Candidate 91                                           Centre: New Dehli
Final FRCS (Glasgow)                                                Date: Sept, 2006
My name is Dr. Khalifa Mohamed Ali and I am from Libya. I passed the FRCS (Glasgow) part B examination held in September 2006 (New Delhi). I like to thank my family especially my family and wife for their support.  The examiners were helpful and asked logical questions.  I found this web site to be extremely useful for preparation. Last but not least I like to thank Dr. Hussin Soilam VERY MUCH for his valuable assistance. 

Here is my experience of the examination

Viva 1: Ophthalmic Medicine 
( Professor Mohan + a British Examiner) 

Question 1 ( Professor Mohan)
I was given a visual field and asked to comment on it? I looked at the reliability indices which were reliable and told him it was a reliable Humphrey visual field of the left eye using the central 24-2 threshold test. The field showed paracentral scotoma with a median deviation of 28 (severe reduction in the retinal sensitivity). He asked why I thought the field was reliable. and asked the upper limit of the percentage of fixation loss,  of false positive as well as of false negative in deciding the field relaibility? I answered it should not exceeds 20%, 33%, 33%. Then asked about the differential diagnoses of this field ie. paracentral scotoma.

Question 2 (Professor  Mohan)
Coloured photos of one eye + FFA of proliferative retinopathy with tractional RD and laser marks. Asked to comment on the picture and give a differential diagnosis. He asked about management so I said I like to find out how the other eye was like. He said the other eye has proliferative changes but no traction. I said I will perform laser (PRP) to the contralateral eye. As the eye he showed me had TRD (tractional retinal detachment) involving the macula I will counsel the patient about undergoing par plana vitrectomy and the prognosis. He gave me a paper and asked me to show him how I would perform laser photocoagulation. This was followed by discussions of complications associated with laser photocoagulation. He asked how I would perform the laser to ensure that this patient does not have visual field defect which may interfere with his driving.  I said I will leave spaces on the horizontal meridian (do not laser),  toward the nasal region (nasal to the optic disc) as well as temporal region (over all more than 120 degree on the horizontal meridian) and 20 degree up and down. Finally asked about the classification of diabetic retinopathy. 

Question 3  (The British Professor) 
A mother brings a 6-month old child to your out-patient clinic and is concerned that the baby cannot see. How would I proceed?  I started with the  history: beginning with pregnancy like rashes to exclude maternal infection, diabetes mellitus or drug use during pregnancy. History of prematurity and normal development and growth. Then examination; look for nystagmus, ability to fixate on an object with each eye separately.  He asked me how to examine visual acuity to this child. He asked me in details about every test (How to do). Then I said torch examination of the ant segment for corneal opacity, cong cataract, pupil reaction. Aniridia or microphthalmus (PHPV). Fundus exam to exclude ROP, optic nerve atrophy or hypoplasia, leber cong amaurosis (+ ERG). Cycloplegic refraction to exclude extreme refractive error. CT scan or MRI of brain in cases of optic atrophy to rule out brain tumors and evidence of trauma or hydrocephalus. If every thing is normal it might be delayed maturation of the visual system takes up to 12 months. 

Question 4  (The British Professor)
Coloured photographs of two eyes and FFAs showing  ARMD of the wet type in both eyes.  Asked about differential diagnosis? What are the latest modality of treatment of wet age-related macular degeneration. I mentioned intravitreal injections of nnti-vascular endothelial growth factor (Anti-VEGF such as a vastin, macugen).   The professor asked about the mechanism of action of photodynamic therapy and the precautions when giving it.


Question 5

Colorred Photos of two eyes and FFAs of 30 year-old male patient showing a right subfoveal CNV with dysplastic optic disc. Left multiple parafoveal chorioretinal scars. However, there were no myopic changes in the fundus.Asked about the diagnosis; I started with histoplasmosis, the examiner said the patient is not an American. Then I said PIC (puntacte inner choriodopathy) but qualified it by saying that the patient is commoner in myopic females. Then I mentioned AMPPPE. The examiner was not happy with my answers and I was not happy either.

Then he asked about management. I said I will repeat the FFA and then I will treat the right eye accordingly depedning if the CNV is subfoveal, juxta or extrafoveal.
Then what I was looking for the bell rang 


VIVA 2: General Medicine and Neurology 

(A Scottish  Professor and an Indian Professor)

Question 1 (The Scottish Professor)

A picture of 50 year-old male whose forehead had red lesions. The examiner gave me the history of headache and sudden visual loss. I answered giant cell arteritis (GCA) and the reasons of  either AION or CRAO. Then showed the picture of the optic disc which was typical of AION with oedematous optic disc with splinter haemorrhages. Asked about management and how long would I give steroid for? I mentioned the treatment will be dependenet on the level of ESR and usually takes one to two years. I also mentioned that I would perform steroid work up prior to starting steroid? Asked how I would do this. Asked about management of osteoporosis: I mentioned calcium supplement. Asked about peptic ulcer: H2 blocker. (ranitidine). Other complications associated with steroids Asked why you give mega dose? I said in order to protect the other eye and not for the treatment of the affecting eye? 


 Question 2 ( The Scottish Professor)

Given a picture of a pale optic disc (primary optic atrophy). Given the history: the disc belonged to a 30 year-old female and the other eye is perfectly normal. I said primary ON atrophy either due to optic neuritis, compressive lesions or nutritional causes.  Asked what I know about nutritional causes of optic atrophy? Then how to exclude compressive lesion. I said ultrasound, CT and MRI  of the orbit. Then shown CT scan of axial section of the brain and orbit. I looked at the picture which was tricky. A very small meningioma of the optic nerve in the orbit (tram track sign). Followed by management.


Question 3 ( The Scottish Professor)

A young patient in the post-operative period complained of breathlessness. What are the possibilities? Discussion went into management of acute severe asthma and pulmonary embolism (including clinical signs and findings on investigations and management in details). 

Question 4 (Indian professor)
Given a scenario. You were on call and the physician in the medical department called you to see a 50 year-old patient presents with severe headache, dilated pupil, ptosis and out ward deviation of the right eye. What conditions can you think of? Mentioned third nerve palsy and most likely a cerebral aneurysm. Discussion went into diagnosis and treatment. Then asked about the latest modality of treatment. I mentioned intervention radiology with catheter and coils. The examiner was happy. Then what I was looking for the bell rang 

VIVA 3: Ophthalmic Surgery & Pathology 
(The English professor and an Indian professor)

Question 1

Given a picture of of flat bleb with positive Seidle's test. The patient was second day post-trabeculectomy. Asked about detailed management of this condition.This was followed by a picture of blebitis. Asked about maangement including organisms and belb-related endophthalmitis. 

Question 2 
What are the factors that lead to involutional entropion. How would I manage a case of involutional entropion. Given a paper to illustrate how I would perform a lateral tarsal strip procedure. 

Question 3 
Asked to describe in details how to carry a dacryocystorhinostomy (DCR).


Question 4

Another scenario. A patient with pseudoexofliation presented with phacodonesis and cataract and poor pupil dilatation. What would I approach the case. I began with vision assessment, IOP measurement, try to dilate with tropicamide and phenylephrine in order to assess the amount of subluxation. The examiner interrupted me and said the pupil does not dilate. I said I would counsel the patient about the operation and we might do phaco with or without tension ring or ICCE + AC IOL depending on the amount of subluxation after inserting iris hooks. Asked  precautions during phacoemulsification of this patient.

Question 5

What precautions you should consider in  patients with sickle cell anaemia and retinal detachment. I mentioned I would perform vitrectomy because of chances of getting anterior segment ischemia after buckling. Also hypoxia is dangerous during and immediately after the surgery, give oxygen and the anaesthetist informed in advance.

Question 6

Indications of primary vitrectomy in rhegmatogenous retinal detachment. Indication for subretinal fluid drainage. Asked about different types of temponades ie. silicone oil, gas etc and their durations and complications 
Then happy moment I was looking for: THE BELL. 



(Professor Mohan and a  British Professor)

Patient 1 
Slit lamp examination of a middle aged female with vacularised leukoma adherent to the right iris. I was questioned about the possible causes and management. This was conducted by Profssor Mohan. 

Patient 2 
Slit lamp examination of a 16 year-old girl with phthisical bulbi of one eye with band  keratopathy and iridodialysis.
Questions on possible causes and management. Again conducted by Professor Mohan.

Patient 3 
A 14 year-old bespectacled boy. Professor Mohan asked me to perform cover test and ocular motility. 
The boy was orthophoric for near and far with glasses but had alternating exotropia of about 15 degree for far without glasses. The ocular motility was normal. My diagnosis was alternating exotropia of about 15 degree caused by divergence excess that is correctable with glasses. Asked about the management of this patient. I said glasses as the tropia was controlled with them.

Patient 4: 
The British professor asked me to look at the fundus of a young girl with bilateral secondary optic atrophy and a left exotropia measuring 45 degrees.
Asked why did I say secondary and not primary optic atrophy. I answered, and then he asked what are the causes and management of each one. 

Patient 5:
Indirect slit lamp biomicroscopy examination (+90 D) of a middle aged man without a history of diabetes mellitus. The right eye showed proliferative retinopathy with equatorial neovascularisations and vitreous haemorrhage. The left fundus was perfectly normal. I described every single detail seen. The  British professor asked about the diagnosis. I said this might be CRVO of the ischemic type or sickle cell anaemia or even sacrcodosis. He asked me about the causes of CRVO taking into account the age of this patient and how to manage the condition. The British professor was not happy with my answers and I was not too happy either after this case. 

Patient 6:
Indirect ophthalmoscopy of a young girl that showed a huge left posterior coloboma involving the whole nasal retina up to the ora serrata. Questions about systemic associationsand aslo questions on precaution with regard to the retina. I mentioned prophylactic laser to areas surrounding the coloboma to prevent retinal detachment. 

Patient 7: 
A young boy of about 15 year-old with left complete ptosis. The Professor asked me to perform eyelid examination. There were complete ptosis, dilated pupil and exotropia with intact intorsion. I diagnosed isolated surgical third nerve palsy. The examiner was happy and so was I as the bell rang at the same time.

My e-mail is:  Please contact me if you require any help. 


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