I am Dr. Khair Ahmed Choudhury from Dhaka,
Bangladesh. This is my second attempt. Both were fromn Delhi. In my first
attempt the clinical part was the reason for my failure.
I attempted again in Septmeber, 2008. The examination went well and Allah makes
my dream true. I passed FRCS (Glasgow) in ophthalmology. Actually all that was
needed was the right combinations of all the things on that day .
The written questions were
A 57-yr-old man presents with a one-week history of severe headache and has also
become aware of a field defect in both eyes. He has a history of atrial
fibrillation and is taking Warfarin. On examination, the visual acuity is 6/9 in
the right eye and 6/18 in the left with a possible rAPD in the left eye.
Give a possible D/D for this presentation and describe how you would investigate
and manage the patient.
Possible causes are – AION, Pituitary adenoma, Cerebran aneurysm, Subarachnoid
Hemorrhage, Craniopharyngioma, Multiple sclerosis.
A 40 year old woman attends your clinic enquiring about refractive surgery. Her
acuities are 6/18 with -9.00 DS in Rt/eye and 6/6 with -4.00 DS in the left. She
previously had right retinal detachment surgery 20 years before. You note she
has an early cataract in the right eye and a clear lens in the left.
How you would manage this case and what risks and possible problems would you
specifically discuss with the patient?
- Regarding refractive surgery of Lt eye my answer plan was to maintain spectacle
because as there is RD in Rt eye, risk of Lt eye is there.
Regarding Rt eye pt cango for Cartaract surgery but no need of refractive
surgery. Overall pt can go for contact lens.
A 75-year-old woman presents with intermittent diplopia. She has previously been
seen at the clinic with right-sided epiphora. On examination, there is some
limitation of abduction of the right eye, which is displaces laterally. She has
lost a considerable amount of weight recently with recurrent chest infections.
What are the possible causes of these symptoms and how would you manage the
Answer - Possible causes are – Rhino-orbital mucormycosis,
Non Hodgkins B-cell Lymphoma,
Secondaries (Primary site is Breast),
Thyroid Eye Disease
As I passed ICO before, MCQs were not needed.
Next day was my oral
I was the 1st candidate in my ophthalmic medicine board 2 examiners, 1 is Indian
and 1 probably Malayasian. Very polite and gentle. The Indian examiner started
with a colour fundus photograph (Laptop) mentioning this pt with type 2 DM
presented with this features (There was soft exudates, flame shaped hemorrhage
involving whole fundus of both the eyes and also macula was involved). So I
mentiond that was a case of NPDR with CSME. Next Q-What u r going to do with
this case, Ans-I will go for FFA, why? To see macular edema/ischaemia. Then FFA
was shown , there was leaking, Ans was Grid laser but before that anything to
do? Yes will go for consultation with his Physician regarding status of DM and
to check other organs, what r the other organs r affected in DM, Ans- NS (Sensory,Motor,
Autonomic), Brain, CVS, Kidney, . Will also do a Lipid profile, HbA1C. next Q
was a photograph shown in Laptop whwer there was congested Conjunctiva, central
hazy cornea, limbus was also congested- asked for Dx only because bell rang, so
I told it Acanthoemeba keratitis – smiling expression only.
Next a Malaysian examiner started with a HVFA –there was superior altitudinal
field defect, asked the description of the field- so I mentioned all in
chronological order , then Q-causes of this type of Field defect-Ans-POAG,
Inf.BRVO, AION, Inf.RD. Started with Glaucoma, Glaucoma suspect and anti
glaucoma medication – details with advantage and side effects(Beta blocker,
Prostaglandin analogues-M/A, S/E, alpha2 agonist, topical C-A inhibitrors,
combinations of drugs), management protocols- like I will start with a single
drug-betablockers for 4 weeks, the will follow up if satisfactory target
pressure is not achieved then will add another or a combination of drug will
Another field with Rt sided temporal field defect and mentioning similar type of
defect in Lt eye also (Bell rang) Asked for Dx with site of lesion, Ans-
Bitemporal field defect, Chiasmal lesion Q-what lesion Ans-Pitutary lesion.
Both the examiners Expression was very satisfactory.
Next board – Neurology and General Medicine
One Nigerian examiner (With impaired English pronunciation) and one Indian (Good
looking and questioning). Indian one started with a Chest X ray-multiple
cavities in Rt lungs asking for Dx (Male 45 years, repeated chest infections
with haemoptysis) Ans- Pul.TB, Wegeners grnulomatosis (Quiet happy with Wegeners)
and started asking details of wegeneres , its presentation both ocular and
systemic (Kidney, lungs), Dx-cANCA, other conditions with cANCA positive.
Next with 4 phots in Laptop with butterfly rash inface, picture of both
hands(Ranauds phenomena), mouth and alopecia Dx- SLE, details of SLE with ocular
presentation, Rx of Dry eye. S/E of steroid, Fracture neck femur-ocular
presentation, fat embolism, types of emboli, management-consultation with
orthopaedic surgeon and medicine expert. Xray of pelvis and lower end of
vertebral column- bamboo stick appearance (Male with 25 years), Dx-Ankylosing S,
ocular presentation-Ant uveitis, what else –bell rang so escaped answer not
known. The next Nigerian started with AS, ocular presentation-Ant.Uveitis,
anything more-pass. Treatment of AS- NSAID, toxicity of Chloroquin, cumulative
dose of it & Hydroxychloroquin-answered well but asked if pt take all the
cumulative dose in single attempt, ocular effect? Retinal toxicity, couldn’t
answered well. Started with a photograph in Laptop of a pt with Wrist sign-
Dx-Marphans, other features except ocular, why this type of pt comes to a
physician , Ans-Cardiac problems like Dissecting aneurysm , Mitral valve
prolapse, Aortic regurgitation, satisfied answer. Next photo of the back of neck
(Difficult to identify the neck as photo was so small) Luckily identified with a
chain in the neck-chicken pluged appearance- Dx? Pseudoxanthoma elasticum,
expressionless, asking the features of Pseudoxanthoma elasticum and its
presentation to a physician – atherosclerosis, so HTN. Next photo with a lisch
nodule- NF type 1, presentation and why this pt go to general physician – Ans-
HTN(renal artery stenosis-secondary HTN). Bell rang-Quiet happy with this board.
Ophthalmic pathology and surgery-
2 were Indian (Fine in all aspect), Started with Histology (photograph)-BCC,
Why? Basal cells involving dermis, keratin (Ketotic type of BCC), pallisading.
Next two didn’t do well one was normal muscular structure and one was
lymphocytes. Causes of appearance of lymphocytes, Ans- Inflammatory conditions,Q-inflammatory
conditions of the eye- Pyogenic granuloma, Chalazion, Orbital pseudotumour. Then
discussion went with Pseudotumour, what r the Pseudotumours, Answered well.
(Happy with the examiner as he started to come out from histology)
Showed a photo showing a swelling in Rt sac area – Dx-Mucocele of the Sac-Happy
with the answer, Treatment – If no acute inflammatory signs then will do an SPT
to exclude the swelling is within the sac or outside the sac, go for DCR. Asked
about DCG, it’s procedure. Given a photo-showing a swelling in the Iris-Dx-Iris
Given the punch forcep of DCR, use, bones? Size of the osteum (12-15mm).
Next examiner started with surgical needle (types-Cutting, Reverse cutting,
Spatulated, round body), asked to draw the pictyre of spatulated needle( I drawn
the picture collected from the chua eye page, but he didn’t agreed , given one
from Shndeep Suxeena (Indian book). Types of suture materials, absorvable/ Non-
absorvable, biodegradation?, Difference between Nylon and Silk, Difference
between Dexon and Dacron, Braided and Unbraided, Answered well. Then discussion
started with Keratoplasty, details, size (7.5mm), if larger?, if smaller?,
suture technique, disadvantage of interrupted sutures, distance between the
sutures, Knot technique – Satisfied answer. 16 yrs boy with moderate ptosis,
poor LPS function, Management plane- will go for LPS resection 19mm. Methods of
LPS resection details , difference between Transcutaneous (EVERBUSCH technique)
and transconjunctival (Blaskovichs) approach, Merits/demerits of both the
technique. Q-after closing the wound what steps is the next- Fops suture to
prevent exposure keratitis for 24 Hrs, if no lagophthalmos will open in 1st POD.
Immediate complications of LPS resection? Very satisfied answer. Bell rang
–Quiet happy with the three board.
At evening I got my result and was able to proceed to the clinical part.
At the clinical part faced One Indian and One British examiner (Very descent in
all aspects). Started with a case (20-25 yrs male) sitting in the slit lamp
asking to see the fundal glow with direct Ophthalmoscope- Ans-Deminished fundal
glow and an atypical shadow not very distinct something wrong with Lens. Asked
to go with Slit Lamp- Subluxates lens Rt-Sup.Nasally, Left Nasally, Q-Cause of
subluxated lens- Answered all nicely, Management- BCVA, IOP, Angle study. If
there is cataract? What procedure? Lensectomy with scleral fixation IOL/CTR/
Aphakic spectale correction (But willn’t go for ACIOL). Allso mentioned will see
the fundus with Indirect to see peripheral part, if any degenerative change in
the periphery will go forprophylactic 360 degree laser before surgery. Asked to
see the fundus of the left eye with 90D Volk, myopic fundus, no other pathology.
Asked refractive status of the patient-Myopic.
Next case –about 75 yrs man asked to see Fundus with Indirect, very non-cooperative
patient, may be due to poor vision, didn’t see details with indirect, so asked
for 90D, permitted, but still didn’t see well because pt was moving the eye like
anything, asked to see with Direct-permitted, there was proliferative changes in
the fundus with involvement of macula with hypermetropic disc, asked for
probable cause – PDR( examiner told that pt is non-diabetic but Hypertensive), so
next Dx-Old CVR-happy face, asked what to do next-wanted to see IOP and angle,
Why? Neovascular glaucoma, Q- if there is Neovessels in iris with Ischaemic CRVO
what to do, - PRP, asked for the study associated with this issue.
Next case with dilated fundus asked to see fundus, choice is mine, I choose
Direct-as pt was away from Indirect and Slit lamp (To save time I choose
Direct)-Rt sided Optic atrophy(Primary), Lt –temporal pallor, Dx? Wanted to
excude ICSOL (MRI), Lesion? Chiasmal –then told MRI is normal. Next Dx is Toxic-
Causes (Including drugs), Mechanism, Treatment. Satisfied answer.
Next case with a 25-30 years male , asked to examine, given my choice either
with slitlamp, Indirect/Direct or Ant. Segment, I choose ant segment examination
and started with Hirschberg reflex-15 degree XT-Lt eye, started cover
test/cover-uncover, alternate cover test for distant, there was alternate
concomitant XT of about 15 degree, I wanted to go for near, but examiner told
that time is up. I was very satisfied with…. And was waiting for the result.
At last I got the expected result at about 4-30PM, on the same day. I passed.
Really it was one of my most memorable part of my life. Thanks Allah for giving
me the such type of result.
My advice to all future examinees:
Kanski is the book you must know inside out.
Reference – AAO
For problem solving – Prof.Muthusamy is the the the best (Practice makes a man
perfect, so practice more and keep contact with Professor).
For oral – Very often asked –Collagen vascular diseases, DM, Systemic diseases
with ocular manifestations, Surgery anything can be asked, Must be well enough
practice with Histology
Slides/Photographs can take help from Chua eye page.
For clinical practice video clips are found in Chua eye page and to practice
regularly, keep in touch with the cases regularly.
ABOVE ALL PROFESSOR MUTHUSAMY’S Help. So try to make regular good contact with him and his