Final FRCS

Centre:   Muscat

   Date:    Dec 2010

My name is Dr Ahmed Lotfy Soliman, 35 years old,  originally from Egypt and work in Saudi Arabia. I am candidate 58064. Thankfully, I passed the 1^st part of the FRCS in 11/2009, the 2^nd one in 6/2010 and lastly the 3^rd part in 12/2010 (Muscat). Fortunately, I successfully passed all the three parts with the attempts. I owe deep gratitude to God without the support of whom I would not have passed and in the name of whom I joined these exams to acquire more knowledge with which I can help my patients.  May God accept my intent and work.

I should thank my adorable wife, the truly supporting angel, for her patience with me sacrificing a lot of things during my successes. May GOD bless her.

My recommended sources:

Actually, I had a good scientific background before the preparation for this exam thank to my master exams in 2003 then MD exams (Cairo university) in 2007.  I am not a genius but only have a fair deal of  knowledge. I recommend some sources that initially may look surprising in their simplicity but I think they will be sufficient:

Ophtha medicine:

a)    Kanski (preferably the 6^th edition) though I studied the 5^th one; my old source in previous exams. This book should be deeply memorized by heart and I think it provides 95% of the commonly asked questions. It is deficient in few subjects like ( the new classification of diabetic retinopathy & intravitreal anti-VEGF doses.)

b)    Wills Eye Manual: the 1^st chapter of (DD of symptoms and signs), investigations of retinal artery and vein occlusion, vitreous hemorrhage. HLA-related uveitis, non-physiological visual loss, investigations of uveitis (available in 6^th ed of Kanski also)

c)     Wong's textbook is surely useful but I did not depend on it

d)   Ophthalmology secrets: very useful book. I read it years back but not so essential in the exam

e)    American Academy (strabismus volume): I deeply studied it previously as I am interested in squint but Kanski alone provides fair idea about squint medicine

    Ophtha surgery:

        Though I had multiple readings in previous exams (MSc and MD) thank God, but I felt that this exam tests the basic and main disorders (in surgery and medicine) and does not need extensive reading. Therefore, Kanski is sufficient in glaucoma and vitreoretinal surgeries. It is valuable in cataract but needs some additions in phaco and subluxated lens. In plastic, which is a common subject in oral questions, study the main disciplines of surgeries for entropion, ectropion and reconstruction of lid from Collins. Study ptosis surgeries and complications in more details. Read main ideas and complications of refractive surgeries from any concise source (ophtha secrets may represent a good example). In general, a good source for surgery is (Essential ophthalmic surgery) for Alexander Foss though it lacks refractive and retinal subjects.

Ophthalmic pathology:

Some candidates assure that you may not be tested on any single pathology slides or questions (which nearly occurred with me) but you cannot depend on this assumption because some others have encountered questions in pathology. So study main subjects with their microscopic picture e.g. BCC. SCC, MM, Retinoblastoma. GCA,..etc from any source. For me, I resorted to my old source (ocular pathology) for prof Dr Mohammed Ayoub [an Egyptian source] to remember main subjects

General Medicine:

This was my nightmare. Emergency chapter in Oxford's clinical medicine should be memoriezed by heart. You have to add some other subjects from Oxford e.g.ECG, HTN, Warfarin , digoxin, complications of steroids and immunosuppressives, preop preparation of diabetic patients and those on anticoagulants and hyper and hypokalemia, calcemia, magnesemia and natremia. The Yahoo FRCS group provided a powerpoint presentation of general medicine containing practical situations of possible questions (fainting during FFA or of a diabetic patient,..etc). In addition to all of this, you need the care of God as you may be asked strange other questions. But, if you study the previous subjects, you can pass I think. Kanski may be adequate for neuroophthalmology.

Chu eye page: is an indispensible friend for FRCS candidates. It is very valuable in clinical examination videos, previous candidates experiences and sutures and needles as well as CT, MRI, US and FFA

FRCS yahoo group and Prof DR Muthu virtual university sites are very valuable though I did not have time to get use of them

The more sources you read, the more knowledge you gain but also the more distracted you may get. So,  studying a few sources well is better than reading many without collecting solid data.

Lastly, I should confirm important points. You should be confident during the exam and not worried.  keep collected and calm and answer the questions at ease as if you were managing a case in your clinic. The examiners are usually gentle with the candidates without stressing or pressurizing them. They may even guide you to the direction they want in your answers and you should be intelligent enough to pick this guidance e.g. what is the commonest cause of papilledema? I said: Idiopathic increased ICT. The examiner said: Ok but idiopathic means no cause.. I understood it is not the correct answer. So I said "space occupying lesion". If you do not know an answer, do not waste a lot of time and say" I cannot recollect the exact answer of this question" to give you more questions and more chances

Your answer in  good English and quick practical confident way has a dramatic impressive effect on examiners. If your English is not good, practice in front of a mirror or by recording your answer then relistening to it or answering questions in front of a colleague or even your wife.. This will improve your performance. Clinical experience is essential. So get some training in clinical examination on your routine patients esp. in squint and plastic cases. Discuss with colleagues whenever possible. If your experience in a certain branch is deficient, try to concentrate on it.

Viva:

I-General Medicine & Neuroophthalmology: my nightmare!! I did not like to start with it..

Indian Ophthalmologist & Omani Internist:

1-The Indian Ophthalmologist: I will ask you first in general medicine related to ophtha. I am ophthalmologist….this made me feel comfortable.

Q- Fundus picture of disc oedema: describe this+ DD

Q-If bilateral, what is the most common cause ? Answer: Papilloedma

Q-causes of papilledema? Investigations? role of ophthalmologists?

Q-causes of idiopathic intracranial HTN? Management?

Q- how papilloedma appears in visual field?

Q-Field of vision bitemporal superior quadrantic hemianopia? NB describe systematically: central 20-2 threshold test of both eyes showing good reliability indices and mild reduction of retinal sensitivity and…

Q: causes? A-pituitary adenoma DD of bitemporal hemianopia?

Q-investigations? Management?

 Q-treatment of pituitary adenoma?

2-The Omani Internist:

Q-a patient faints in your office, how to manage?

A-Shout 4 help, ABC, ask relatives about his systemic conditions

Q-he's diabetic

A-hypoglycaemic coma or diabetic ketoacidosis

Q-treatment of each?

Q-how differentiate between them?

Q-if you don't have facilities to differentiate, which to treat?

A-hypoglycaemic coma

Q-patient seizures, what to  do?

I mentioned ABC, help call, medical treatment in doses

Q: what is the important precaution? Protection from injury

Q-patient with headache & periocular pain, 75 ys old, heavy smoker , what DD?

 I mentioned some causes e.g. HTN, GCA (He looked happy), glucoma, migraine, ..etc

Q-investigations & examination?

 mentioned some investigations and examination.. he was saying what else?

The bell rang.. He quickly asked: you said now GCA? How to diagnose? I quickly answered: ESR and CRP.. He rapidly asked: clinically? I said: temporal tender.. he said: enough…thank you

They were smiling and looked satisfied

Oh my God, I will have no more nightmare

II- Ophthalmic Medicine:

Old British examiner with a hearing problem and an Indian examiner as well as a third examiner just observing (mostly a trainee)

1-The British examiner:

Q-causes of night blindness: I started to mention those written in Wills (constricted field)..the 1^st answer was : high myopia..he was surprised! How can myopia cause night blindness? I said: with extensive chorioretinal degenerations in the periphery.. He said conservatively: what is else? Retinitis pigmentosa,…etc

Q-manifestations & investigations? I mentioned them involving ERG.. He asked after I stopped: Is ERG valuable in diagnosis? I felt surprised as I mentioned it but repeated it..

Q-how to differentiate with ERG between RP & congenital stationary night blindness? I started mentioning clinical pictures of CSNB including normal or abnormal fundus and the latter includes fundus albipunctatus and Ogushi disease..When he heard this classification, he looked satisfied

Then he showed me unclear photo of anterior segment with epibulbar nodules, papillae or a mass at the lower fornix with the lower eyelid retracted: DD? I mentioned all what I can (inflammatory, neoplastic,..) but could not reach what is in his mind.. So he asked coldly, what are the types of conjunctivitis? When I mentioned chlamydial, he asked: what is CP? What is ttt?

2-Indian Examiner:

Q-thyrotoxicosis: how does it affect vision ?

Q-how to treat associated optic neuropathy?

Q-sight threatening uveitis? I mentioned how uveitis affects vision..but still unsatisfied.

Q-how to treat uveitis?

Q picture of inferior corneal marginal ulcer: causes? How to investigate and manage? If due to a systemic disease, how to investigate and manage?

They finished questions but still 2 minutes remaining. So he asked (outside the curriculum and giving you more chances for more scores)

Q-Give me some names of immunosuppressive drugs?

Q-causes of infectious uveitis?

Q-a patient with tuberculous uveitis do you give steroids?

He looked again to the British one as if asking if he had more questions

 He asked: complications of immunosuppressives? I said : lowering immunity so opportunistic infections.. He said: yes what else?

Bell Rang before answering…they were happy

Thank God

 III- Pathology and Surgery:

This session  was like happy dreams. Dr Fathy El Sayad, an Egyptian examiner with another Egyptian female Doctor.

1-Dr Fathy El Sayad:

Q-how to treat lid retraction caused by thyrotoxicosis?

A-first we repair orbital problems like proptosis and any problems in the extraocular muscles before we treat lid retraction

Q-She has nothing of this and she's also euthyroid, and has only lid retraction, how to treat?

A-I asked: what is the degree of lid retraction?

Q-he said: moderate

A-I said: mullerotomy will correct 2 mm , if there is still residual, I will do Levator recession

Q-he said: suppose that she doesn't want a surgery, do you have another solutions?

A-I said: theoretically we can inject botox in the levator, but it will induce complete ptosis

Q-he asked: is there any medication to give to her?

A-I thought (lid retraction may be owing to contraction of Muller's muscle which is due to oversensitization of the catecholamine receptors by high thyroid hormone level, so, …)So the answer jumped: we can give sympatholytic.

Q-like what?

A-Guanithedine     he said: OK (It stroke home)

Q-what are types of ectropion?

A-I enumerated them

Q-how to treat each? Just enumeration of the names of surgical procedures without details

A-I replied quickly… In the names of surgeries of involutional, I was exhausted to remember (Kuhnt Szymanowski operation) but it was not a problem

Q-he showed me a photo of malignant melanoma at the optic nerve head and asked about lines of management and prognosis

2-The Egyptian female doctor:

Q-what do you know about Fuch's endothelial dystrophy; FED?

Q-precautions before cataract surgery in a patient with FED? (This is an example of God's support..as this is mentioned in details in the 6^th ed of Kanski that I did not read but accidentally my colleague in the hotel's room mentioned in details at the previous night when we accidentally mentioned that subject!)

A-pachymetry in the morning if CCT> 630µ I'll warn the patient that he may need keratoplasty. I'll do phaco with minimal U/S settings

Q-how to treat corneal decompensation?

A-medical ttt then keratoplasty

Q-a 5 years old child with alternating esotropia of 30∆,wearing a +3 glasses. The angle of deviation is equal in far and near vision. How to treat?

A-what is angle without glasses?

Q-30∆ also

A-when was the onset of this condition?

Q-the examiner  got confused for 2 seconds. she didn't prepare this  information, then, she said:2 years ago.

A-I said; this is basic esotropia and will need surgical correction

Q-what will you do?

A-bilateral medial rectus resession 4.5mm

Q-do you have other options?

A-I paused for a while

Q-she asked: could you operate on one eye only?

A-I said:yes, but monocular recess resect is better for moocular tropia not alternating

Q-she said: what will you do? I said: MR recession 5mm and LR resection 7mm. She smiled: why so large parameters ? how much prism diopters corrected by each 1mm resession or resection of LR?

A-I picked her opinion and regressed, she agreed

Q-what are complications of squint surgery?

At this point the 2 examiners looked at each other and said:we finished and looked happy. There was  still 3-4 minutes . We remained silent for a while, then, Dr Fathy El Sayad said: we will ask you some questions outside the counter, no problem if you can't answer them

Q-what are other types of keratoplasty you know?

A-lamellar keratoplasty

Q-indications?

A-keartoconus or anterior dystrophies

Q-other types of lamellar KP?

A-deep lamellar and endothelial or posterior KP

Q-indications of endothelial KP?

A-endothelial decompensation as in Fuch's endothelial dystrophy or psudophakia

Q-complications of lamellar KP?

A-astigmatism, rejection

Q-is rejection common with it?

A-no, not as PKP

Q-the female doctor asked: you mentioned slipped muscle in complications of squint surgery, how to manage?

A-I will try to restore the muscle, if I spare the check ligament this will help me to get the muscle, if I couldn't get it I'll do (Hammelsheim) procedure. She said: also if you catch a tissue and bradycardia occurs, it is a muscle

She showed me a picture of limbal dermoid..What is this? When to treat? Astigmatism or cosmetical. How to treat? Lamellar keratectomy and sclerectomy and removal in one mass or lamellar KP. What is the syndrome associated with it? Goldenhar. What is it?.....

They looked to each other again, pause, then the bell rang. Dr Fathy said many times: thank you!!

Thank God….It was like dreams!

Clinical

1-Posterior segment:

The same Egyptian female doctor and a young British examiner:

1-a case of diabetic maculopathy with previous  PRP and Grid laser, they asked about management of diabetic macular oedema and indications of laser in diabetic retinopathy

2-a case of retinitis pigmentosa, we talk about it for a while

3-myelinated nerve fibers with pripheral old standing RD or retinoschesis

Bell Rang

2-ocular motility: an  an Omani Young female doctor and an English female doctor

1-intermittent  exotropia.. I felt the angle is larger in far than near. I said: it looks divergence excess XT but I should differentiate between true and simulating ones by either monocular occlusion for 15 minutes or +3 lens. They looked to each other as if they already took the decision of the mark!

2-monocular  elevation deficit: limited elevation in all direction. It is really difficult for non-strabismologists

3-ET with limited abduction but no narrowing of PF in attempted adduction.. so 6^th nerve palsy

4-RAPD

the discussion was about RAPD, what are possible causes? how to examine? How to investigate?

Can a lesion in optic radiations cause RAPD? I said: yes but vermiform..She said: what is the light reflex? When I mentioned it? I discovered the answer: any lesion behind LGB does not do.

6^th nerve palsy:how to investigate? How to manage?

3-Orbit: Again Dr Fathy El Sayad and an Indian Examiner

1-severe unilateral congenital ptosis: Dr Fathy El Sayad asked how to examine? What are you searching for when you examine?management?

2-anterior orbital lesion bulging through the lower lid: what are the possibilities? It was a soft compressible lump. It could be capillary haemangioma, orbital varices, neurofibromatosis,traumatic..what is your investigation and management?

4-Anterior segment:

Libyan and Nigerian examiners

A repaired corneal wound with sutures still present, aphakia with no posterior capsule and widely dilated pupil : he asked what are the problems this patient will have? how to manage? if you will put an IOL, which type will you use? do you prefer scleral fixation IOL? Or do you think it will solve his problems? I said; glare is a major problem, we should try to do iridoplasty or aniridia IOL.

 The examiner seemed to be against surgery in this patient when he said: his vision in other eye is  6/6. I said

A young female patient (about 30years old) with after cataract, posterior synechia, periphearl iridotomy.

He asked:what do you notice by inspection?

I said: slight exotropia

he said:right. Anything else?

 I said: a scar in the forehead.

He said:OK examine her.

I said:this may be after cataact or traumatic absorbed lens.

He said:why do you see suggesting after catarat?

I said: the presence of peripheral iridotomy.

He said:what do you expect to be the cause of this condition? I said: traumatic or complicated cataract

He said: no trauma but look for these scars..do they suggest the cause?

I said: atopic eczema?

He said:I have never seen atopic eczema involving the tip of the nose!!

Actually, the room was not dim, I hardly saw that scar) but once he said "tip of the nose" I got the point and said: yes, this is herpes zoster ophthalmicus.

He said: what is the name of this sign?

 I said: Hutchinson sign.

He looked satisfied and said: now give me the scenario of events that happened to her.

I said:she had herpes zoster ophthalmicus with anterior uveitis which lead to complicated cataract and  the surgical removal of the cataract was complicated with after cataract and posterior synechia.

he said:what could be the cause of her visual impairment?

I said: the after cataract, glaucoma, RD,…

He said: what shall you do for her?

I said:U/S.

He said: U/S is normal and retina is flat, What will you?

VEP to asses the function of th ON.

He said: VEP is normal

I said:we can do a guarded prognosis surgery to remove the after cataract, dissect the synechia  and implant an IOL

He said:by the way the V/A in her right eye is 6/6, what do you expect the vision to be in this eye?

I said: very poor vision

He said:do you still insist that surgery is suitable for her?

I got the message and said: Surely, I will not be the surgeon, he smiled and said: thank you.

The results were available 2 weeks later….I am very happy.

I lastly advise all my colleagues to have good intents and motives for joining this exam (and virtually all things in life). Make your intent to acquire knowledge that makes you a good ophthalmologist that really solves the problems of his patients and to get benefit of time and to spend money in something useful and to have a certificate that enables you to be independent,…etc. All these intents will be rewarded by God whether you pass the exam or not. But if you wanted the FRCS to be a rich man, money could be collected in easier way,..and if you wanted it for reputation and fame, football players and actors will be more famous than you whatever you do and without any certificates!! My best wishes.