First I like to relate my experience of the previous examination in Tripoli

First day written exam+ MCQ:

1.  A 13-year-old girl was brought to your clinic by her mother complaining of reduced vision. Visual acuities are 6/18 in both eyes, reading N8 unaided. Her parents have just been divorced. How would you manage this patient and what investigations may be appropriate? 

My answer plan was:  Hysterical, but I should exclude other causes of diminution of visual acuity in children and don’t forget to refer to psychologist.
 

2.  A 55-year-old man who works as an engineer has attended the eye clinic previously with latent angle closure glaucoma and has bilateral peripheral iridotomies performed. His refraction is +7.5DS in the right eye and +8.00DS in the left. On this occasion vision is reduced to 6/12 in each eye because of cataract. What potential risks would you perceive with this patient and how would you manage this cataract? 

My answer plan was: this engineer had two problems which should be managed simultaneously according to severity of each one, according to the patient needs. Problems of shallow AC, dilatation, Iol calculating, anisometropia and anisokonia especially with unilateral cataract extraction. 
 

3.  A 33-vear-old woman has been aware of a degree of left-sided proptosis for several months. She presents to your clinic with a 1-week history of pain and redness in the left eye, reduced vision, and an apparent corneal ulcer.  Explain the possible causes of this patient's symptoms and how you would manage her? 

My answer plan was:I defined my problem as a corneal ulcer that may be related to the proptosis (Exposure) I excluded serious condition of infection. I discussed thyroid as the most logical cause of proptosis here but also excluded serious condition of malignancy and other causes of proptosis.  Remember VEIN (vascular, endocrine, inflammatory, neoplasm). 
 

MCQs
You must be sure of at least 160 questions if not do 180questions don't try to answer all questions you may loss marks
 

2nd Day Viva 

Ophthalmic Surgery and pathology:

The first Scottish examiner: (was very kind and smiling)

a photo of a young female with unilateral proptosis (TED and pathogenesis, other possible causes).
• photo of child with unilateral lid swelling  (chalazion + histopathology, management, other possible causes.
• photo of Morgagnian cataract (pathogenesis and management and complications).
• photo of neonate with amniotocele (management don’t forget to reassure the parents)

 

photo of anterior segment show bleb and inferior iridotomy (glaucoma details) 
• photo of trabecultome (congenital glaucoma)
• female with myopia (glasses, CL, LASIK, phakic IOL (types of phakic IOLs)
• endophthalmitis 

causes of uniocular diplopia (astigmatism, keratoconus,….).
• causes of child with diplopia and ptosis ( third nerve palsy, migraine).
• causes of third nerve palsy. 
• causes of proptosis.

a laptop picture of pigmented fundus lesion (Malignant Melanoma,……others, how to manage).
• causes of non pigmented fundus lesion (secondaries,……others, how to manage). 
• fluorescein photo of CNV (causes, grades and management).
• OCT (can be done without dilatation?, uses….).

He asked me about an old female patient coming for fundus fluorescein angiography and the nurse told me that this patient lost consciousness how can you manage lonely? I answered that this may be diabetic for fear of hypoglycemic coma than hyperglycemic. I will check ABC, call for help, to give her a sugar, exclude other causes of coma as vasovagal attack…etc. Then he asked me about the ocular features of diabetic retinopathy?
• An old man had surgery 2 days ago, complaining now of chest pain (How do u manage this patient?). My answer was that, I'll call for help and check ABC then I have to exclude life threatening conditions as pulmonary embolism and myocardial infarction. He answered ok he had myocardial infarction how would you manage again? I answered by calling for help, ABC, aspirin then ECG. He demonstrated to me an ECG and asked about its interpretation, it was a recent inferomedial infarction.
• He asked me if this had been a case of pulmonary embolism I said I'll check the vital signs, DVT at lower leg, calm environment, IV morphine 10mg, and 5000 u IV bolus heparin. 
• He asked finally a very strange question what are the causes of high blood pressure with weak pulse and how to manage? But the time had ended, the answer he was after was Cushing crises.

He gave me neurological field and asked me what it was. What is your diagnosis? (bitemporal hemianopia, bitemporal field). What are the possible causes.
• Fundus fluorescein of cystoid macular edema  tell me what is this and how can you manage this question took all the time and the examiner was always unhappy 

Before relating my Dehli experience, here were the cases  and experience I encountered in my first attempt. I was the last one that entered the exam the room was dark there was many patients , two examiners with no place to move, I was very irritable I missed many signs especially that the instruments were not so good .

The first case was buphthalmos with all the related (associated) clinical signs that you can imagine and I missed a peripheral retinal detachment. 
• The second case had  neovascular glaucoma and I missed the rubeosis irides.
• The third was unilateral proptosis (TED); don't forget to examine the thyroid, the pulse, and the limbs.
• The fourth was bilateral ptosis. I knew it was a case of myasthenia but I didn't mention that although that I work in the oculoplastic subspecialty.

First day Written exam+ MCQ:
 

1. 75 year old woman has been attending the clinic for some time with an indolent left corneal ulcer. There is a history of joint pains and weight loss, and she has dry eyes. She presents acutely with worsening pain in her left eye and blurring of vision .on exam u notice the ulcer has perforated with flat AC. Describe acute and long term management & what investigations are appropriate. 

My answer plan was: Collagen disease leading to perforated corneal ulcer. I must admit the patient and work with rheumatologist, exclude infection manage according to the site, size of perforation, consider the visual acuity, and the depth of anterior chamber, may be medical or surgical. Taking in consideration that rheumatoid make joint deformities that affect the patient in putting the eye drops, in doing surgery (neck stiffness), also consider the associated dry eye and scleritis, and the systemic treatment as systemic steroid may induce cataract and glaucoma. Don't forget in old female to check the endothelium.
 

2. A 3 years old boy has been seen at the clinic for 2 years with bilateral watering & has had 2 probing procedure performed. On both occasions the probe was passed easily. The Rt. Eye has settled but on the left side he is having recurrent dacryocystitis every few months requiring systemic antibiotics. His parents are angry and are demanding something is done or a second opinion is given. Explain how would u manage this situation & write a letter to the GP detailing your action

My answer plan was:First I'll reassure the parents regarding that this can occur with success rate of 70% but we may be in need reevaluate the condition. Exclude other causes of lacrimation and examine for epiphora (remember BLINK= blink to examine the pump, Lid examination, Imbrication, NLD examination and kissing puncti). Don’t forget to write the letter by a formal way starting by dear colleague and ending by thanking him. And don't forget that this child'll take general anaesthesia for the 3rd time so refer to pediatrician. Our plan was reprobing, intubations (Ritling tube) versus DCR.
 

3. A 50 year old male artist in known to have small bilateral Inferior retinoschisis. He presents to his optician having become aware of some distortion in his Rt. Eye with a change in color perception. The optician thinks the retinoschisis has enlarged on the Rt. Side and is now encroaching onto the macular area. The patient is referred for your opinion. What is your DD, and how to investigate & manage him?

My answer plan was: DD should include optic neuropathy, macular disease, and other causes of distortion and other causes of color affection (don't forget cortical lesion and MRI) 
 

2nd Day Viva 

Ophthalmic Surgery & Pathology  (was a very long exam but also a very pleasurable one. I didn't want the bell to ring) 

Indian examiner Questions 

Basal cell carcinoma common and dangerous sites and management.
• Differentiate capillary from cavernous haemangiomas.
• Fracture orbital floor how to manage (assess diplopia, defect (CT),  medpore plate) 
• Types of suture and the indication of vicryl. 
• Types of cataract and types of surgery (ICCE,……MICS).
• Types of IOLs (multifocal with +3.5D, accomodative). 
• Myopic young female need refractive surgery, what are the complications of the clear lens extraction (CLE).

The Scottish examiner Questions

Drew a retina detachment and asked me to look for the tear then how would I manage?
• When to proceed for conventional repair and when to vitrectomy? 
• What are the types of buckle and the indication for each? 
• How to manage a macular hole ? 
• What are the tamponading substances and the indication for each? 
• How can you proceed for vitrectomy and what is the site of cannula in phakic versus aphakic. (take care to say that you will refer to the post segment consultant but you can explain what he would do)? 
• What are the indications of trabeculectomy ? 
• Explain pseudoexfoliative syndrome ? 
• What are the antimetabolites when to use and how to use (2 answers under the conjunctiva, under the scleral flap)? 
• Draw the steps of trabeculectomy surgery (fornix, versus limbal base approach) ?

 

DD (differential diagnosis) of red eye.
• DD AACG and uveitis.
• Why the pupil is oval with vertical axis (due to the sphincter muscle arrangement)
• How to examine ACCG with corneal edema
• What are the types of goniolens (don't forget the Zies)
• How to manage taking in consideration that the patient was coming in the night shift
• Child 3 years old with esotropia (cycloplegic refraction). Refraction was +6 and +6 for both eyes at 1 meter (I'll subscribe +5 remove the effect of distance only). He only improved for 2 weeks only (recheck the refraction and the AC/A ratio). I felt that the examiner wasn't happy I don't know why?????
• Then he asked me what are the causes of esotropia I suggest that maybe we should exclude 6th nerve palsy first?????. I mention Duane, but still he remained unhappy

 

Started with the same question of this child that has esotropia I was astonished, why the same question? Especially I had given the same answers! ( can anyone help)
• Photo of a female with unilateral lid swelling (preseptal cellulites)
• How to differentiate from orbital cellulites (don't forget proptosis see oxford ophthalmology).

Diabetic female patient came for fundus fluorescein photography and the nurse told me that this patient lost consciousness how can you manage lonely? I answered that this may be diabetic coma with the most serious is the hypoglycemic coma. I 'll ask to give her a sugar if still conscious, but if in coma ABC, call for help, exclude other causes of coma as vasovagal,…. Then he asked me; if arrested how can you mange still ABC, call for help and CPR.
• What is TIAS and Amaurosis fugax? What are the causes? The complications? When you proceed for endarectomy?
• How you manage pulmonary embolism ? 
• DD of breathlessness 
• How to manage anaphylactic coma?

Malignant HTN FFA describe and possible causes
• Causes of unilateral dilated pupil and headache (I mentioned everything except Adie's please don't forget as the examiner was quite unhappy??)
• What are ocular complications of steroids. 
• What are the analgesics used postoperative NSAIDS , morphia
• Mechanism of action of NSAIDS [detailed from the cell wall and the phospholipids (arachnoids acid,)]
• Antidote of morphia ( Naloxone)

He was a patient with homocystinuria with subluxated lens. I asked to examine the systemic features, all the marfanoid features were present, the patient when standing was very tall.
The Scottish asked me how would I manage, I answered in this case assess refraction, glasses, follow up. He asked what's your expectation regarding his refraction and vision? I answered myopic astigmatic he told me only myopia ok how many diopters, I told may be 8 D. Ok what would the distance he would see at without glasses, 100/8, if subluxated, so ICCE, what are the complications? RD.

Patient 2: 

Patient 3: 

Patient 4: 

Patient 5: 

My e-mail is: eman.nasr@magrabi.com.