|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.
Calculation of vertical phoria
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.
Hess Chart: 6th nerve palsy ( Most straight forward station)
FFA: We are shown 20 pictures with colour control. I think it was a
CNV. Asked about the principles.
CT scan of the brain showed hypodense area in parietal lobe. Was asked
about the type of visual field defect.
HVF: Again showed homonymous hemianopia (same side as previous answer)
asked how accurate the test was.
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?
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
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
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
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.
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.
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
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
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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