral uveitis how will you
treat..i told treatment ,then he said will you give IOP lowering drug
,I said yes because there is rise of IOP in viral uveitis.
Photgraph showing optical corneal section with grey colored KP on
edothelieum..i said this is Fuch s hetreochromic iridocyclitis.He
asked clinical features in detail then about glaucoma and angle in
these patients.
Examiner 2
Photograph showing hazy cornea ,with hypopyon,five sutures on limbus.
What is diagnosis.i said post operative endophthalmitis.we discussed
treatment of post op endophthalmitis.He said Vision is hand movement
in this patient .Next scenerio ,he said if surgery was ok ,after five
year this patient got blunt trauma of this eye ,what will happen and
how do you treat.i told all possibilties then we discussed types of
hyphema and medical and surgical management of hyphema.
Fundus photograph venous phase showing hyper flourescent spots in
periphery ,a few patches showed leakage.he asked what it can be first
I told the spots with no leakage can be telangiectasias ,then he asked
if patient is from afro-caribean origin what it can be…I said sickle
cell disease.he said ok.what are manifestations of sickle cell
disease.
He said will you treat this patient.i said if there is evidence of
leakage we should treat with photocoagulation.he said will it work.i
said theoretically it should work but I never come across a patient
with sickle cell disease.He asked if this is a case of proliferaive
diabetic retinopathy ,will you treat,I said yes its emergency and
should be treated.
He showed me photograph with marginal infiltrates on cornea.He asked
what is this , I said marginal keratiatis..he said good..bell rang
Station 2
Ophthalmic Surgery and Pathology
Examiner 1
Photograph of involutional ectropion,what is diagnosis.classify
ectropion,what are treatment options ,if generalized ,if only medial,
if associated lid laxity.
Scenerio 2 year old boy with white pupil,what are possibilities,I told
DD of white pupil,then he said if it is retinoblastoma , what other
clinical features,then classify retinoblastoma,how do you proceed. I
started from history ,examination under anaesthesia ,investigation I
said Bscan,CT Scan and MRI he said why..?then he asked treatment
options for retinoblastoma.
Examiner 2
Photograph of corneal abscess with thinning and perforation,how you
will proceed, I said history , corneal scrape ,conj swab for culture
and sensitivity to know organism then I will start antibiotic
treatment.He asked any test you can do in ten minutes to have idea of
organism ..i was confused on this question ..what to answer then 1st
examiner gave me hint do you know any staining ..i said ok we can do
gram staining and giemsa staining..it can help…he asked have you
performed staining by yourself..i said no.He said if etiology is
fungal , I said we will you use anti-fungal therapy depending on
filamentous and non filamentousfungi..Natamycin or amphotericin B.He
asked what antibiotics you want to start.I said ceftazidime and
vancomycin fortified prep…under cover of antibiotics I will plan
tectonic corneal graft..he said no graft will not stay in this
situation,other option I said glue he said no glue will not
stay..other I said conjunctival flap,,he said ok….this is needed
here..how do you perform conjuntival flap..i told procedure.
Station 3
Medicine and Neurology
Examiner 1 Medicine
40 year old male presented to you with severe headache one side and
drooping of eyelid and difficulty in upgaze,what can be diagnosis , I
said this is case of third nerve palsy other possibilities are
myasthenia gravis,myositis, myotonica dytrophica,CPEO/kearns sayre
synd..he asked what is significance of headache in this case I said
then Migraine is possibility bc it can cause cranial nerve palsy. Then
he asked causes of third cranial nerve palsy.
Photograph showing optic disc edema , he said what are possibilities I
told him causes of unilateral disc swelling then bilateral disc
swelling.He asked what do you want to see more in this photograph I
said macula for edema and macular star in Hypertension , vein
occlusion ,artery occlusion he said what else I said haemorrhages.he
said ok.
Then he gave scenerio of idiopathic intracranial hypertension,
discussed in detail ,medical and surgical treatment .then asked why it
is important for ophthalmologist to know.i said it can lead to optic
atrophy.
Examiner 2 Neurology
Photograph showing peripheral corneal thinning with mild congestion
.He asked what is this? I told peripheral ulcerative keratitis/
peripheral corneal thinning..what are other possibilities.I told
mooren ulcer,terrien marginal degeneration etc.He said tell me causes
of peripheral ulcerative keratitis ,I told all systemic causes like
RA.then he asked if patient is having epistaxis then what ..i said
likely possibility is wagner granulomatosis.He said ok how you will
manage.i said I will confirm diagnosis by test c ANCA , then I will
start treatment with cyclophosphamide.He said ok
Photograph showing swollen white chalky optic disc,he said this is 80
year male,with loss of vision with pain…diagnosis.? I said arteretic
anterior ischemic optic neuropathy.cause? giant cell arteritis.He said
ok tell me systemic features of GCA.then investigations.then treatment
options.aim of treatment.I told him all in detail.bell rang and it was
over.
I was happy and satisfied that day but worried about my posterior
segment sement station because of that indirect ophthalmoscope event.
Result came after one week.My friend zeshan told me on facebook that
you passed but he was not sure about my Roll number..i confirmed my
roll number ,so I have been passed..Thanks to ALLAH Almighty………So a
dream of my life came true.
My email ID:
naeem_eyesurgeon@hotmail.com
Skype ID: awan_naeem
My cell number: 00923214299307 |