Candidate 117

Final FRCS (passed)                          

Centre: New Delhi                             

Date:    Sept. 2008 

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.

Answer - 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?

Answer - 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 case?

Answer - Possible causes are – Rhino-orbital mucormycosis, Non Hodgkins B-cell Lymphoma, Leukaemia, 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 choose.

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. Treatment.

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 cyst.

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 virtual university.