My name is Nermin Elsakka and this was my fourth attempt in Tripoli on April 2006 and finally thank God I passed. 

I dedicate this certificate to the soul of my father (finally I did it Dad it may be late but I really did it), to all my family especially my brother (thanks a lot you have been a great support ), to all my friends and colleagues (thanks a lot) and special thanks to Dr Hussein Swelem and Dr Ayman Ghonemy for their kind efforts and supports.

I'll start by what made me fail in my first three attempts.

First attempt:

General medicine:
The professor shows me a picture of bilateral papilloedema of 20 ys old boy asked me how to manage I started with exclude space occupying lesion do CT (he said it was normal) MRI (normal). I said take history if he is hypertensive or diabetic (no history was available) I kept silent (simple test u can do it in your clinic even your nurse can do) I kept silent again then (he said what your DD is?) .......(What about blood pressure?) I said malignant hypertension (How would you manage it) I'll refer to the physician (How?
Write a paper or send the patient to wait in the clinic?) Write a paper and tell the patient it is an emergency (So how do you think the physician will give him) Diuretics or Beta blocker then the bell rang he wasn't satisfied. I got 5.

The right answer was admitting the patient to control the blood pressure on the same day and not wait until later.

I also get 5 in MCQ. 

Second attempt
                      
Clinical exam: 
I did every single mistake this site advise against doing. For example when I found pigmented KPs on the back of the cornea I came out with a single answer without further examination and could not think of anything else the examiner kept asking for more differential diagnosis and I have to ask to examine the patient again..

Young boy 10 years with bilateral ptosis I did every thing to prove it was a congenital ptosis but it turned out to be aponeurotic due to a coble stone papillary conjunctivitis. 

Also I got 5 in MCQ again. 

Third attempt:

Problem solving: 
15-years old boy has sustained a severe blunt injury to his right eye. On examination his vision was Hand movements with iris rupture and a partially subluxed and cataractous lens. There is vitreous in the anterior chamber which was deepened, and there is no view of the fundus.How would you manage this?

When I started to write about U/S I completed my answer as if it is an IOFB. Foregetting that it was a blunt trauma. I got 5. 

General medicine: 
The professor asked me about complication of diabetes in general and the earliest finding in urine analysis I said increase protein in urine (He said it is called microalbuminurea) (Asked me about the CNS signs of sarcoidosis and the other doctor asked me about a patient presenting with acute chest pain and shortness of breath I said myocardial infarction. (Ask what else?) pulmonary embolism (How would you manage this?) I'll take a history and send him to do chest x ray and ECG (What are the findings?). 
I got 5again. 

The right answer was:

• Bilateral facial n palsy in sarcoidosis. 
• Admit the patient and give him oxygen 100% give heparin on suspicion do V/Q lung scan and spiral CT.

Fourth and Final attempt 

1- A 13-year-old girl is brought to your clinic by her mother complaining of reduced vision. Visual acuities are 6/18 in both eyes, reading N8 unaided.  Her parents have just been divorced. How would you manage this patient and what investigations may be appropriate?

My answer was :
Hysterical but I should exclude error of refraction and bilateral post viral papillitis.

2- A 55-year-old man, who works as an engineer, has attended the eye clinic previously with latent angle closure glaucoma and has bilateral peripheral iridotomies performed. His refraction is +7.50 DS in the light eye and +8.00 DS in the left. On this occasion vision is reduced to 6/12 in each eye because of cataract. What potential risks would you perceive with this patient and how would you manage his cataracts?

My answer was:
History: detailed PI when and how?
Acute congestive glaucoma? What treatment he is on now?
Examination: IOP, Ac depth, gonoi, PI how many? Patent or not?
Assess the cataract? Fundus and cupping?
Treatments: Counsel the patient about combined?
Problems of dilataion, Iol calculating, shallow AC?

3- A 33-vear-old woman has been aware of a degree of left-sided proptosis for several months. She presents to your clinic with a 1-week history of pain and redness in the left eve. Reduced vision and an apparent corneal ulcer.
Explain the possible causes of this patient's symptoms and  how you would manage her?

My answer was:
I'm facing a case of lt corneal ulcer in a proptotic eye.
I'll manage as it is an infictive keratitis until prove otherwise so admit tj
And give fortified eye drops and scraping then assess the proptosis and treat as  exposure keratits until the lab results is available. 

MCQ was long and difficult I remember a question about Still disease I left it completely blank. You have to answer only 180 of total 300 to pass safely don't answer unless you know it 100% sure.
 

General medicine: 

The English professor asked me about a 45-year-old woman coming to you complaining of rashes on her hands and red eyes what is your DD? I said I'll look to her face searching of acne rosacea (No) Systemic lupus (no) sarcoidosis (No)….(if I told you she is on tetracycline?) It is allergic and I'll stop it (if she said she forget to tell you she has an oral ulcer)I said ll think of ocular cicatretial pimphigoid and Steven-Johnson (ok what are the difference between both of them?) Obliterated caruncle in ocular pemphigoid. And chronic progressive. (How would you manage?) Artificial tear and lubricants (Tell me about herpes virus and the eye?) ( What viral do you know hae neuoral affinity) I started to give DD between simplex and zoster then the bell rang finally …..Thanks God.

The Arabic professor: asked me( The nurse called you telling you that the old lady 65 years that you did cataract surgery yesterday complaining of acute chest pain) I said I'll consider pulmonary embolism give her oxygen 100% give heparin on suspicion 5000u do V/Q lung scan and spiral CT( Don't you consider doing simplest test?) I said to my self the other professor in the third attempt did't like it so what I'm going to say? I said we can do ECG  and chest x ray but might be normal(ok how are you going to manage in the future before surgery ) give her ssprin or heparin or at late sages she can do vena caval filter as my last resort. (How we can follow up patient who is on heparin?) PTT (What other anti coagulant u know?) Warfarin(follow up ?) PT with INR. (Tell me about Pancost tumor.) Horner preganglionic (What other findings?) miosis,anhydrosis, enophthalmos (ok if the ptosis was bilateral with dysphagia and weakness in upper limb?) I'll consider nuclear 3rd n paly it is the only site that can cause bilateral [tosis (no no I mean in this ptn with pancost tumor.) I'll think of cerebello-pontine angle tumour (why do you consider metastasis only, have you ever heard of LmbertEaton Syndrome?) I said yes it is a small cell carcinoma of the bronchus and has a myasthenia like picture DD with electromyogram which increase with activity. (If they asked you to treat a 25 years old boy how is recently diagnosed as hypertensive?)I said the most common is idiopathic but I have to exclude secondary causes such as renal problem and pheochromocytoma (What drug would you give him?) ACE inhibitor (Why and what else?) Diuretics (What are the side effects?) Potassium depletion so I'll give K+ supplements or give K+ sparing drug such as spironolacton. The bell rang (You are saved by the bell.)Thank you sir.
 

Ophthalmic Surgery:

An English professor. (Picture of post-enucleated eye with choroidal melanoma ask about it and pathology management and prognosis.) (Patient with +7sph +3cyl  6/36 vision has cataract other eye +6sph +3cyl  6/9 How would you manage his cataract ?What difficulty would this patient have with different power of IOL? ) yes I'll consider multifocal  IOl, monovisin, (Would you make one is myope for near?)yes ( The other eye is +6.0?) oh yes I'll not sir I'm sorry ( if u did so what is the complication) anisiometropia (How will you treat?) contact lens and I'll do a cataract to the other eye (OK How would you  treat the astigmatism? ) limbal relaxing incision (picture of entropion asked for managements?) I said I'll do lateral tarsal sling (Ask for a more simple operation.) wedge resection (Even simplier) Everting sutures were what he was after. (Another picture of mass in the upper lid and told this was iatrogenic and asked if I knew what this might be?)  I thought it was a forign body of sort. ( What if I told you it is gold?) gold weight for treatment of lagophthalmos of 7th nerve palsy ( what else we can do?) tarsorrhaphy the bell rang. 

An Indian professor.  He was very supportive and speaking very slow to give time to think as I was very tired after the English professor ( An old lady coming 1st day post operative after cataract complaining of painless diminution of vision and u find corneal oedema what u'll do?) I said I have to exclude endophthalmitis (How?) Looking for cells and flare (you can't see from oedema) do U/S (She came back after 1 week with only oedema?) ok sir I'll consider corneal decompensation (Managements?) steroids every hour hypertosmotic saline eye drops(the patient is not satisfied wants to have surgery?) penetrating keratoplasty (why not penetrating?) because the problems in the endothelium pump sir.(ok if another ptn with herpetic keratitis and disciform keratitis ) antiviral (after one year she is still complaining of blurred vision ask for surgery) lamellar keratoplasty which is better for vision if the interface is clean the lamellar is better (no) ok sir the penetrating is better if there is no rejection. (A mother come to you with a 3-year-old with an eye deviating inward, how would you manage?) I'll take history intermittent or constant one or both eye measure the vision do cover uncover test,ocular motility,doll's eye exclude 6th palsy. Do a cycloplegic refraction.  (Time of action for the cycloplegia?) I said we give it then after 5min another drop then after 20 min another drop then do the refraction he said after the bell rang in India it works after 20 min in Cairo 30 min and said you are free to go.
I got 7. 
 

Ophthalmic medicine

The Egyptian professor,  The first thing he said to me was that I know you tell each other the questions so I'll ask a new set of questions and I got shocked and said ok sir (Tell me about anti arrhythmias drug that causes corneal deposition.) Amiodarone cause vortex keratopathy ( What else?) chloroquine, indomethacin (What else?). (What are the other side effects of amiodarone) posterior subcapsular cataract, optic neurpathy.(What else cause deposition in the cornea?) Iron such as  Fleischer's ring in keratoconus, stockler infront of pterygium, (What else?) Hudson stahli of aging.(what systemic disease can cause vortex keratopathy?) Fabry's disease. (Show me a picture of angoid streaks and subretinal haemorrhage and asked to describe.) I told him there was amacular scar and he I told  him this is choroidal neuvascular non age related (What systemic disease we find in angoid streaks) psudoxanthoma elasticum, Ehler-Danlos, Paget's disease.(tell me side effects of steroids)  posterior subcapsular cataract, raided IOP(why) steroid responder depend on the type duration. (Picture of OCT and asked to describe) Stage 4 macular hole(what other finding  can we find) cystoid macular oedema , traction, follow up treatment and injection of triamcinolone (Asked about nerve fibre layer thickness and glaucoma and is it earlier than the perimertry?) yes sir.(Asked me about ocular hypertension study?)I told him (risk factors?) central corneal thickness (why) false low reading (if  decided to treat a young patient with chest trouble? )I'll not give Beta Blocker I'll give Latanoprost (side effects) conjunctival irritation and pigmentation.(when will you treat?) according to the study it'll progress to open angle glaucoma 1%  per year .It is progressive optic neuropathy. The bell rang.

The English professor (He showed me a picture of heterochromia and asked about way to manage this condition?) I want to see his old photo to know which iris is abnormal (Both professors laughed at me and I'm still wondering why? Till now} then he said the brown one is the abnormal) so I said is there a history of trauma (there is a history of intraocular surgery) I said I'll consider siderosis ( OK, what else?) Fuch's heterochromic uveitis which can cause hyper and hypochromic iridis. (We'll return to Fuch's later but what else?) I said latanoprost which I forgot to say it with the Egyptian professor (OK) about Fuch's (what do the KPs looks like?) small, feathery fibrin filaments, never pigmented (Did the pupils of both eyes react equally?) yes sir (Why?) no synechia show me picture of cavernous haemangioma and large corneas) I said Sturge-Weber ( What is the mechanism for the glaucoma?) Elevated episleral pressure ( What type of surgery?) I said because of clear cornea I'll do goniotomy (He asked why.)…. (What is the procedure of goniotomy?) I said we open in the trabecular meshworak then I realize my mistake so I said I was saying the surgery of congenital glaucoma not Sturge-Weber sorry sir can I take my words back (he laughed and said yes you may take it back.) then he asked about a mother brings her 2 years old boy complaining of bilateral blepharospasm and lacrimation (What are you going to do?) I'll take a history to look for any precipitating factors. Can he see  and walk alone? ( What is the most likely diagnosis?) I said error of refraction (What about lacrimation?) I said I want to exclude bilateral nasolacrimal duct obstruction. (What else?) The bill rang he said ok you are free to go.
I got 7. 

We had to wait 4 hours to get the results to find out who will get to the clinical exam. and these were the worst hours ever. Thanks God I passed with all my friends which was very nice.

The clinical exam:

I wore my white coat which was relieving as it was like doing my actual clinical work and I asked the examiner if I can speak in Arabic to the patients and he said ok which was very nice.

1-Cover uncover to 10-year-old young girl wearing a glasses she had partially accommodative alternating esotropia with residual angle of 15 degree.

2- Slit-lamp examination of the right eye. Posterior subcapsular cataract, very small inverted hypopyon emulsified silicone in the anterior chamber.. Examine the fundus with +90 lens: eye contained silicone oil with large macular hole. Examine the other eye also showed large macular hole he asked what clinical test u like to do Watzki's sign. OCT.asked me about silicone complication, biometry error with silicone.

3-Young boy with a right buphthalmos, nystagmus and high myopic lens; the other eye shopwed plano lens and anterior staphyloma then asked me about buphthalmos in details. And surgical correction uses of anti metabolite and the dose .how to calibrate the applanation.

4-Indirect ophthalmoscope of the right eye. The center was normal so I started to look at the periphery. I found pigmentation in the upper temporal area then the examiner told me sorry we forgot to tell you that this patients complained of decrease night vision so I told him it was retinitis pigmentosa of the atypical type and asked about family history and any cardiac problem and deafness. He asked me about the mode of inheritance and other systemic disease associations.

5-Slit lamp examination: Bilateral Sturge-Weber's syndrome with bilateral shunt operation. The examiner asked if I can tell the type of the shunt used. I said sorry sir I only know that it might be valvular or not. He said it is ok.

6-Slit lamp examination of a young lady. Examination of the left eye only because she has a painful left eye I found temporal incision and anterior chamber phakic IOL. Asked about what type of surgery was done? I said refractive surgery for hypermetrope. He said why did I mentioned only hypermetrope? I said it is the most common operation and if she was myopic she would have clear lens extraction and as she is old I thought hypermetropia is the most likely (come to think of it probably not the correct answers). He said thank God the patients can't understand English as she was not that old. I looked again at the patient and agreed she was not that old. I was asked about the complications of clear lens extraction. The other painful eye was examined and she had a corneal ulcer with poor tear film. We ran of cases and the English professor said you still had time and you may stay with us if you liked. I said it was my pleasure sir but the other Arabic doctor asked me to go out. I said thank you to the professors and the patients.

I have got 7 and I passed finally  Unfortunately all my best friends did not. But don't worry I'm sure they will pass the next time. I'm more than happy to help those taking this examination.

My email is 
nel_sakka@yahoo.com or
nel_sakka@hotmail.com

N.B: I'm preparing some of medical emergency papers that'll be ready soon in our yahoo group (frcophth.com).