Problem solving question(Day-1, 2 hrs): 
(Please read  the questions carefully and repeatedly) 
1. A 60-year old sailor with poor vision and pale disc.He has completed course of antiTB drugs 5 yrs back. How do you investigate and manage the patient. 
Answer: Glaucoma, AMD, drug optic neuropathy ,cataract, ref. error came into my mind. As the patient is a sailor, one needs to consider syphilis.       

2. Post-operative trabeculectomy, the patient complained of pain. Examination revealed shallow AC, corneal haze. How do you proceed? 
Answer: It can be pupillary block with incompetent PI, malignant glaucoma, excessive drainage with shallow AC. 

3. A young girl with head injury(1 year back) developed R/E sixth palsy and left side head tilt. Patient wants surgery. What are the risk factors you would explain to the patient. How do you proceed with the patient? 
Answer: This was a tricky question-PT. is having R/E 6th ner. with R/E 4th nerve palsy and I discussed management of these together. 

Afternoon( 2 hrs)
MCQs relating to eye were ok but medical ophthalmology were difficult because we usually don’t read medicine topics. Read all the disease in medicine with ocular association and the MCQ books by Chua et al. 

Viva Day-2 
(Most stressful 60 mints of my life- never had that feeling before)

General medicine and neurology related to ophthalmology
(most failures occurred in this viva and in the MCQs)
 

• Tell me field defects in lesions from chiasma backwards. Why pupil is not involved in cortical lesions. Common causes of above. 

 
• How do you assess clinically the severity of CRVO(RAPD and cotton wool spots - as these indicates capillary closure). 

 
• How do you test RAPD? What is Adie pupil? How will you test for poor dilatation after constriction? (ask the patient to read some magazine for 15-20 minutes ). 

 
• When will you treat CRVO if its your eye- I mentioned laser if there were significant capillary dropout on FFA (5 DD) and I won’t wait for NVD or NVE to appear- he smiled, agreed- bell- and told well done.

 
• How will you go about a 51 yrs old hypertensive male complaining of attacks of blurring of vision- I told in detail the investigation of  CVS and carotid system for the source of thrombosis and emboli. He was satisfied, then he asked how to go about the same patient if he is having a clot in the heart shown by the tests- I mentioned  prophylactic anticoagulation and he asked for details on this. I said iv low molecular weight heparin and oral warfarin to start with then shift to warfarin only based on INR (can be found in Oxford Medical Handbook ) – examiner was very happy with my answer. He asked me what is INR? International Normalized Ratio - prothrombin time was my answer. 
• Your patient collapses in your clinic- what will you do — I regarded this as a cardiac arrest and mentioned checking the vital signs (ABC),  call the physician  and  go for CPR and along with this try to find out any history of diabetes mellitus, hypertension, cerebrovascular accident from the records. He agreed and asked me the procedure of CPR— I told him the procedure and half way through the bell rang and I was the most relieved person in the universe.

Ophthalmic surgery and pathology 
 
First examiner

• Tell me the type of anaesthesia in cataract surgery—I mentioned all –he asked me about the techniques of peribulbar and subtenons anaesthesia. What will happen if more fluid is injected during anaesthesia. I said an increase in vitreous pressure with increase chances of posterior capsular rupture during operation. He asked in detail the treatment  of  posterior capsular rupture (machine settings for vitreous cutter, separate irrigation probe to maintain the anterior chamber, avoid hydrating the vitreous etc) and the choice of implants after anterior vitrectomy.
• Next, he showed a photo of ptosis and asked for causes. Also questions on the mechanism of postoperative ptosis (levator dehiscence). Asked to demonstrate the method of testing levator function.Then the thing came for which I was waiting— the sweet sound of bell.

Second examiner

• 2 days post cataract surgery. A  patient complained of decreased vision, pain and examination showed hypopyon. I mentioned endophthalmitis.  How do you differentiate between infection and inflammation, treatment pertaining to this case, complications of amikacin (maculopathy). 
• Shown a photo of BCC involving the medial canthus - asked me the special feature of this site. Answers: risk of orbital invasion and the spreading down the nasolacrimal route. The examiner was happy with the answers. Types of flaps in trabeculectomy ie. limbal versus fornix based, their advantages and disadvantages, name of the punch used to remove the sclera. 
• What is histopathology of capillary and cavernous haemangioma? What is pathology of chalazion and its treatment?--- Bell rang and I ran.

Ophthalmic Medicine
First examiner

• First question was what are the macular studies I know—I told the names of four studies, then asked me the recommendations of MPS ( Macular Photocoagulation Study) - I mentioned FFA—extra, juxta, subfoveal in detail— examiner was satisfied. 

• Then he showed me the colour photos and FFA of CRVO and BRVO—he asked me the findings and diagnosis. How would you advise the patient with regard to prognosis in CRVO I mentioned the presence of RAPD and other signs of ischaemia will determine the prognosis and complications. He was happy and the BELL rang.

Second examiner

• Shown a colour fundus photograph- ask about findings and diagnosis. It was the wet type of AMD (greenish gray membrane at the macula). She agreed and asked me what to do next —  I mentioned FFA and she showed me the FFA of same patient and asked about findings and management. I mentioned laser as membrane is not at the fovea – she agreed. 
• Then she showed me colour photograph of diabetic retinopathy—findings and diagnosis,  then FFA of the same patient. The FFA showed macular ischemia and asked the treatment. I mentioned the use of scatter laser for the ischaemia but not for the macula because of the ischaemia. Questions on what constitute clinically significant macular oedema in diabetes mellitus. 
• Next she showed me FFA and colour photograph of of a 35 year-old female complaining of decreased vision and there was a membrane in the macular area. I said there is some inflammatory pathology, she said may be and asked what I thoug it is. I went for macroaneurysm as there was haemorrhage, she said no and gave me a hint 'There is inflammation as you mentioned earlier.' Before I could answer the bell rang, this was the only question which I could not answer but as soon as I got up the answer struck me and I think histoplasmosis was the answer because the FFA showed lacy pattern with haemorrhagic membrane. I was very relieved at this point as all the viva were over and I felt I did ok in all.

In viva they ask a lot of questions because they want to cover as much as possible, so one has to answer fast. Don't waste your time by thinking a long time if you don't know the answer, admit to the examiners you don't know the answers (hopefully not the important ones like clinically significant mauclar oedema) so that they can give you clues or move on to the next question.  In the evening we got the results and I made it into the clinicals. I was one of the 15 candidates who made it through out of a total of 34 candidates.

The 3rd day was a rest day but it was very stressful to have to wait another 24 hours.

Clinical ( 4th day )  

1. First case – Demonstrate confrontation visual field test ( one should be quick in performing all types of ophthalmic procedures because time is very short and you have to see more than four cases to pass).  The patient had tubular (tunnel) vision. She asked about the cause. I mentioned a few causes and then examined the fundus with a 78D lens, the patient had an advanced glaucomatous disc.

2. Next, she told me to examine the anterior segment -- patient had trabeculectomy with bleb (don’t forget to examine the conjunctiva and the fornix which is very common mistake ), peripheral iridectomy, pseudophakia, posterior capsule opacities. The other eye had shallow anterior chamber with RAPD — she asked for diagnosis. The answer was narrow angle glaucoma,  then questions on posterior capsular opacification and pseudophakia. 

3. She told me to look at the macula of both eyes with a 78D — the patient had bilateral well defined lesions with yellow deposits at the macula. The lesions are larger than the optic disc. She asked for the diagnosis, I mentioned heredity dystrophy, old central serous retinopathy (which she did not agree ), might be hole (she was not happy with this either). I asked and she showed me the FFA. The answer was  Best vitelliform dystrophy.

4. The examiner asked me to use the slit lamp to look at the anterior segment—I did everything and the eyes seemed to be normal. He asked me to concentrate on the cornea and after struggling for a minute, I saw very mild thinning of the cornea at the limbus both superiorly and inferiorly. He asked for the diagnosis –I gave pellucidal or Terrian marginal degeneration. He asked what else would I do? I said corneal topography. He asked about the treatment and I mentioned contact lenses. He asked about the types of contact lenses.

5. The first examiner asked me to perform the ocular motility and gave a diagnosis.  Patient had Type 1 Duanes retraction syndrome. With up-shooting on adduction. She asked me the possible types of surgeries for this.

6. Back to the second examiner again, he asked me to perform indirect ophthalmoscopy on a patient in a sitting position. Patient had diabetic retinopathy with laser marks at the mid-periphery (he asked about findings in detail). He also wanted to know the risk factors that can exacerbate diabetic retinopathy, treatment of ischemic maculopathy (I said I won't touch the macula). He asked about new in drugs—I mentioned antiVEGF drugs like macugen (pegabtanib sodium), lucentis and intravitreal triamcinolone—he was happy.

7. The male examiner again asked me to examine an upper lid growth. I mentioned the findings and noticed that the time was running short.  I gave a differential diagnosis. He told me the diagnosis is a BCC and how will I treat this. I mentioned Mohs micrographic techniques as the gold standard for ensuring complete removal of the tumour and at the same preserve the tissue. He asked about the methods of lid repair and I told him that the method will depend on the size of the defect and gave him all the possible methods. He was happy with the answers and the time was over. 

I was satisfied with my performance. Then again the tense moment of waiting for the result. Cases shown to other candidates include facial nerve palsy, 3rd nerve palsy, carotid cavernous fistula and dissociated vertical deviation.

The result was declared in the evening, I was very happy to see that I cleared the examination. This site has helped me tremendously in passing the examination.