8th December 2003 (9.00 to 11.00) Essay:

1) A 72 year old woman presents with recurrent left anterior uveitis. Examination demonstrates a cilliary body mass. Describe the management options available.

2) A 34 year old man is referred for excision of a 1cm diameter, non tender, partially mobile lesion of 6 months duration situated over the right supero medial orbital rim. Describe your management and differential diagnosis.

3) A 26 year old with a refraction of -7.00 Diopters in each eye enquires about refractive surgery to correct his myopia. What key investigations would you undertake and what surgical options are available to him.

NB: in all those questions: you have to consider that this patient is really in your clinic and write exactly what you are thinking. You have to consider possibilities of trauma because that is not excluded in first 2 Questions and you have to consider metastasis too. I wrote every condition with its characteristic features like what is mentioned in Wills' Eye Manual. Majority of us passed in this stage and we could not make out what’s 100% correct or 100% wrong. We came to know that they mark papers by looking for a key word and the more you write , the more you make it difficult for them to find it. I wrote about 3 pages for each question and I got 7. Just headlines and key words would make you pass, NO ESSAY.

8th December 2003 (13.00 to 15.00) MCQs:

They were medium difficulty and I think no body failed them as long as you are not guessing. The invilgilator told us if you attempt around a 100 without guessing then you are securing a 5 out of 8 which is a pass. I did the following procedure.

I started attempting only what I know very surly and I marked the answers directly on the answer sheet. I then counted and I found that I did around 215. That was more than sufficient. I revised to exclude those with 95% sure but I found none. I filled the rest as DON’T KNOW and I left. I secured a 7. You are in trouble if you attempt less than 150 then you must go back and gamble, attempting those with 90 then those with 80 to reach about 200. Every body should pass as long as they are not guessing. that’s a rule. Most of the Questions were out of the pool and I think its useless. Many questions were about inheritance and drugs and some about pathology but non were from anatomy or physiology. They asked about pigments (retina, choriod, syndromes with systemic associations and external ocular pigmentation). One tricky Question was about VISIBLE light and its effects, glass blower cataract, solar retinopathy, microscope injury during cataract extraction and one was about climatic keratopathy. Another tricky Question was about the motility defects in 4th palsy with first branch as absence of intorsion. They answered the question for us. Be sure they are very serious regarding mobile phones and electronic devices and talking during the exam. If you had attempted plenty of MCQs before the exam then don’t worry and don’t guess.
 

10th December 2003 Orals:

They divide you into 2 or 3 groups depending upon total candidates. We were about 56 so we had 2 groups. I was in the second one. 

Every candidate must go to 3 stations. Each station had 2 examiners with 10 minutes each. Those 10 minutes were the longest in my life so don’t estimate what 10 minutes can do. Every examiners would ask you and the other would write things. They write questions and how you handled the direction of the exam and your confidence during that. They also record how you handle education by seeing your response to what every new thing they tell you and well as your response to wrong thing you said when corrected. Many candidates failed because they said the right stuff but in a hesitant way. Many others were in a miss if they were told they answered wrong.

The examiners are humans and many would really make your night mare if you push your self to dark corners. In differential diagnosis: never tell what you can’t answer. If you are really hopeless they might tell you something like: your patient is dead or see you next time but that is rare. On the other hand my examiners were very encouraging and some smiled what I said something right. Majority is mask faced and that’s alright.
Every round they change the examiners so those that took your surgery would take medicine for the others and thus questions are rarely repeated but there are hot topics like cataract and trabeculectmoy in surgery and emergencies in general medicine.

General medicine is most of the candidates' night mare. They would ask very difficult thing and the fact that they are not ophthalmologists make thing worse. They might forgive you if you don’t know angina but they never forgive if you fail a common scenario like some one just became unconscious beside you in a bus. What would you do?

My first station was surgery and pathology, one was British and the other was Arabic surgeon. They started by showing me a picture of black person with white pupil. They asked me what I see ( colour photograph showing a face of a black person with conjunctival melanosis and white pupil) what made this person come to you (cosmetically for melanosis or decreased vision due to cataract) what type of cataract might this be (mature or intumesent) what treatment would you do for it (extraction) what procedures can you do for cataract ( ECCE and phaco) what machine are you using (Guider) what are the setting of the machine during different phase( depends upon you preference…tell him one thing and stick to it) is it peristaltic or venturi (peristaltic with super added venturi function) what technique you usually do ( I like divide & conquer) why ( I simply learned it this way ? ) OK….he thought for a second then said tell me is phaco proper in this case ( no but I would like to practice capsulorrhexis on this case) how is that done if you see no red reflex ( I stain it) with what ( trepan blue) tell me how to make a side port (15 degrees super blade just anterior to surgical limbus) do you stain under air or Helon (I like under air) why (good distribution) …here he lost hope of this topic and he jumped to trabeculectmoy. What type of trab do you do (limbal based) why ( I told him I like mitomycin C) OK..tell me indications (list them in order of frequency) what is the most common complication do you see in your practice( shallow anterior chamber) how do you mange that ( medically and I told hm the drugs with dose and frequency i.e. acetazolamide 200 mg tab qid for malignant glaucoma) what if those failed (surgery) what type ( we have YAg in our department) what is your most common complication when you do that (lens opacity and cataract)…the time was over and the second examiner handed him my evaluation card and he started showing me slides on his lap top. They were not named and even he was surprised from some slides.

1. Dislocated crystalline lens in AC: What do you see? ( I told him ) He looked very uncomfortable so he asked why !( I told him its very clear thing) he then took a deeper look at the photo and he said OH..The hole in the optic is not clear …it was a dislocated IOL or so he thought. What do you do for such a case ? (management of dislocated lens).

2. A slide with lots of cells: What is this? ( I asked him where is it taken from to give a diagnosis) he told me its not relevant and the slide is not clear either and I told him it looks like a cellular collection , might be inflammation. He told me its acute inflammation.

3. Myopic fundus: What is the abnormality here? (No abnormality seen and it’s a normal myopic fundus) What are the other things you would examine? (periphery for tears and degeneration).

4. Molluscum contagiosum: What is this? (I told him) what does it cause in the eye (a symptomatic but chronic follicular conjunctivitis is a possibility) how do you remove it (shaving, cryo and argon laser).

5. Failed penetrating keratoplasty: What is this? Is it a good procedure? Why ?( I missed the size which was about 8.5) and I said its good but I need to when was the graft done. The examiner did not waste time and asked what is the ideal size( 7) why (balance between rejection and astigmatism).

6. Optic nerve avulsion: What do you see? (coloured photo of fundus but I cant make out the eye (right or left ) because of extensive haemorrhage) What is your diagnosis? (optic nerve is missing so its avulsion) how do you manage the patient? (conservative with good care of the fellow eye) Will this person see again with this eye? (no).

7. Lattice dystrophy: What do you see and why is it lattice? Then what is inheritance? (AD) Where is the level (stromal) Is it recurrent in the graft? (yes) Have you seen many such cases ?(no not that many).

8. Optic nerve drusens: What do you see? Why? (told him characters) How can FFA help with diagnosis? (autoflourcence and associated macular pathology) What is the treatment? (reassurance, risk of subretinal neovascular membrane).

9. Sclerozing mass of the lid with loss of eye lashes: What do you see? (I described the lesion) what could it be (SCC, SBC or BCC) Which do you think is the most likely in the upper eye lid (SBC) Why? (characteristic location) Why? (more sebaceous glands) How do you treat the lesion? (that of tumour and that of the lid defect) What procedure is your favourite? (it depends upon the size of the defect).

They then thanked me. Two hours later was my next viva.

Its was ophthalmic medicine and there were one British and one Arabic examiner. 

1. They stared by showing me a photo of a geographical Dendritc ulcer stained with rose Bengal. What do you see? (apparently geographical ulcer with rose Bengal) OK...why (is the patient immunocompromised) no, what else? (is he on topical steroids) YES , an idiot put him on pred forte ? Now what are you going to do for him (stop steroid then antiviral drugs) which are those (Viroptic1% solution 8-9 times daily and acyclovir ointment 5 times) what is Viroptic (trifluoridine) do you use concomitant oral treatment too (no) why (no super added 
benefit) do you batch (no) what if its not healing (consider another diagnosis, compliance or therapeutic contact lens)…OK…

2. What are the diagnostic features of herpetic iridocyclitis? (those of anterior uveitis plus skin signs) What do they do to the iris? (segmental atrophy)..OK

3. Photo of a child with half his face covered with capillary haemangioma: what do you see( I described the photo) What is the diagnosis (just capillary or part of Sturge-Weber) what other signs of Sturge-Weber( I told him from the Kanski) what is the mechanism of glaucoma (post trabecular) how do you treat this child (spontaneous and 
    if extensive Co2 laser) what other danger to this child (ambylopia as it was covering the pupil)..OK

4. Photo of a 25 M with very black pupil with blackish lower lid and green pupil on the other side: What do you see? (I described) What is your diagnosis? (any history of trauma?) well…tell me some DD (it might be trauma with hyphema on this side and black eye and it might be a total iridodialysis) No , no trauma (then there is no history of IOFB to explain heterochromia) well that’s not possible in this case but which eye is faulty here (I presume the eye with black eye lid) yes any other DD (I kept silent for a sec) any malignancy you know of ( is he an AIDS patient) Yes [with a smile] (Kaposi sarcoma). OK

The bill rang and I looked towards the other examiner and he had a photo album with about a 30 photos on it. He told me to take my time and tell the most common diagnosis (no DD or fooling around ? ) …ready (yes sir):

1. Picture of BSV field with right half shadowed and diplopia written to the side: what is this (I took my time as he told me and I said its Binocular single vision, its called Estermann in UK and its used as a prerequisite to driving license in UK) he lost patience and told me …on with the diagnosis (diplopia in right half of BSV) why (right 6th palsy is a possibility)..OK..

2. He turned every other one and this time it was a diabetic retinopathy pre proliferative stage: What do you see? (DR) which stage (pre) why (IRMA was very clear)..OK

3. Subretinal haemorrhage: What do you see? Why is it subretinal haemorrhage? (the vessels are passing above it) what is the most common DD (trauma) like what kind (chest compression) What is the name of that retinopathy?  (Purtchers)..OK

4. Photo of morning glory disc: what do you see (morning glory)..OK

5. Eye looking down with Munson sign positive: What do you see? (eye looking down) why you think I made her look down (testing for motility defects) what else (in this case Munson is positive) when is it positive (Keratoconus) what other sings are there (I started describing the whole disease) no , no tell me what is the name of corneal stria? (Vogt) is it vertical or horizontal (Vogt for Vertical – Haab for Horizontal)…OK

6. He asked the other examiner to turn a video clip showing a young woman with bilateral INO: what is the defect (bilateral INO) what is WEBINO syndrome (Walled eye bilateral INO) where is the defect (in which one I asked) he smiled and said if you are so confident, tell me that of one and a half syndrome (I smiled and  told him realizing it was a mistake trying to flex my muscles) he smiled again and said OK..what is the most probable disease behind all those defects (MS) .. right…what do you do next (send her to a neurologist) he was surprised and said are you not going to check any thing else before that (yes ON) and …( I stared at him 
for a sec) ..OK what will your neurologist do (my neurologist is very busy man and he would do MRI straight away ? ) OK…what HE might find (typical peri ventricular plaques)…what is ONTT ( I told him from Kanski) and what if the patient came to you already taking oral steroids (nothing but I would expect higher recurrence) for how long would you let him on steroids (an expert opinion is needed form internal medicine specialist)..OK

Both thanked me and told me to be ready for my last viva. 2 hours later was my General medicine viva.

They were as usual a British and an Arab and they were very polite and introduced themselves and told me its very easy and I should answer whatever I know and it would be a discussion like not interrogation !

The Arabic man asked what do you know about hydrocephalus ( increased intracranial pressure) ok..is that an ophthalmic disease( no its neurological with ocular manifestation) do you expect to see papilloedema (yes) how would you help the neurologist in this case (follow the optic nerve for him) ok…what other ocular signs might be preset (I forgot all what I had prepared) I will help you …the baby will be looking down all the time (yes sir) why (pressure is damaging saccadic eye movements) how do you test that in a child (OKN drum) ok..tell me about giant cell arteritis ( I started reciting from the book) ok..that's fine. What are CNS manifestation of GCA (…) ok..it affect arteries right? (Right sir) what happens when arteries are occluded in CNS (focal neurological damage) good. Where is that damage (in whole body depending upon the site) (he lost hope) ok..lets discuss a patient with breathlessness…he is having difficulty breathing (yes sir) he is in your ward and he is due to be operated tomorrow (yes sir) he said its just he cant breath (yes sir) what will you do (I send a call to a chest specialist, then take history of medication or diseases then I auscultate his chest and decide upon what I hear) you heard nothing. its just normal breathing sounds (pulmonary embolism if he is old and been in bed for too long and I must consider pulmonary oedema which is early if I cant hear any thing) that’s might be correct but how will you mange him (revise his medication and wait for the chest specialist if its not urgent) right. The patient started turning blue (that’s an indication to start O2 therapy and I treat it as emergency with a call to emergency department)..he wanted to ask something else but the bill rang and I thought ..its the longest 10 minutes in my life…but I was wrong ?

The Englishman started by asking me: what’s Pancoast's tumour: I felt very nauseated as I did not expect the shocking question. I said its one of the Paraneoplastic syndromes then I paused…no no it’s …The man said 'Well,  relax and we are going to start over…take your time … what’s Pancoast tumour? (What I am going to say is not totally correct but that’s what I said any how) (a tumour invading the lung) he started his education session and told me well. Its arising form the lung (yes sir) what are lung tumours ( oat cell) that’s correct but rare…any other ( ….) ok the most common would be bronchiogenic carcinoma (yes sir) ok what causes that. I mean risk factor (smoking) correct what is oat cell Ca (small cell) how rare is that (very rare) right…why is pan coast important to you ophthalmologists (lung apex) right what’s important in lung apex (sympathetic plexus (I was happy I am guiding him to shallow waters) right…Horner you mean (yes sir) fine what’s the 5 sings that characterize Horner ( I mentioned 3 and forgot anophthalmos) he said fine…how to demonstrate anhydrosis (….) OK don’t panic , try to device a technique (I started mumbling something about sub cutaneous adrenalin ) he said well that correct but very dangerous…OK let me make it easier to you. he is sweating on one side and I want to know that the other side is not sweating what can I do ( … I lost hope at this point) OK..you can paint his face with starch and see the side sweating turning colour due to reaction with sweat ammonia (yes sir) How useful is this information to you? (very useful) why (I can be certain that anhydrous is present with non invasive or expensive technique) Very good..what is the degree of ptosis in Horner (I went very happy…its ophthalmology again…2 mm) why (Muller's muscle) What other sympathetic muscles are present in other parts of the body? ( I felt this man is very obsessive…..) think…( erector pilli) very right..thats enough of Horner and lets go some where else for more ophthalmic aspects (please sir) alright …tell me about different syndromes that cause hyperviscosity states ( do you need their fundus picture !!!) no, no, tell me about the diseases it self and to make it easier for you tell me just 3 of those ( I started with Multiple myeloma MM) right. What happens in MM ( large amounts of Ig are made) no they are massive amounts …what is the type (sorry I did not get the question) what type of immunoglobulin is there ( I don’t actually recall that sir) ok..what is the fundus picture in MM ( I told him venous stasis , congestion and haemorrhages) why are there a haemorrhage ( increased capillary bed pressure and blockage from massive immunoglobulin? ) right what is the treatment of MM (…) its easy …think (they donate blood) no,,that makes thing worse (no sir we will take blood from them) oh …that but donation means charity and mental welling …plus they would lose all other blood elements (I got the point and told him plasmaphoresis) good..goood…what’s next (Leukemia) nice. what size is bizarre WBCs ( very large !) yes. do you know the classification of leukemia (acute and chronic) that’s enough for you and how would you treat (chemotherapy) good ..Now time is running out..whats the 3rd one (poly cythemia vera) good. Did you ever see a patient with that ( yes sir) how did he look like (red and very congested) right. How did you treat him ( I did not but I presume he got some anti erythropiotin drug) right…its radioactive P34..What do you do until radioactive phosphorus takes effect (…take blood from him?) right..thats called vene section. The bill rang and I felt …that’s it. I am doomed but I discovered they gave me a 6 which is very good because I was conservative and called for help very often and they liked that ?

They announced the proceeding numbers after 3 hours and only 17 made it from 56, most of the fatalities were in general medicine and a lot of good candidates were not among the list. It’s very sad you can’t prove yourself in the clinicals unless you pass the non-ophthalmic stages.

11th December 2003:

They divided us into groups. every 3 candidates in one group. They had 3 rooms with 4-5 patients on them. You have 45 minutes to see them but time is not relevant actually as you might take less or more time as the condition dictates. They told us not to worry if we took less time as the examiners made their mind way before your 5 cases. I thought this is really bad sign.
They let you in with what ever you had brought with you. They have equipment but as every clinic they might be faulty or not clean from previous candidates. I brought a direct and a 78D lens which I really like. Some brought red and white pins too but I felt very comfortable using my finger which simulates every day clinic.

Case 1
55 M sitting on chair and they asked me to examine him indirectly both eyes. He had full blown picture of RP and he had a small naevus inferiority on right eye. I started to examine periphery then centre and he asked me what I saw. I told him the findings and he asked what you diagnose. (RP and Choroidal Naevus) why you think he came here (RP) how do you treat (counselling, aids, genetic advise, diamox, sympathy, groups) what’s side effects of diamox (from book) why you said its naevus (size, margins , colour, lipofusin. Drusen) how do you manage ( follow up for growth) is RP and naevus associated in any syndrome (no!)…O.K. do field testing for him. I started confrontation and the man had a tubular vision. he looked satisfied

Case 2
50 F on slit lamp: examine both eyes by slit lamp biomicroscopy. I asked him to use my own 78 and he refused and he handed me his 90D. it was dirty and I told him so , he lost patience and asked me directly…can you do 90 D or not? (Yes sir I can) he cleaned it for me and I started...( should I describe what I see or tell you at the end , sir) describe (right eye is having a pale ON with pre retinal membrane and haemorrhages of variable sizes plus area of hyper pigmentations out side the arcades and they look like laser marks) see the other eye (its diabetic retinopathy but with no laser and its detached with retinal  stars and tractional bands) what this lady would need now (diabetic vitrectomy in left eye and silicon oil plus conservative management in her right eye) she refused surgery (left eye is untreatable without surgery) will she need laser again in right eye(that depends upon FFA) she has no leaks on her FFA( then no) then what would you do (drugs) like (daflon, trivestal, doxium) what’s the active principle of doxium (Ca debosilate) what is the dose which you use (250mg twice daily) do you think its effective (there is no trial but I usually see stabilization of DR with laser and drugs like doxium)…OK

Case 3
6 F with normally aligned eyes: examine ocular motility and take your time and finish every thing. I will not let you see the patient again (should I do to reach a diagnosis or full motility exam) do it fully (the kid had a lolly pop in her hand and I used it to direct he to different directions and when I finished he asked me) is that all (no sir I have yet to do saccades and convergence check) ok do it( so I did) …fine. What is your diagnosis (its typical brown syndrome but there are other DD) like? (IO palsy) that’s very remote…tell me causes of brown (congenital, iatrogenic, mechanical..etc) how will you treat (depending upon cause) in this case (it should be conservative with refractive correction if any) he acted very surprised…! The parents are very worried and they paid money and time to see and then you let them go?? !! (Yes sir, she is aligned properly in primary as well as reading position, she shouldn’t be operated) ..o.k. If you would treat surgically what would you do ( tenotomy, tenectomy and spacer) what’s that spacer 9its operation devised by Kenneth Wright in which we use a silicon bad to lengthen the So tendon) its quite difficult procedure( yes sir) why do you go to such an extent (it’s the most durable method) what’s the single trick in this operation( the tendon sheath must be very carefully dealt with) ..That’s fine..Ok

Case 4
45 M with red eye at the slit lamp: examine his red (right) eye with light torch: he had a penetrating keratoplasty..ok..how did you know that (sir I can tell if he had a keratoplasty when I see it from stitching , two level cornea and history) OK..do you think its viable (I have to use the slit lamp for that) fine. Use it ( it was nice operation and viable it was) why you think we had to do PK for him ( I have to examine the other for that) Fine. examine his left eye (its opaque central lesion with midstromal to anterior epithelial opacification extending from just after the limbus to the other side with hazy intervening corneal stoma) what is it? (macular degeneration) what is the inheritance of that (AR) do you expect his father to have the condition (No) when would you do the other eye (not less than 6 months from the first) the patient is very rushy about the other eye, what do you think (no I prefer even not to touch the other eye) till when (5 years) why (recurrence of original disease and late rejection) are your patients satisfied with your policy (they usually manage with one eye especially after good management of astigmatism)..That’s enough..

Case 5
33 F with aphakic correction on: examine right eye with slit lamp (anterior or posterior) anterior: she had a lousy cataract extraction with loss of posterior capsule and vitreous in pupillary plane, she had a fixed slightly dilated pupil with iris membrane and I described that to him) examine post segment (which lens) what every (I got my 78 and I had difficulty as she moved her eyes a lot and the pupils were not well dilated so I complained) just do it , this is the usual in your clinic…(yes sir I said: she had a sheathed vessels and a myopic degenerated fundus with coarse pigments which looked like scars. it does not make sense. myopic with aphakic correction, I told him so and he said ignore that) ok..whats your diagnosis (ECCE with loss of post capsule and no IOL) he was not satisfied. Examine the other eye and the second I got the light on her cornea he said enough (sir I did not see any thing, I have not even focused yet) he said well that was enough (may be sir but I did not see any thing) ok take another look (and there it was a nice shell and I asked him should I examine the socket) no…leave the patient and turn your slit lamp off (I did that). Now tell me what is the condition that causes us to do cataract on one eye and we were not sorry for the loss of her post capsule and cause the loss of other eye to the degree we had to use a shell? (I paused and I made a list in my mind but none met his criteria, I said, sympathetic ophthalmia) that’s very remote and she did not have any injury (then it might be RD in left eye with phthisis and laser to other eye but where does the cataract fit in) it does not fit and I told you to ignore that (those marks might have been RP and she lost the other eye) its not RP…he stared looking at me and said you have to say the condition and I cant help you any more (you call that help! In my mind I said) the last thing was iridocyclitis and I said it in despair…he almost jumped from joy…YES>>YES….thank you …you may leave.
 

I had 5 cases and mostly things did go well but I was very worried especially knowing they would pick the best out of the 17 candidates. They announced the result after 2 hours and only 9 passed.They invited us to meet the examiners and we shock hands as we took pictures, they asked every one of us where is her from and where did he took his qualifications. Is it his first time. Out of those 9 passed only 3 were first timers , the rest were second and only one was his 3rd. one of the examiners said he got it from 3rd time and the rest of examiners did not reveal the shocking history ?

I will be pleased to help any body prepare for his exam, just email me at drsamer@hotmail.com I will try as much as I can but remember to keep discussing with your friends and all those who are in examination stages for Msc, MD or FRCS.

Wish you luck.
Yours truly,
Samer J. Bashir
Msc, FRCS
Eye Surgeon