My name is Khalid Ghaith; I
passed the exam in Muscat, December 2008 from the first time (Thanks GOD). I'd
like to thank my Family, my friends for their kind support during these days
before and during this examination, I'd also like to express my deepest
appreciation for consultant Dr. Ahmed Reda who organized my knowledge and give
me the most important tips during the different stages of the exam.
First Day: Written exam 30/11/2008, 9:30-11:30 am
1. A 40 year old lady is seen in your clinic with a history of intermittent
pain, redness and watering of the left eye for 60months, occurring particularly
night. During the last attack 5 days ago, the vision in the eye had become
blurred and she had been aware of colored haloes. On examination acuities were
6/6 with refraction and both eyes were quiet with normal intraocular pressures.
What are the possible differential diagnoses and how would you investigate and
treat this patient?
2. A 25-year-old female patient is myopic and has always had reduced vision in
the left eye. Her best corrected vision is 6/6 right with -4.00 DS and 6/60 left
with -7.50 DS. She usually only wears a soft contact lens in her right eye. Two
days before her wedding she is referred to your clinic with pain and redness in
her right eye and an obvious corneal opacity.
How would investigate and manage this case?
3. A 75-year-old lady who is carer for her invalid husband presents with sudden
loss of vision in the right eye with the left having been poor for many years.
On examination acuities are counting fingers left and 6/60 right and she has a
macular branch retinal vein occlusion in the right eye. On the left side there
is a dense cataract.
What are the possible treatment options for this patient and how should she be
Most of the candidates managed the first case as intermittent ACG, DD are those
causing haloes, pain and watering. The investigations should be aimed for
systemic associations, gonioscopy, and field of vision. In the management we
should consider the other eye, use of miotics and counseling the patient about
YAG PI in both eyes.
The second case most of us considered as ocular emergency (contact lens related
corneal ulcer) and talked about admission because she is nearly single eyed,
sexual history (in any young patient), history of the corneal opacity, C&S of
the corneal scrapings and for both the contact lens and its case, fortified
drops, systemic antibiotics, Postpone her wedding, search for any correctable
cause of drop of vision in the other eye and treat.
The third case it is a straight forward case BRVO in one eye (best seeing) and
old standing cataract in the other eye. The patient can't afford long hospital
stay because she is the only carer of her disabled husband. If she is to have
cataract we should asses her posterior segment condition and the visual
potentials of this eye. Consider topical and local anesthesia. it can be done
during the follow up of the vein occlusion. Search and treat any systemic cause
of the BRVO, consult internal medicine and anesthesiologist treat the vein
occlusion according to the BRVOS. I forgot to mention low vision aids if the
macula is ischemic and the other eye have low visual potentials.
Second Day: Viva exam 1/12/2008, 9:00-4:30 pm
Pathology and Ophthalmic surgery:
After introduction the first question was a surprise for me (pathogenesis of
diabetic cataract) I hesitated for a few seconds then I remembered Dr. Ahmed
Reda advice about starting with an introduction. I said DM causes a
hyperglycemic state and excessive glucose in the lens will activate the aldose
reductase enzyme transforming it to something toxic (the examiner said sugar
alcohol) then asked me, what does this cause to lens? I said transform soluble
lens proteins to insoluble proteins, he asked me what else? I said osmotic
damage by increasing intra-lenticular water, then he asked about how to manage
diabetic cataract and what possible problems you may face (here we are back to
ophthalmology where anyone who had experience can do well) he continued about
how to manage each problem intraoperative and postoperative management of this
He started by showing me an anterior segment photo with posterior synaechia
asked me about causes of this condition, chronic uveitis, post traumatic, post
AACG, how would you manage? I mentioned ECCE, preoperative dilatation, with all
means, intraoperative by viscodilatation, mechanical and sphincterotomies. He
said is it good idea I told him this is last resort and may increase
postoperative uveitis, I told him if a senior consultant will do he might use
iris hooks. He asked about PCO after cataract surgery. I mentioned YAG
capsulotomy, he asked how, I mentioned we should counsel the patient first, he
forgot the YAG and asked about counseling and post YAG macular edema and its
management. He also presented a post cataract refraction of +2 DS/+2 DS×180, and
the non operated eye +1 DS/+1 DC×180 and asked what to do, I started by
selective stitch removal, then remembered the other eye and said it is
correctable with glasses also. Also asked if it is preoperative astigmatism, I
said we will plan the incision in the steepest meridian. The bell ringing does
not protect you from answering, if you have important answer tell it if you
don't KEEP silent.
General medicine and Neurology:
Dr. Madi (Arabic examiner) he started by asking me what is bad headache, It was
strange start also, I mentioned it may awake patient from sleep, has
neurological signs or symptoms, signs of menengism, loss of conscious, and
fever. He asked DD of severe headache, I mentioned subarachinoid he, SOL,
infection. He asked also about patient with bacterial meningitis. I answered it
is an emergency we should call neurologist and admit the patient, secure IV line
and start antibiotics, support patient vital signs if he is comatosed. He asked
what type of antibiotics, I mentioned cefroxime 1.5 gm IV /8 hrs. He asked what
the use of Beta-blockers is and I mentioned hypertension, arrhythmias and
thyroid and the bell ring. The examiner kept silent after each question and gave
no clues or hints to enrich the disscusion.
Professor: Gobta he started by asking me do you use beta-blockers in thyroid
ophthalmopathy, I said no it is for cardiac manifestations. Then he asked about
cause of optic disc swelling, I asked unilateral or bilateral, he said
bilateral, I asked about any age preference he told me, give DD, I started by
GCA in old, demilination in young and then other causes, he asked how to
differentiate and we started a discussion about each cause and it
differentiating signs, symptoms and investigations, he said what about CRVO, and
I mentioned that edema and hges will extend outside the disc, he also asked
about drusen and I mentioned its signs and symptoms and field changes, he told
me what about calcifications in X-ray I told him yes it cause this. He asked the
mood of inheritance of Leber's optic atrophy. I mentioned mitochondrial DNA.
Really it was very objective station and Professor Gobta has a very good
experience in managing the discussion.
She was an English lady. She started by showing me slit lamp photography of 34
years old patient with paracentral corneal epithelial defect 4 mm diameter and
stained by rose Bengal, and mentioned that the patient has sore eye for 3 weeks.
I mentioned we will treat as bacterial ulcer. She said can 3 weeks corneal ulcer
look like that. I asked about medical history, it was free, ocular history, sore
eye one year ago. I shifted to viral corneal ulcer HSV or HZV. She said OK what
are corneal manifestations of HZV, and I mentioned it, except neurotrophic
keratitis. She continued to ask what happened after HZV heals (here it came to
my mined by Gods well) just before the ring. She was searching for Neurotrophic
Ulcer. She was very helpful. All this 10 minutes I was telling my self why I
mentioned Zoster in the DD and at the end it was the required answer.
Dr. Khalid Sharif. Jordanian Consultant. He started by asking what other ocular
manifestations of HZV, I mentioned uveitis, scleritis, PORN, ARN. He asked about
what is the characteristic feature of uveitis, I mentioned sectorial iris
atrophy, and he then asked about secondary Glaucoma, I answered. Then asked
about rubiosis irides and its causes, management of diabetic rubiosis, cataract
with rubiosis and rubiotic glaucoma. He asked for the DD of 34 years old female
with unilateral proptosis, I said the most common is TED, vascular, neoplastic,
he asked about ON meningioma and I answered in details. He asked me just before
the ring about the DD of a baby with bilateral opaque corneas, I said birth
trauma, MPS, then the ring then I said Buphthalmus. He was very objective and
managed the discussion very well.
Third Day: clinical exam 3/12/2008, 9:00-4:30 pm
The English examiner showed me a case of posterior segment to examine by the
I/O. I asked if I could talk to patients in Arabic. He said OK but explain what
is going on. It was a case of mild Diabetic retinopathy in one eye and BRVO in
the other eye which had a large C/D ratio (same as the last case in the written
exam but here I mentioned low vision Aids if the macula ischemic), he asked
about the management.
Female doctor from Oman she was very decent and objective. She showed me a case
on the slit lamp with UL cicatricial entropion trichiasis with corneal
opacities, LL ectropion, asked about possible causes and the mechanism of senile
entropion. What are the manifestations of trachoma in the eye? , what are
Herbert's pits I said degenerated limbal follicles, she asked about the sign of
old trachoma and I said healed pannus.
5 years old boy with left congenital severe ptosis, left head tilt, and facial
asymmetry on the left side. Asked me to examine ptosis and explain every thing I
do, I mentioned the previous data in inspection, then I did the measures
comparing both eyes, then I but my finger on the patient forehead to measure the
levator function he asked me why I put my finger on the forehead I said to stop
frontalis effect. He asked me what is this I mentioned this is severe congenital
ptosis with poor levator function, but I like to examine ocular motility, he
said OK go on, I examined the motility and told him he has also congenital right
fourth nerve palsy, he asked about the left eye is there any thing in it, I
asked to examine again and did so, I said he has left hypotropia. He asked about
what is the most important thing to ask in history I said the duration of ptosis,
and in the examination I mentioned VA. He told me what if he had poor vision in
the ptotic eye, I said we should correct any error of refraction and treat
amblyopia, he asked how I mentioned patching of the right eye.
Young male patient with bilateral corneal dystrophy, the discussion went with
the female examiner about level of opacity, it was in all layers, with clear
zone from the limbus, asked me to demonstrate sclerotic scatter and specular
reflection, and she asked me what kind of dystrophy, I said it might be
granular, she said is this how granular looks like, I said I didn't see this
much dystrophies to differentiate. The English professor said OK. Let's move on.
Middle age male in his fifties. Asked me to examine left anterior segment and
tell what I see. He had a circular corneal opacification and I said it is post
refractive surgery complications and I said mostly LASIK, he asked why do you
think he had low vision after the surgery, I said he had dense cataract, he said
apart from cataract, I said interface dense opacification. The time was up.
For any information or help, please don't hesitate to contact me