Hi everybody,

I am Rishikesh and I passed FRCS (Glasgow) in September 2008 in first attempt. I would like to thank my family members for their support and Sankara Nethralaya, where during my post-graduation, the basic foundations of clinical ophthalmology were taught to me. I had taken the exam only because I had cleared my part-1 and had decided not to attempt again if I did not clear this time. For guidance, I went back to what I trusted most during my DNB exam i.e. Kansky, Wong, Chua’s website and Dr. Muthusamy (mvupgo.com). In addition, Dr. Ayman’s presentations were of great help. My special thanks to all the candidates who have shared their experiences through this website…….that was really helpful and comforting throughout my exam period.

Day 1
Clinical Case interpretation

1. A 57-year 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 on Warfarin. Visual acuity is 6/9 RE and 6/18 LE with possible RAPD LE. Describe how you would investigate and manage the case.

2. A 40-year old woman attends your clinic enquiring about refractive surgery. Her acuities are 6/18 with -9.00DS RE and 6/6 with -4.00DS LE. She previously had RD surgery 20 years back. You note early cataract in RE and clear lens LE. How would you manage this case and possible problems you would like to discuss with this patient?

3. 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 displaced laterally. She had 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?

MCQs
To prepare for mcqs I read Kanski and solved mcqs of this website twice. At least this gave me the thought process to attempt mcqs with negative marking. In the first go, attempt the sure-shot ones and if they exceed 200, don’t go any further. Learn all inheritance patterns, HLA-types, sexual predilections, chromosomal associations and specific pathological features of ocular conditions (eg. palisading for BCC), by heart. Also remember incidences of uveitis in various systemic diseases and glaucoma secondary to various ocular conditions (pigment dispersion, PXF etc).


Day 2 (VIVAS)

Mine was in the first session of second day.

Ophthalmic Medicine

First examiner
Clinical photo, red free photo, FFA and OCT of CSR. Listen to the examiner’s question carefully, he asked me the diagnosis, and I went on describing the photos, though the diagnosis was obvious. He started asking me various phases of FFA. Moral of the story: if diagnosis is obvious, tell it straightaway. Let examiner decide whether to ask for justification of diagnosis or further management. Second photo was a corneal pathology and AC details were not clear. I thought it was fungal ulcer, but time got over
Second examiner
HVF showing inf.arcuate scotoma. Discussion on possible disc changes, medical management of glaucoma. Next was bitemporal field defect and discussion on chiasmal compression and MRI.

General Medicine and Neurology
First examiner
X-ray of hilar lymphadenopathy and pulmonary fibrosis. I was not very sure of this, but examiner nodded and hence got relieved. Discussion went into systemic and ocular manifestations of sarcoidosis, investigations and management. Next was a clinical photo of lady with goiter. Asked medical management of hyperthyroidism. Next was classification of diabetic retinopathy and I answered before time was over.
 

Second examiner
Question- Person on slit-lamp suddenly collapses suddenly. What will you do? Told him about the possibilities of vaso-vagal shock and hypoglycemic coma. He nodded and then stretched out his hand and drew an ECG of ventricular fibrillation. Asked me about further management and details of defibrillation. Next, clinical photo of a man with café-au-lait spots. Discussion on neurofibromatosis, ocular and systemic features. Then clinical photo of a middle aged lady with proptosis and lid-retraction. Asked commonest cause and I said thyroid. Bell rang.

Ophthalmic pathology and surgery
First examiner
Gave me a photo and said it’s an orbital tissue. I started describing the lymphocytic infiltration. He showed me an area and told me it was muscle tissue. Oh no, not again, it was thyroid myopathy. Then a pathological photo of capillary hemangioma, molluscum contagiosum (not very clear), and said I am not sure. Then a clinical photo of swelling in lacrimal sac area and discussion went into management of acute dacryocystitis. Then he showed me Kerryson’s punch and details of DCR.

Second examiner
Photo of filtering bleb. He said it is 5 years old and now the IOP is 5mmHg. What can be the causes? I thought of choroidals, but then he showed me a photo of Seidel’s test. He asked me the details and how to manage a wound leak. Not very satisfied with the answer. Next, complications of RD surgery, and comparison of C3F8, SF6 and silicone oil. I went on answering and his frown started disappearing. Next, he gave me 2 readings, 15 prismD XT for near and 30 prism D XT for distance, vision BE 6/6, how would you manage. At last, there they entered into my field, squint. I described patch test. Then he asked when to do surgery, squinting for >1/2 waking hrs and deteriorating stereopsis. What surgery, I said bilateral recession. He asked why, divergence excess I said. I wanted to go into details about surgery but time was over.
Results came in the afternoon and 34 out of 61 proceeded to clinicals and I was there.

Day 4

Clinical

I think the best way to approach the clinical is to think as if you are working in your outpatient dept. I am a squint person so I had decided to try to finish examining squint and neuro-ophthal cases early, so that I can spend extra time for fundus cases.

To my good luck, the first case examiner asked me to check motility. Within no time I concluded it was Duane’s-type3 and he asked when shall you do surgery and what will you tell patient about the condition. The discussion must have lasted for a minute or so.
 

Second case- 90D exam. I dimmed the room lights and took my time to diagnose it as CRVO. He started asking about filters on slit-lamp, then when will you do FFA for this patient.
 

Third case- Direct ophthalmoscopy (I am not good at it), anyway I saw the disc and said NVD. Then he asked to do indirect of the same patient. I am more comfortable with that and saw it was old STBRVO. Described the findings. He said what field defect do you expect, I said nasal. He asked to do confrontation fields for the same patient to conform.

Fourth Case- Again a squint, but I messed it up a bit. Ocular motility. Patient had left exo and adduction limitation with lid retraction on attempted adduction, but motility did not fit into any type. I described the findings, he asked what do you think, I replied I am thinking of partial III nerve with aberrant regeneration but I am not sure. He showed me the glasses of the patient. High hyperopia, more in LE and asked me to look closely at LE conjunctiva. She had a scar. I said she probably has undergone squint surgery for the LE and being anisometropic amblyope, squint has recurred. He nodded.
 

Fifth case- young male with proptosis and lid retraction. I was asked why proptosis and not ptosis in the other eye. I said superior scleral show. Asked to elicit lid-lag. Probable cause thyroid, but also CCF. I said I would like to check motility, pupils and slit-lamp. Examiner asked me to perform pupillary examination, but was normal.
Sixth case- child, asked me to quickly check with torch. I said RE microphthalmos with iris coloboma. He asked about LE, but I could not see and coloboma there. He was not very satisfied, but the bell rang.

My heart sank and I thought I had messed up a squint case and the coloboma in the end. Was tensed and tried to calm myself by reading newspaperand watching TV, but the thought of exam could not leave me. In the afternoon, when I was on my way to the centre, got a call from my friend that I have cleared. I thought entire world at my feet. I confirmed the result myself 5 times and have also taken a photo of the result sheet on my mobile. 10 years back when I was in my medical school, I would not have dreamt to be FRCS one day. My medical career has been full of ups and downs, but I consider FRCS passing as one of my greatest successes so far.

In case of any queries, feel free to mail me at rishimayee@yahoo.com or rishimayee@gmail.com.

Regards,

Rishikesh.