Salam. my name is
Islam. Thank God, I have passed FRCS Glasgow this spring from the
first attempt. I'd like to share my experience with you.
First: study materials
I studied Kanski,
oxford hand book ophthalmology (great book) , Wong, emergency chapter
in oxford hand book medicine, made easy ECG and this website (
irreplaceable significance especially the past candidates experience
and the clinical multi-station exam). It took me one and a half month
( full time - unemployed) to study all of them just once however I
greatly recommend to cover the website, Wong and oxford at least
twice. Wills eye manual is a good book with a differential diagnosis
for every topic but I didn't have time for it.
second: exam tips
1* it is an easy
to pass, easy to fail exam! my exam included essentially straight
forward basic info and skills, if you just concentrate enough you will
2* I had never
been asked how to perform a surgical procedure or about refractive
surgery . I don't know but that was my exam.
3* they do
actually repeat questions and cases. I read past candidates experience
in this web site starting from the most recent and found that my exam
included many of them. so my advice is to cover at least the recent 40
candidates or so and search for the answer of every question
practice and practice is the key. share cases with your colleagues,
discuss them and let somebody examine you. even while you're studying
books do so in a loud voice so you can hear yourself and judge your
thoughts and confidence.
5* if you are
asked a question be systematic and start from the simplest part. many
times I started to answer and was stopped just a few seconds later
once they found that my answer is systematic. when asked how to
approach or management always answer: history, physical,
investigations and treatment.
6* each clinical
case is given 6 minutes. from my experience 6 minutes is nothing and
pass like a blink. you never know how time passes and suddenly you
find your clinical exam ends when all what you remember is that you've
just started. so concentrate 'heavily' in the clinical and practice
examination in a very short time and practice observation as my
clinical often depends on observation alone.
7* there was
sterilium in every room to use between cases but to be honest I used
them not in all my cases! Indeed, I forgot to do so.
8* when you enter
the clinical, they ask you to remove any jewelry except a wedding ring
and to cuff your shirt up to the elbow and neither to introduce
yourself to the patients nor to take permission for the examination.
9* you are not
expected to be perfect and answer all the questions correctly, no one
will ever be! so just relax and try to do your best and forgive
yourself for a few mistakes and don't let them change your confidence
during the exam.
10* I found that
all the examiners are good, supportive and helping. many times you can
tell that your answer is true or wrong from the facial expressions of
the examiner! when you are taking the right way of answering they are
always encouraging. They also like spontaneity a lot, I frequently
didn't wait for the next question and mentioned the required points
when following a systematic way in answering.
Third: my exam:
* posterior segment:
1-SLE of middle
aged female, examine fundus of the right eye that showed large hypo
and hyper pigmented macular scar involving fovea with fine surface
gliosis that extends to the optic disc, clear vitreous.
Q: - describe: I
answered: the vitreous is clear, the vessels are ok, the disc has
surface fine sheet of gliosis and the macula had a scar that.. - are
you sure the vitreous is clear? yes. - is there any other lesions? I
returned back and examined again; there were none. -differential?
-trauma, if bilateral I'll think of macular dystrophy. - what type of
macular dystrophy can lead to such a scar? best disease. -if I tell
you that this patient had this condition since childhood and she went
to the UK at that time for treatment, what could be the condition?
retinoblastoma. ( he said right). -management? I answered: history,
physical including other eye, he stopped me.
2- they appeared
impressed from my first case so they told me to come and have a quick
look with indirect ophthalmoscope to a boy with ?? inferotemporal
retinal dialysis. I told them there is a retinal elevation
inferotemporally - what's that? I said retinal detachment vs
retinoschisis. It appeared obviously that I didn't pick it up, so they
said ok, forget about it and come and see case 3.
ophthalmoscoe) examine right eye in a middle aged female: large subRPE
discoid hemorrhage with central barely identified macroaneurysm with
another small hemorrhage away from it. vessels were sclerosed and
attenuated (HTN retinopathy).
Q:- describe: - I
can see a homogeneously darkly pigmented 4 disc diameter lesion
straddling the inferiotemporal arcade not involving fovea, minimally
elevated, well demarcated, the disc is normal with cup disc ratio 0.2,
the vessels are significantly attenuated. there is another one disc
diameter sickle shaped flat lesion inferonasally. -differential
diagnosis? I stupidly said : melanoma, CHRPE, he stopped me: is that a
melanoma? is it elevated? - no sir! what could it be? I wondered
desperately but couldn't pick it up! the other examiner said: could
you see any other hemorrhages ( yes they always try to help you) I
again stupidly answered: no there is no other hemorrhages! - what
could it be? again I didn't reached it! - the other examiner another
time tried to help and said: you've just said the vessels are
attenuated, how could this be related? - no answer!
I said B scan. - it is flat on B scan, what else? no answer! ( I
should have mentioned FFA but I don't know what was happening to me! )
then the bill rang..
I was totally
depressed after this case and I really thought of running away from
the whole exam as my devil told me "you will never pass after this
case" but hey my devil, I did it!
* orbit and oculoplastic:
1- observe and
describe: middle aged female with right lower motor neuron 7 CN palsy
with poor blinking, marked lagophthalmous and a white material on the
lower lid ( the patient was wearing a scarf, I missed to observe
behind ear and around the parotid). -why do you say it is lower
motor? because the upper facial muscles are involved. - what do think
is the white material? eye ointment -why? because of lagophthalmous.
-differential causes of 7 CN palsy. I said: starting from the facial
nucleus at Pons, it could be a lesion at Pons, cerebellopontine angle,
parotid..- how could you differentiate? what other associated lesions
are present and the taste in the anterior 2/3 of tongue. -what if I
tell you that she also has 8 CN palsy, where is the lesion? I said: at
the cerebellopontine angle. - like what? I said tumors like acoustic
neuroma, .. but he seemed unconvinced and searching for a specific
entity, ( some other candidate told me that it was a case of gardingo
2- observe and
describe: young dysmorphic adult with bilateral symmetrical proptosis,
shallow orbits and talengectatic vessels in the inferior half of conj.
-spot diagnosis ?
carotid cavernous fistula (?) - no it is not, what if I tell you that
this patient had this condition stable for a very long time? I said: I
don't know sir! ( till this moment I don't know what it is).
3- observe and
describe: a child with unilateral severe ptosis, defective blinking,
brow suspension scar ( it was a very fine scar and the boy had a long
anterior lock of hair that I didn't elevate so I missed the scar!)
history physical and surgery - do you want to do something before
surgey? oh, ya vision and refraction. then he gave me his glasses to
test, I use the floor blocks ( myopia with astigmatism ).
* neuro and squint:
1- observe and
describe: a young man with nystagmus, I said: I can see a young man
with bilateral conjugate horizontal uniplanar low frequency moderate
amplitude pendular nystagmus. -continue exam? I performed
cover/uncover, EOM, saccadic and convergence, I commented: jerky in
side gaze, not affected with covering one eye or convergence. ( I
learned nystagmus exam from oxford, very nice neat six pages about it-
highly recommended). -type of nystagmus? pendular. then been asked
about sensory, motor imbalance, up and down beat nystagmus.
alignment and EOM: young very very very uncooperative child with
I observed her and found that she had bilateral eso but I didn't
comment as I was thinking could that be possible? then I performed
cover/uncover, alternate cover, prism/cover with and without glasses
then EOM. she was extremely uncooperative and not fixating and barely
could I observe limitation in abduction bilaterally, eso was around 20
for far and 15 for near as I remember but there was also hypotropia??
that measured 8. I mentioned all that and when asked about my
diagnosis I said bilateral 6 CN palsy but need to retest her when she
is not tired. From this case I recommend that if you face an
uncooperative patient don't panic, just perform your exam fully,
comment on whatever you find and mention that you'd rather re examine
later at a better condition, as an uncooperative tired patient is
highly expected in such an exam.
history including congenital vs acquired, physical including vision
and refraction and treatment including surgery depending on the
patient complaint ( I forget to mention temporary measures like
* anterior segment:
1- examine on SLE:
child with right valve and left failed trab ( fibrosed bleb) , I
definitely would miss them if I didn't elevate the upper lids. they
asked me to comment while examining so I started from the lids, conj
-type of glaucoma?
I looked at the patient, she was around 12 years, so I said it could
be congenital vs juvenile glaucoma. - is the left trab functioning? no
sir because it is fibrosed, - if IOP is still high what surgery would
you perform? either augmented trab or tube. -which one would you
choose? tube. - why? what are the complications of valve in this
particular age group? as the eye is small I will expect the plate to
interfere with ocular motility and .. he stopped me and said true. -
how would you manage a baby that came to you as a suspected congenital
glaucoma? beside taking history I will examine him under general
anesthesia preferably ketamine and measure IOP, corneal diameter,
optic disc.. he stopped me and said ok, that's fine.
2- examine on SLE:
middle aged undilated man with right IOL, clear cornea and PXF. left
central faint subepithelial haze, PXF and cataract. same thing they
asked me to comment while examining so again I started from lids, conj
- if the patient
is complaining of his left vision, what will be your treatment? I
should address both the cataract and the corneal scar. - ok, how would
you treat the corneal scar? I don't know may be PTK ( I should
mentioned the need to know the cause of the scar, duration, corneal
OCT to determine the level then decide) - ok, never mind, let's talk
about the cataract what precautions to take? I would expect zonular
weakness and poor dilation, so I will intensely dilate him preop -
what will you give him? ( it would be better to mention the drugs
right away rather than just saying intensive dilating eye drops).
ORAL: ( all
the questions are preselected from the college with each examiner
supposed to ask you about a couple of cases with an answer sheet that
should be ticked for every true answer, so try to mention any thing
that come into your mind as there is predetermined specific answers
you need to mention to gain points and wrong answers don't count! ).
* general medicine:
gave me a scenario f middle aged man with unilateral granulomatous ant
diagnosis? infective, non infective and masqurade. - like what?
infective like herpetic, toxoplasma - and what? TB ( he was looking
for it) -non infective? sarcoid, VKH, sympathetic ophthalmia -sarcoidosis
clinical manifestations? I answered: ocular and systemic : ocular
starting from skin: sarcoid granuloma, lupus pernio and.. he stopped
me and systemic? lung involvement that is classified into 4 stages
first stage.. again stopped me - ok, how would you treat him
systematically? I would send him to an internal medicine physician -
ok, what do you think he will give him? systemic steroid and
azathioprine ( it is not true methotroxate is the right answer) - ok,
what will you check before starting steroids what are steroids
contraindications? I said: peptic ulcer disease, active systemic
infection - like what? TB, sir ( again he was looking for it) .
2- scenario of 62
yo female, unilateral headache and loss of vision - I don't know why
when I looked at this examiner I feared him and lost my concentration
though I don't know him and never saw him before!
- spot diagnosis?
GCA -differential diagnosis? It was a long pause that ended me saying
I don't know sir, total mind block! -ok, GCA what other things in the
history? jaw claudication -other? - I can't remember! ( he was looking
for polymyalgia symptoms) - ok, physical? - loss or decreased
pulsation of the superficial temporal artery, ocular movement defects.
ok, investigations? CBC, ESR, CRP and temporal artery biopsy.
treatment? systemic steroids. -which steroid will you start her? oral
prednisolone 1mg/kg ( he surprised) - is there any other faster
option? oh, ya IV methylprednisolone 1g daily for 3 days then oral. -
(again) what will you check before starting steroids? peptic ulcer
disease, TB, - and at this age? osteoporosis -how will you do that?
DEXA scan -(surprised) will you do dexa right away? what will you need
to do before? Ca and Po level - supposedly normal, what else? history
of hormonal replacement therapy - (surprised) do you expect her to be
on HRT? no sir, I am sorry, history of recurrent fractures - yes, now
you're right ( and put a tick on the answer sheet) .
3- he then gave me
a scenario of 75 yo female at the day of cataract surgery, she co
indigestion the nurse informed you and done an ECG, he handed me an
ECG that has no name or date, it showed ST elevation on most of the
Q: - what does
this ECG show? ST elevation suggestive of acute MI ( I should have
told him that pericarditis is also a differential) - how will you
manage her? I'll put her on high flow O2, chewed aspirin, sublingual
NTG and IV morphine in addition to taking blood samples for CBC, U &
E, troponins, CBK MB. ( I think it will be better if I mentioned
taking detailed history and risk factors at the beginning). - suppose
this woman had been treated for her condition, when will you perform
the surgery? not before 6 months (I don't have a solid info about the
earliest time but I read it from one past candidates answers! though
during my exam the examiners appeared unconvinced by my answer and the
other examiner asked what if she have a retinal detachment? I said to
escape answering: it depends whether macula sparing or involving. -
macula involving? I said desperately pneumatic retinopexy!).
4- then given a
picture of CRVO in 50 yo HTN male
Q: describe? a few
hemorrhages with mild disc swelling, I need to examine under slit lamp
to determine if there is edema or not. -spot diagnosis? CRVO, mostly
nonischemic. -difference between ischemic and non ischemic? I
answered: history, physical including, vision, RAPD, fundus changes,
investigations.- what investigations will you order for this patient?
FFA and OCT. - management? systemic and ocular, systemic
investigations like CBC, BP, lipid profile, U & E, FBS and referral to
an internist. ocular depending on vision, FFA and OCT findings.
5- 25 yo female co
headache , bilateral disc swelling
Q: spot diagnosis?
idiopathic intracranial Hypertension... time is out.
* ophthalmic medicine:
1- picture of
Q: describe? large
central dendretic multiply branching lesion but no obvious terminal
end bulbs. -differential diagnosis? herpetic, healing traumatic,
acanthameobic. -which herpes? mostly simplex. -diagnosis using:
history, physical and investigations? history: of skin lesions,
recurrent corneal disease, physical: other corneal manifestations but
most importantly decreased corneal sensations (he greatly stressed on
this sign), investigations: PCR and cell culture. -treatment? topical
acyclovir. -duration? about two weeks but the rule is at least three
days after the lesion disappear. -other types of topical antiherpetic
drugs? I mentioned idoxuridine but couldn't remember any other.
-types of herpetic corneal diseases? desciform, stromal, metaherpetic,
geographic. -when to use oral antivirals in corneal disaese? he said
there is a strong indication, I mentioned the prophylactic one but he
2- 7 yo child with
right upper lid swelling and redness of 24 hours:
diagnosis? orbital, preseptal cellulitis, allergy, trauma ( he seemed
happy when I mentioned the latter two) and the remote possibility of
embryonal sarcoma. - about orbital cellulitis: how to proceed? histoty
including history of trauma, sinusitis, fever, physical including EOM,
RAPD, pain with eye movement, fundus exam, then I will order CBC and
orbital CT and ask for ENT consultation. - what to look for in the CT?
distinction between orbital and preseptal, sinusitis, orbital
complications like abscess. -cause of orbital air fluid level?? I said
anaerobic infection but it appeared it is not the right answer. then
they skip it and asked about the treatment? intravenous antibiotics
(they didn't asked which ones). -what if CT showed maxillary sinus
collection? I will ask the ENT team for sinus drainage.
3- picture of an
optic disc with temporal B zone, CDR 0.4 vertical and 0.3 horizontal.
clinical approach? I will examine other eye then take intraocular
pressure. -what's the differential if bilateral symmetrical? I said
glaucoma, myopia and idopathic. -how to differentiate? other myopic
fundus findings, IOP, refraction, visual field and optic disc OCT.
4- picture of
CHPPE with partial depigmentation.
Q: spot diagnosis?
clinical significance? the typical type is clinically insignificant
but the atypical is associated with familial polyposis coli and
related syndromes. -which doctor you will consult? gastroenterologist.
5- picture of
keratitis with history of agricultural trauma 5 days ago
abscess ( ?? descematocele). -approach in history? age, other risk
factors, progression, pain. -physical? I will take a swab from the
discharge and scrape the cornea. -how will you do that? with blade 15
taking part from the base and the leading edge starting from the
normal towards the infected cornea. -culture? blood and chocolate
agar, sabourud dextrose for fungi. treatment? I will start him on
fortified vancomycin and ceftazidime with close daily follow up and
add antifungal if no improvement within 48 hours. ( I think I must
also have mentioned admitting the patient)
* surgery and pathology:
1-hazy picture of
fundus with three white retinal lesions
Q: spot diagnosis?
( candida retinitis ). risk factors? IV drug abusers, IV dwelling
catheters, immunosupressed, diabetics and malignancy patients.
treatment? IV amphotricin B. -mention other antifungals? azoles like
variconazole, ketokenazole, itrakenazole . natamycin and flucytocin.
2- picture of
Q: describe? spot
diagnosis? inheritance pattern? autosomal dominant. -presentation?
either decreased vision or recurrent erosions. -management? depending
on the patient complaint and remainder of eye exam but the cornea can
be treated by PTK, anterior stromal puncture or lamellar keratoplasty.
3- a boy with
blunt trauma with a stone that caused zonular dialysis at one side.
time, complaint, previous ocular disease. -physical findings in blunt
trauma? I mentioned them all starting from orbit to retina.
-management of this patient? vision, refraction, if cataractous lens
4- picture of
erythematous raised medial canthal lesion. -diagnosis? to be honest I
first thought it was a skin mass and gave a diagnosis of basal vs.
squamous cell lesion but as I caught up the examiner's dissatisfaction
I thought again I found it was an obvious picture! -management? warm
compressors, oral coamoxiclav, later DCR. -what if the patient come
back two days later not much improving and the abscess is pointing? I
will open up the abscess at the maximally tender point keeping in mind
the risk of iatrogenic fistula formation. ( I was taught that it is
forbidden to open up a lacrimal sac abscess, I told him that but he
5- a rupture globe
patient is on the operation table, what do you want to look for?
time is out and I
left the examination room feeling that I am going to fly finishing the
exam since I dedicated my whole time for many days for studying and
studying neglecting my home, highly supportive husband and my nice
cute baby. Finally I am free!
I wish that anyone
who read this summary will benefit from it. Good luck!