Dear colleagues,

 My name is Waleed Alorabi, an ophthalmologist from Syria working in National Guard hospital Riyadh, KSA. Thanks Allah, I passed the final FRCS exam in Glasgow (Amman 2013) from the first attempt.

First and most important advice: think positively and think positively and think positively….. Use the power of thinking to pass … and you will pass.

Be confident and don’t believe all the myths about how difficult to pass this exam, you will pass….Otherwise, if you go there without self-confidence, you will fail…

I dedicate my success to Allah, my country (Syria) and my family, especially my parents, wife and sons who supported me without limits.

Please don’t hesitate to contact me should you need any help with your preparations for FRCS exam, my email is:

waleedalorabi@yahoo.com.

I found Kanski is enough as a single reading book; however AAo is a good and very helpful adjunct book.

Shua pages is a MUST, particularly the past candidates experience.

My experience in the final Part of FRCS in Amman 2013.

Oral exam:

First table: Ophthalmic medicine, one Arabian and one UK examiners. Showed a picture of VKC with giant papillae and shield ulcer, discussion went about management of shield ulcer and vkc in general, what other clinical findings of vkc?? (I forgot pannus!!), what the clinical term of limbal papillae???!!!!

I don’t know sir.

Another picture of best’s disease, hypopyonstage, was asked about staging and VA in this stage? I was a bit confused and did not give clear answers. Then discussion went about genetics and diagnostic exam (EOG) is the exam of choice in all stages.

Pic of pigmented round lesion at the mid peripheral fundus, prescribe and spot diagnosis.

It was heavily pigmented and surrounded by a halo of hypopigmentation. I said the most likely diagnosis is RPE hypertrophy but choroidal melanoma should be ruled out. Then asked why do you think it is not melanoma?? I said: small size, hallo, no lipofuscin; pigment, flat ….. He looked satisfied.

A pic of markedly injected eye with thick mucous discharge, I described the findings and he was happy when I told him about the pseudomembranous, I gave a DD of adenoviral conj, then asked about management I replied quickly because the bell had rang.

 I was not satisfied after this part because it supposed to be the easiest part, but I didn’t lose confidence.

Second table: surgery and pathology one UK and one Arabian examiner.

Started with a photo and scenario AACG…….. How well you proceed?

I said this is an emergency, first I will confirm the diagnosis by measuring IOP and quick history of past similar attacks ….etc. and then I will put the patient supine and start topical and oral anti-glaucoma meds….. If IOP is more than 50 mmhg I well consider IV Diamox or mannitol…I mentioned to the examiner that there no benefit from pilocarpin initially but he was surprised … why??? Will it harm??? I said no … he said plz if I came to you give me pilocarpin!!!!! I smiled … ok sir.

Was given scenario of 3 days post phaco op onset of pain and decreased vision, I gave DD of post op endophthalmitis….. What is the management?? Again this is an emergency; I will admit the patient for vitreous sample culture and intra vetreal antibiotic inj or PPv if VA is LP or less…..Then asked what factors can affect visual outcomes in this case???? I answered:

VA at presentation.

Virulence of the causative organs.

Delay in treatment…..etc. looks satisfied.

The Arabian examiner showed me a pic of corneal dystrophy; I said this is Avellino’s dystrophy and I described the findings…. Discussion went about features, management, staining and genetics….

A scenario of a young boy assaulted to his eye with glasses on, c/o pain and decreased vision, how will you manage?

I discussed in details the management of a ruptured globe from a-z, special focus on suggestive features of a ruptured globe and surgical repair in details.

A Question about the causes of decreased VA post cataract surgery.

I gave a long but a well-organized list but I forgot the most common cause!!!!! The refractive errors.

The last question was a pic of a large ulcerative lesion at the lateral canthus, causes?

SCC, SGC, melanoma….. Merckl cell carcinoma…

The UK examiner said: Thank you, you did well. Thank God, my hopes revived again.

Third table: neuro-opthalmology and general medicine.

Pic of few brown iris nodules, I said it is lisch nodules commonly seen in NF1, Question about ocular findings in patient with NF1.

Question about the possible causes of visual impairment in NF1…. I answered:

Optic nerve glioma.

Meningioma.

Glaucoma….etc. then discussion went about optic nerve glioma, what the management in 7 years old boy with good visual acuity? I said observation if the tumor is not growing rapidly.

Other treatment options: resection, chemotherapy, radiotherapy. Was asked about medication used in chemotherapy?! I said vincristine, etoposide, but I was not sure. He said OK.

Fundus photo with yellow exudates extending from the optic nerve around the macula at the upper temporal arcades. I said it is most likely a CMV retinitis in an immunocompromised patient. Discussion went about CMV and available treatment options (gancyclovir).

Was given a scenario of a patient with acute chest pain, how will you proceed?

Call for the help, brief history especially type and duration of pain HTN, DM … pain radiating to the shoulder and the arm….. MI management …. Don’t forget blood works particularly CK and troponin. Aspirin, morphine………

An 11 years old girl, obese, short, c/o decreased vision? The bell rang, but I think it is a case of Bardet Biedl syndrome.

The examiner was very satisfied at the end…. Thank God I did well in this difficult part.

Clinical exam

4 rooms, 8 patients.

Ant-segment: a case of PKP, I was asked about types of keratoplasty, when to remove the sutures?

I examined the other, it was keratoconus. Discussion went about pathology, inheritance, modules of management, farther about cross linking technique (the slit lamp was very old and I asked to decrease the illumination in order not to burn out the lamp!!!! The view was very poor so I increased the light!).

Second case: old lady with bilateral diffuse central corneal opacity in the anterior stroma + early cataract with pxf. I told the examiner this could be a case of central stromal dystrophy op François, he said ok the diagnosis doesn’t matter but tell me how will you manage this case?

I replied this depend on the visual acuity and patient complaint, I will start with glasses if not work I will discuss the possibility of cataract surgery with the patient, I will do ECCE because phaco will be extremely hazardous due to poor view and zonular weakness   and poor dilation, then discussion went about how to manage the small pupil before surgery?

Posterior segment:

First case: examine the fundus of a young lady with the indirect ophthalmoscope. It was optic disc coloboma accompanied by adjacent choroidal coloboma; discussion went about etiology, systemic associations and invx.

Second case: an old man with decreased vision OD, examination by 90 indirect lens. It was a case of wet AMD, there were some exudates at the macula with RPE changes, I described the shown a FFA demonstrating an occult CNVM with late leakage. I mentioned the deference between the classic and occult CNVM, discussion then went about treatment, a said anti VEGF is the treatment of choice, then discussion about type of anti VEGF and the deference between them.

Neuro-ophthalmology:

First case: a 29 years old lady with a history of headache for 6 months, I was asked to examine the fundus by 90D, I found pale optic discs in both eyes, macular pigmentery changes both eyes. I got confused regarding the macular changes, but I told the examiner honestly I can’t reach the diagnosis but the history is consistent with IIH, he said ok you are right and this is a resolved papilledema which can cause macular changes, discussion then went about the diagnosis and management of IIH….. History of headache, type, severity and visual symptoms…etc. enquiry about current medication (contraceptive pills, naldexic acid, tetracycline…etc.) and previous trauma. Then complete eye exam + brain MRI+LP….

Treatment: D/C any suspected drug, diuretics…. f/up for routine exam + visual field exam…

Second case: a young lady with recent onset of diplopia, examine the ocular motility.

There was a limitation of upper gaze in the right eye but no obvious squint in the primary position. I gave DD of TED, orbital myositis, blow out fracture, Brown’s syndrome….. Discussion went about diagnosis and management of blow out fracture, particularly the indications for surgery.

Oculoplastic:

A very kind Indian examiner asked me to examine the eye lids of an old man. I found a cystic lesion at the lower lid, I described it and I used my torch to illuminate it (the examiner seemed impressed!!), I gave DD of Zeiss cyst, Moll cyst, chalazion… I also found the patient to have mild ectropion, I showed the examiner how to measure lid laxity and medial and lateral canthal tendon laxity, and again he got impressed. Then discussion about treatment options of this patient.

Second case was a young boy with bilaterally blind eyes from congenital glaucoma with right eye ptosis, i did a complete ptosis exam, it was a ptosis secondary to volume loss (phthisic eye), and then discussion went about the treatment options of this boy, in this case as the eye was cosmetically unacceptable, one may consider removal of the eye and put an implant to correct the volume loss and tis alone may alleviate the ptosis itself. First a said we can insert a scleral shell but tis alone will not correct the ptosis. Discussion then went about the type of ocular implant post evisceration and enucleation; I talked about the advantages and disadvantages of porous and nonporous implants, materials: PMMS, hydroxyapatite….. Examiners were happy.

Thank God it was as fast as a short dream, I felt comfortable and happy at the end of the exam mainly because I did it and I’m free now………………………….

Having any question please contact me on waleedalorabi@yahoo.com .

Good luck