FRCS Glasgow Part B Ophthalmology exam model;

Exam Shedule  is as follows;

3 days exams; Written, Viva and Clinical

1st day ; Morning 9.30 to 11.30 am , A problem solving paper

Clinical case interpretation in relation to ophthalmology of three questions:

1. An 85 year old man has had advanced primary open angle glaucoma for 30 years. He had a trabeculectomy performed on the left many years ago  but the vision has been poor in this eye ever since the operation.Visual acuities are 6/12 right and Hand Movements left and despite being on maximum medical  treatment to his right eye the pressures are 28mmHg right and 10 left. His visual fields are grossly restricted in both eyes and he is on Warfarin tablets for atrial fibrillation.
Discuss this patient's  management  and explain the risks to his vision.

2. A 30 year old General surgical colleague presents to your clinic complaining of redness and blurring in his right eye for 1 week. He had had bilateral laser refractive surgery 4 weeks back and although his vision had initially been good it is now reduced to 6/36 right and 6/6 left unaided. He is busy and just  wants you to give him some drops.
Describe how you would deal with this situation and what possible investigation and treatment would you recommend.

3. A 10 year old boy is found by his optician to have reduced vision in his right eye. On examination acuity in the eye is 6/36,there is a relative afferent papillary defect and fundoscopy shows disc pallor.
Discuss the possible diagnosis and explain how you would  manage the case.
 

First day, 12.30pm to 2.30pm 
MCQ paper encompassing the topics of ophthalmic medicine, surgery, general medicine and neurology with particular reference to ophthalmology. 
 

2nd Day Oral Exams: Three Stations

First Station : 
For me it was Ophth.Surgery & Histopathology specimen;

Two examinors (a British & an Indian) in all stations:

I greeted them before sitting down.

First examiner
First question was from British doctor, it was a picture of prolif.diabet.retinopathy(PDR) in labtop with NVE only, then asked all about classfication of DR,treatment strategy,laser parameters,complications of laser Rx, about choroidal effusion.
Then he asked one patient with h/o DM  >10 years duration with severe eye pain and IOP > 50, what was DDs, answer was NVG, then all about NVG, it's Rx option.
Then question was Rx of painful blind eyes including laser cyclocryo, intraocular implant.
Now Indian doctor showed  a picture of psuedoexfoliation syndrome, then it's diagnosis, diff. from true exfoliation, eye findings, gonioscopy features,glauc.capsulare, complications during cataract surgery,management during PC rent etc...

Second examiner
Indian Doctor asked the causes of shallow AC after trabeculectomy, it's diagnosis, management, then Rx details of malignant glaucoma.
Then he showed histopath.specimen of eye ball showing large ant.segment like congenital galucoma and asked all about cong.glaucoma.
He took DCR Kerrison ronguers for enlarging osteotomy in DCR, then type of anasthesia in DCR, procedure,bones removed in DCR, indications.
Then he showed a colour photo of dark person with big ulcer of lower lid, asked diagnosis,replied BCC ,then bell was rang to finish the section. 
 

Second Station:
Ophthalmic Medicine &Peadiatric oph.

Question 1
Indian doctor ,showed a picture of vernal conjunctivitis, asked its diagnosis,Rx,complicatons of steriod Rx, instructions to the patient &parents that it is  a long standing disease & don't over treate this condition.

Question 2
British doctor asked the management of a 50 year old man refered from optometist with high IOP, asked DDs, causes of high iop, about ocular hypertension (OHTN), glaucoma, target IOP, max.tolerated Rx, surg.Rx,etc...

Question 3
Indian doctor asked about 2 year old child with squint, DDs, management, retinoscopy, full cycloplegic refraction, class.of accomm.esotropia,use of bifocals, role of surgery in acc.esotropia.

Question 4
British doctor; Asked  a 60 year old man presented with blurring of vision ,then how to manage this case; 
In the history taking, examiner said no DM, HTN , NO SYSTEMIC DISEASES.
I listed DDS like ARMDS, Macular hole ,Choroidal melanoma, Intermediate Uveitis with macular oedema.
Then asked all details of ARMD , it's classifications, investigations, management with Amsler grid assesssment.
 

3rd Station 
Neurophthalmology & Medical Emergencies:

Question 1
British Doctor asked 24 year old lady came with defective vision ; how to manage this case:
In the history taking , no significant systemic disease,
In eye examination , RAPD is present  but fundus is normal and ocular examination showed INO . Then asked the all details of Multple sclerosis as age , associated symptoms, signs like Pulfrich phenomenon, Uthoff's phenomenon, nystagmus, MRI findings , treatment schedule ,importance of neurology consultation.

Question 2
British doctor asked 3 year old child brought by parents with history of abnormal eye movements with a short duration, then how to manage:
In the history taking , examiner drowed the type of eye movement like very bizzare  pattern  , then I answered that I will take detailed history of CNS diseases, detailed eye examination, then he asked the site of lesion of abnormal eye movements , I answered chiasmal lesion then he was happy.

Question 3
He again asked different sites of neurological lesions with visual field defects to localize the lesion.

Question 4
Another question was how to manage nystagmus.
I started with Ocular & Neurological classification of nystagmus.
I narrated diff.types of ocular nystagmus with features.
Then Nystagmus of infant with normal eye examinations like congenital stationary night blindness, rod monochromatism & Leber's congenital amaurosis. 
Kastanbaum surgery of nystagmus also mentioned in it's aim.

Now Indian doctor (may be medicine consultant) 

Question 1 
Started medical emergency section like, a 60 year old man came to your eye clinic for eye check up and when you started vision checking , patient suddenly became collapsed, how will you manage this case:
I started the answer with details of ABC care , then examiner said the BP was normal , I started with details ECG for cardiogenic shock in different leads , then he said ECG is normal.
Now the DD is shock with normal BP & normal ECG, then I started features of septic shock like common sites of focus of infection like UTI, RTI, abdominal etc….

Question 2
Then examiner asked how to manage septic shock from lung in detail, then I started common cause is pneumonia like Klebsiella , then asked management in detail, answered blood culture & crystalline penicillin.
3:Then asked how to manage cardiogenic shock in detail , I explained in detail because I have 4 or 5 very good classes from cardiology friend before exam .
Examiner insisted the details of adrenaline ,dopamine etc….

3rd Day 

Clinical Exams: ( One Indian doctor & One UK doctor)

Case 1 
Slit lamp examination of 25 year old lady:
Examination showed circum corneal congestion, descement's folds, and AC shallow, peripheral ant. Synechiae, posterior Synechiae, seccusio pupillae, complicated cataract & hypotony,
Asked me how to manage, answered that the diagnosis was chronic uveitis with complicated cataract with hypotony.
Treatment depends on visual acuity, IOP, B scan to check status of retina & patient complaints like eye pain.
Potential visual acuity meter (PAM) to check the prognosis before cataract surgery.
Asked me the causes of low IOP , answered like ciliary damage, secondary RD , going for phthisis bulbi.
Asked me how to manage phthisis bulbi, answered for cosmetic treatment is enucleation with intraocular implant.

Case 2
Another S/L examination of 18 year old boy.
Examination showed prominent eye ball with opaque cornea with lipid degeneration with tense eye ball and further details of iris & other structures are not possible.
My diagnosis was absolute glaucoma with degeneration.
Asked me causes of glaucoma in this age group, answered like congenital glaucoma (primary) , trauma, uveitis, complicated corneal ulcer, Sturge weber syndrome.
Asked me the details of cong.glaucoma.
Asked me the management of absolute glaucoma.
For the pain , cyclocryopexy or cyclophotocoagulation to make eye phthisic, then put ocular pristhesis if no touch sensation of eye ball.
For still painful blaind eye &cosmetic , enucleation & intraocular implant.
Asked the causes of secondary glaucoma in detail.

Case 3
Ocular movement examination:
Examination needs cover and un cover test;
Examination showed 6th nerve palsy of one eye.
Asked the management , in history DM, HTN ,blood disorders etc….
Eye examination to rule out RAPD, Papilloedema or optic atrophy, DR, HTN retinopathy
For diplopia, patching or prisms for temporary management.
Botulinum injection of MR to decrease diplopia.
For permanent esotropia after 6to 9 months, maximum recession of MR or Jensen's procedure of transposition of LR with SR &IR.
Asked the importance of Botulinum injection than prism or patching, then answered prevention of contraction fibrosis of MR.

Case 4
Fundus examination of 40 year male with I/O & D/O:
Media was clear, disc was pale, margins are not clear, c/d ratio was .3, veins showed sheathing , diffuse areas of pigmentary hypertrophy and
some areas of hypopigmentation like post laser marks and the entire retina is pale.
My diagnosis was consecutive optic atrophy. Answer was correct.
Asked the management.
History of uveitis & associated systemic diseases like TB, Eeal's,
Sarcoidosis, Syphilis, Behcet's, AIDS, Herpes, Toxoplasmosis , autoimmune diseases etc…
Investigations of all the above diseases.
Role of topical steroid, subtenon, systemic steroid treatment.
Drug of choice of Behcet' (Chlorambucil)
Role of immune modulating druge like methotrixate, cyclophosmide, vincristine etc….
Role of photocoagulation in Uveitis  for new vessels.

Case 5 
Fundus Examination of 34 year male:
Media was clear, disc was normal, c/d ratio .4, vessels were normal, macula showed subretinal fibrosis ( retinal vessels passing over the whitish lesion of the retina).
Asked the diagnosis, answer was traumatic subretinal fibrosis;
Management depends on the BCVA.
Asked the other findings of ocular trauma from conjunctiva to retina in detail.
Asked the management of macular hole.
Asked the membrane peeling in EPRM formation in ocular inflammation

Case 6
Another Ocular movement examination:
Examination showed alternate exotropia of 26 year old lady.
Asked the management of this case.
In history , mentioned history of eye glass usage or any surgery.
Examination to rule out myopia ,preference of eye etc…
Surgical management is bilateral LR recession in  detail.
Then time was finished , so no more questions.

Wish you a happy exam & happy life.