Candidate 60
Date:  June 2006
Centre: Norwich
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Although Norfolk & Norwich University Hospital is a new hospital, there were a few complaints from the candidates about the set-up in its eye department. One of my friend said that the Snellen chart was malfunctioning, and the examiner had to hold a pen torch during the retinoscopy. After a while, the examiner asked my friend can he use the 6/60 E instead because he was tired of holding the pen torch! My friend insisted on using pen torch (white light to prevent accommodation)! This might be the first time in MRCOphth that an examiner had to following the candidate's instruction? The other had projector type of Snellen chart but unfortunately the button of the controller was not working well. While she was struggling, she hinted to examiner that “Sir, I am struggling with this controller….” And the examiners just sat there quietly! She wished she told them directly that “…..can you help me with this?”  But some of the candidates get really helpful examiner whom presses the button of Snellen chart for them.

Day 1 Morning

Examination was held in St. Andrew’s Hall. All together there were about 120 candidates. To my surprise, we all finished in a morning. We were divided into two groups, taking turn to do the exam. In the hall, there were 8 rows of tables (each row had 16 tables) and so all 128 candidates could finish the exam in one go! We spent 5 minutes in each station. The last rest station (9th) is the station when we first came in and waited. The printed pictures (I mean yes, no X-ray boxes, no special equipments, even no real CT/MRI films) were all put on the tables. If you happened to come in from the back, you can actually glanced through all the questions/ pictures. We were provided with pencil and eraser on the table. Confusion happened as the candidates were not sure if they were supposed to take or leave those pencil and eraser after each station. When I moved to next station and discovered there was no pencil on the table, I ran back to the previous station to get it.

Station 1
Calculation of vertical phoria

Station 2
Streak retinoscopy. What was the instrument shown and draw a diagram. There are 16 ray diagrams about retinoscopy (according to other bright candidate) I drew the one with movable condensing lens.

Station 3
Hess Chart: 6th nerve palsy ( Most straight forward station)

Station 4
FFA: We are shown 20 pictures with colour control. I think it was a CNV. Asked about the principles.

Station 5
CT scan of the brain showed hypodense area in parietal lobe. Was asked about the type of visual field defect.

Station 6
HVF: Again showed homonymous hemianopia (same side as previous answer) asked how accurate the test was.

Station 7
Picture showed high resolution black and white anterior chamber two dimension view of angle with a hypoacaustic lesion(looked like a cyst) at the back of the iris. What is the investigation? What does it show?

Station 8
Another calculation: A/C ratio with gradient technique. 

The examiners in MRCS Part 2 (Singapore; 12 candidates) said hardly anyone failed OSE. Hopefully the same applied to MRCOphth.

Day 1 Afternoon

I attempted all MCQs as there were no negative marking. The MCQs contained about 50% on optic and refraction and 50% on clinical methods. Relatively easier than MRCS part 2 MCQs. There were no Qs on statistic, epidemiology. There was a Q on polychromic lens. Asked about the detail how electromagnetic energy dissociates the silver and halogen etc. 

Day 2 Morning


Station 1&2
The first two stations were direct and indirect ophthamoscopy. There were two examiners, but only one asked Qs. “Do you have your own ophthalmoscope? Would you like to look at this gentleman right optic disc?” I did running commentary on the glaucomatous disc: Vertical and horizontal cupping (0.7 & 0.6), dots signs, bayoneting vessels, and all the negative findings that may appear in glaucomatous disc. He responded “very good!”(The other examiner kept his mouth shut as tight as a clam so I don't know if I am doing it right or wrong. Both examiners let me do what I thought was necessary!). The other optic appeared normal. Without the examiner asking, I offered diagnosis of right post-traumatic glaucoma that causing the unilateral cupping. Examiner looks a bit disturbed. “Have you examined the angle to diagnose that?” I quickly said that the most common cause still the primary glaucoma with more advance progression on the right eye. I made a mistake here.

Then I was led to another gentleman lying on a examination coach in theclinic. “Would you like to look at his right fundus?” There were pigmented bony spicules located at superior temporal region only. Disc was pale and the vessels were attenuated. I offered a diagnosis of RP. I said the commonly seen RP, I will expect the spicules distributed at mid- periphery of fundus around the clock. “Could it be still RP?” Yes, sectorial RP. “What are the differential diagnoses?” I said old RD. “how about if I tell you the lesion is new?” I said it could be infection causing scarring. Examiners seems satisfied.

Station 3&4: 
I was introduced to a gentleman sitting on a chair. He wore hearing aids. I was asked to examine the pupil. I was straining my brain for possible relation between pupil and hearing aids so much so I forgot to inspect the lids! The pupil appeared similar in size. I requested the room to be dimmed. Direct and consensual light reflex was normal. When I did the swinging light test, both examiners came closer to observe the signs. I knew there must be RAPD which previous candidate missed. But, this gentleman left RAPD was so mild (Maybe only +1) that I said NO (I don’t want to be caught creating signs!). I looked at the examiner expression; they looked at each other and are like saying to each other “agree? Only very minute RAPD, candidates can’t see that” I quickly rechecked and confirmed that. They seem relieved? I was then asked about any pharmacological test to confirm? Strange!!!! I was confused! I just tell everything I know about pharmacological test for pupil. The examiner suddenly realized his mistake and changed his questions to “Tell me how do you confirm Horner’s syndrome?”  What are the causes of RAPD? 

Next, I was asked to examine a young gentleman sitting on a chair. “Would you like to examiner his eye movements? It is complicated but just tells us what you get” I started by asking “May I know the vision” Examiner said “no, you may not”!!! Then I made another mistake by asking “do you want me to do cover-uncover test” as the patient had a left complete ptosis “DO BOTH” she answered. When I lifted up the lids, the eyeballs turn inward and downward. I described everything then I said “normally I will taped the drooping eyelid the do the cover-uncover test.” The other examiner offered to help me to hold the lids. There was nothing of note on cover test. Time up! I was asked only one Q. “What is your diagnosis?” I said 3rd nerve palsy with aberrant regeneration.

Station 5&6
I was asked to use the slit lamp to look at a lady’s anterior segment. I noticed small pigmented KP distributed evenly on endothelium. There was a pigmented nodule at the periphery of the iris. (3-6 clock hours) I made mistake here by suggesting this was Bussaca nodule and committed myself to granulomatous inflammation. 

I was then asked to examiner the visual field of a lady. I mentioned she had skin rash over her face. Examiner asked me to go straight to the visual field (Which mean that skin rash was unrelated) There was right hemianopia on confrontation test with fingers. I then used the red pin to check for macula sparing. There were no macula sparing. I said the lesion maybe at the optic radiation. I made mistake here as I didn’t check for the congruosity of the defect and for the patient to have such a lesion in parietal and temporal lobe, she may have other neurological signs which to me was not obvious. No Qs asked here.

Station 7&8
JVS Keratometer. I used the technique mentioned in Chua's book to level the patient’s eye i.e. I shone a torchlight into the eyepiece then use the reflected light as a guide to make sure patient eye is at the same level as the mires so that I can see the mires easily. I was so anxious that I forgot to turn on the degree button after I get the radius. I said 38 at 180. Then examiner keep pressing me to repeat my answer which made me realize my mistake! 

The last station was on focimeter. I was asked to examine an old bifocal glass. I couldn’t get the add right but examiner keep on asking “what do you normally give to patient? Write it down here on this paper” I have no choice but write add +1. (My friend later tell me it was a multifocal spec)Then the time was up. Examiner seemed wanting to help by asking about the principles of focimeter. I told him quickly: Optometer principle, movable target focus points etc. I even mentioned green light was used to eliminate aberration.

Day 4 Afternoon

I was so lucky to get a cooperative patient who was a retired school teacher with -4 myope both eyes. When I entered the room, I was introduced by an examiner to a lady observer from the college. That meant I had 3 pairs of eyes looking at me while I do my refraction. Fortunately, she helped me by switching on and off the Snellen chart and controlled the lighting. I was allowed to get familiarize with all the instruments. The examiner told me there was no Maddox Rod in the trail lens set! She said “It's ok, you can still do refraction without it” 

I finished doing my objective and subjective ret quite early (15minutes) then to my horror, there weren't Maddox wing and RAF around either. To avoid just sitting quietly there doing nothing, I refined and re-refined my subjective ret till the last five minute I found a Maddox Rod in the lens set!!!!! I showed it to examiner, there said don’t worry. I quickly recheck my answer then time up. I think I was given allowance marks for that as I later found out though I drew the power cross correctly; I write it down wrongly in degree. Luckily my subjective ret was tally with the power cross.
The type of patients and examiner you get in this section clearly determine your chance of passing! Even if you get ‘difficult one’ do not give up and panic. Just do whatever you can, and allowance marks will be given?

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