1. The document describes the candidate's FRCS viva exam, which consisted of 4 stations testing different areas of ophthalmology. 2. Each station had 2 examiners and lasted 20 minutes, with cases involving emergency situations, neuroophthalmology, and posterior and anterior segment pathologies. 3. The clinical exam portion involved 4 stations testing the posterior segment, neuro-motility, oculoplasty, and anterior segment. Cases were presented and the candidate was examined on their diagnostic and management skills.

1. My experience
FRCS Glasgow 3rd part
Amman, April 2019
Samhaa Mohammed Abd Elmoneim
dr.samhaa@yahoo.com
Egypt

2. Viva exam
28th April, 2019
• 3 stations:
1. Emergency/ internal medicine & neuro-
ophthalmology/ motility.
2. Posterior segment.
3. Anterior segment & oculoplasty.
(consecutively as I was examined)
• Each station is 20 minutes with two examiners, 10
minutes with each examiner.

3. Emergency/ internal medicine & neuro-
ophthalmology/ motility station A
1. Diabetic patient at your clinic, sweating then lost consciousness.
• Your DD?
(hypo or hyperglycemic coma). Why hypoglycemic? Due to
sweating.
• If hypoglycemic coma, management?
(call for help, ABC, glucose sticks, dextrose IV 10% as I read! but he
said it is low concentration then I replied 50%. Glucose infusion for
1-2 hs, he said yes)

4. Emergency/ internal medicine & neuro-
ophthalmology/ motility station A
2. Female patient came to you complaining of galactorhea,
amenorhea.
• Your Dx?
(pituitary tumour/ prolactinoma)
• Ocular signs?
(optic nerve dysfunction, field defect, ophthalmoplegia, disc pallor/odema)
• How to treat? (Refer). What do you expect neurologist ttt? (start medical
Bromocriptine/ surgical). When surgery? (failed medical). How to know?!
(prolactin leve!). Yes, surgical approach? (tras-sphenoidal)
• After surgery pt came with polyurea and polydipsea, cause? (↓ADH 2ry
post pituitary removal). Name of disease? (completely vanished from my
mind!, but he was v nice and said ˮ you mentioned ↓ADH, is it diabetes
insipidusˮ → yes sir, missed it)

5. Emergency/ internal medicine & neuro-
ophthalmology/ motility station A
3. Female patient came to you complaining of facial flush & joint
pain.
• Your Dx?
(SLE)
• Yes, investigation to confirm?
(ANA, anti ds DNA). What else, simple test? (I kept silent!) then the
examiner & me at the same time said ESR.
• Systemic signs?
(lupus nephritis, pulmonary signs). He asked, what is the investigation in
urine? (I could not get it, he said cytokines)
• Ocular associations?
(PUK, scleritis, retinal vasculitis, CSR, OID… , he wanted vasculitis)
I should mention also chloroquine maculopathy but I forgot to mention it.

6. Emergency/ internal medicine & neuro-
ophthalmology/ motility station B
1. Picture of multiple nodular skin lesion.
• Your Dx?
(NF1)
• Ok, what is NF1?
(AD inherited disease, oculo-neuro-cutaneous disease)
• She added pt is 10 y old, what you want to search for in ex?
(lid lesions, proptosis, skull base bony defect, angle, iris lisch nodules,
glaucoma, ON glioma)
• Pt has ON ++ in imaging, Dx?
(ON glioma)
• What else you should evaluate in ocular ex?
(chiasmatic involvement, vision, severity of proptosis!)

7. Emergency/ internal medicine & neuro-
ophthalmology/ motility station B
2. Senario of 45y female has diplopia, limitation of Rt abduction..
• Your Dx?
(rt 6th n palsy)
• Manage?
(Hx onset, course, duration, criteria of diplopia, medical hx for DM/ HTN, drug hx like vit A,
tetracycline),
(ex must exclude other cr n involvement 5th, 7th, 8th for CPA, 3, 4, 5, pupil for CSS--- imaging)
• It is isolated, what is the tests you will do in ur clinic? (Bl/Pr) what else?
(VA, pupil, field, motility, fundus, disc), she wanted color vision.
• DD?
(vascular DM, HTN, inflamatory Tolosa Hunt, tumours CPA but they involve multiple Cr N,
trauma, false localizing lesion IICT)
• Treat? (refer, conservative for 6 m ± occlusion/ prism on glasses / botox to MR)
• After 6 m still present? (repeat imaging, free?→ refer, LR resection± MR recession, if
lost function? (Jensen Hummelshleim sharing surgery)

8. Emergency/ internal medicine & neuro-
ophthalmology/ motility station B
3. Female patient with disc odema OU.
• Your DD?
(must exclude space occupying lesion 1st , IICT, inflamatory, compressive,
ischaemic, nutritional, toxic). Toxic drug like what? (drugs antiTB ). It is rar! What
else? Vit A, tetracycline in IICT. I missed to mention amiodarone.
• How to confirm IICT?
(Hx onset, course, duration, weight, vomiting, nausea, drug hx for vit A/
tetracycline/ OCP),
(ex must exclude other cr n involvement, 6th only, fundus, feid, pupil),
(invest. normal MRI/ MRV, normal CSF composition but ↑ opening pr in LP)
what is normal? (< 20 cmH2O)
• Treat?
(refer to neurologist, start with medical CAI Cidamex 1gm divided into 4 doses / d
guided by vision, field, pupil, color, OCT NFL)

9. Anterior segment/ oculoplasty station A
1. The examiner gave me hazy picture..
• Describe…
(well defined limbal whitish elevated lesion, no bl vs, no ulceration
mostly it is benign, may be limbal dermoid, phlycten, sq cell
papilloma)
• Manage?
(Hx onset, course, duration associated pre-auricular skin tags,
skeletal/ vertebral anomalies). What this disease? Goldenhar.
(ex VA, refraction, lid or ocular coloboma)
(invest. AS OCT before surgery)
• Treat?
(parent counseling, conservative, treat EOR, amblyopia)
(surgery in exposure, cosmetic condition)

10. Anterior segment/ oculoplasty station A
2. During you are doing phaco, zonulysis is occurred.
• Manage?
(keep AC formed to avoid ↑zonulysis/ vitreous prolapse, assess site & degree of
zonulysis, lower parameters ± ant. vitrectomy).. <5 clock hrs → CTR/ 3p IOL, > 5hrs
→ scleral fixation/ flap, glue
• How to suspect?
(uneven AC depth, pupil oval, vitreous prolapse detected by triamicinolone)
• Other options?
(Iris claw , Last option AC IOL, Cioni ring scleral fixation, Yamani flanged with
explaining the techniques)
3. Child with unilateral proptosis after falling down. Time was out
and continue with the 2nd examiner.

11. Anterior segment/ oculoplasty station B
1. English examiner said there is no photo but scenario is a 4 y
child comes to you with unilateral ptosis corrected by jaw
movement.
• Dx?
(MGJW)
• How to manage?
(Hx, ex & exclude associated other causes, assess refraction and amblyopia)
• How to treat?
(counseling, conservative, ttt EOR/ amblyopia, refer to oculoplastic surgeon for surgery,
when? (ambyopia, cosmetic, AHP), What surgery? (Levator disinsertion & frontalis
suspension), For one eye? (no both eyes for better symmetrical cosmetic results)
• Pseudoptosis causes?
(ipsilateral nanophthalmos, microphthalmos, contralat proptosis, lid retraction, large globe
in myopia, then he added enophthalmos also. I forgot to mention brow ptosis,
dermatochalasis)

12. Anterior segment/ oculoplasty station B
2. Picture with loss of UL, LL lashes, obliteration of caruncle,
corneal vascularization, lost luster of ocular surface .
Which one is medial canthus? (I said I can not detect but normal lateral canthus
has an obtuse angle, here both are rounded!!). Loss of lashes means? (madarosis).
He added there is adhesion here between UL & LL (not clear in photo but I said
ankyloblepharon) then he asked what is symblepharon? (bulbar & palpebral conj
adhesion)
• Dx?
(cicatrizing conjunctivitis with limbal stem cell involvement).
• Causes?
(chemical burn, trauma, inflamatory OCP/ SJS, ocular surface neoplasia). I did not
mention topical drugs as the picture involved both lids but he added it.
• Cause of corneal involvement in OCP?
(dryness, accessory lacrimal g involvement, limbal stem cell deficiency, corneal
vascularization leads, he want to hear trichiasis which is vimportant)

13. Anterior segment/ oculoplasty station B
3. The examiner said it is an extra Q. Again phaco Q, during your
phaco case, PCR.
• Manage?
(keep hand piece in AC with foot pedal at level 1 irrigation, inject
OVD from side port, call my senior..
• I am your senior what do you expect I will instruct you to assess?
(size of tear, step of surgery, presence of vitreous, dropped part or
not, intact ant capsule or not)
• If there is dropped part, will you try to get it?
(no I will do anterior vitrectomy , removal of the remaining nucleus
with lower parameters and call you as you are my senior for getting
it through posterior approach…. Time was out.

14. Posterior segment station A
1. Photo with CRAO patent cilioretinal a. with disc odema.
(I went for dx directly without description. when I realized it, I got
disappointed in my answers although I knew it well. That affected
my performance and wasted the station time)
• Manage?
(I want exclude giant cell arteritis and embolic source, hx
onset/course/duration, jaw claudication/ recent headache/ pain
durring combing hair/ ms pain, vascular, cardiac hx)
(VA) what do you expect here? (not more 6/60), ok continue (I will
assess pupil, temporal a pulsation)
(investigation ESR, CRP. level ? >50, platelet, TAP, carotid doppler,
ECHO)
(ttt steroid IV for 3 d continued with oral to save other eye)

15. Posterior segment station A
2. Old age patient has wet AMD.
what is his complaint?
(gradual ↓VA, metamorphopsia, scotoma)
• Manage?
(hx OCD/ smoking, signs greyish/ greenish membrane/ odema how
to detect it? By indirect ex with 90 D. other findings haemorhage,
sub, intra or pre retinal)
(investigation OCT, FFA, amsler)
As I started ttt, unfortunately time was out due to lost time in 1st Q.

16. Posterior segment station B
1. Write in your paper this senario, 73y old male has metamorphopsia..
• DD?
(I said macular condition like AMD, PCV, other DD were lost from my mind and I kept silent).
He broken my silence saying macular hole, I said yes, he continued what about ERM, I
started to be shocked, how I forgot these causes!.
• He continued Q, ERM causes?
Thanks to Allah, I started to answer in a proper way (idiopathic, trauma, vascular DR RVO,
surgery PPV/ laser photocoagulation, inflamatory uveitis)
• How is ERM been formed?
(fibro-cellular proliferation of ILM associated mostly with PVD).
• How to detect?
(vs tortuosity, glistening membrane with 90 D, red free filter)
• Treat?
( refer to retina specialist, conservative due to recurrence post op, or surgery in ↓ VA, OCT
macular traction or not and thickness),
• What surgery?
(PPV, ERM/ ILM peeling using double staining)

17. Posterior segment station B
2. The examiner gave me a picture..
(sub macular well defined lesion, divided horizontally into white inferior part and
superior pigmented part (pseudo hypopyon)
• Dx? I asked about the other eye, he said the same.
(Best disease)
• What is Best? (hereditary macular dystrophy, AD). Investig.? (Abnormal arden
ration EOG, OCT for CNV). What about ERG? (Normal)
• Manage?
(hx complaint, FH). (exam VA at this stage is slightly decreased, field, amsler).
(counseling family, nature of disease, social/ psychological support, LVA, what are
LVA? Hand held magnifier!).
• When you treat?
(CNV 2ry to scarred end stage).

18. Posterior segment station B
3. Infant is diagnosed with ROP..
• Risk factors?
(LBW < 1.5kg, preterm < 32wk, O2 exposure).
• Satges?
(demarcation line, ridge, proliferation, sub total RD, total RD)
• Indication of ttt?
( ETROP/ zone1 any stage with plus, zone1 stage3 without plus, zone2
stage 3 with plus). But I got confused at the second indication, he said take
your time and asked me to explain with drawings.
• Draw in the paper zones?
(I explained the zones in details with drawings but time was out to
complete indications of ttt using it)
Any way the 2nd 10 minutes of posterior segment station was extremely
better than the 1st 10 minutes in my performance. Thanks Allah, viva was
finished.

19. Clinical exam
28th April, 2019
• 4 stations:
1. Posterior segment.
2. Neuro-motility.
3. Oculoplasty.
4. Anterior segment.
(consecutively as I had been examined)
• Each station is 12 minutes with two examiners, 2-3
cases.

20. Posterior segment station
1. Case 1: middle age male, examine post segment with 90D,
narrate your finding during ex.
(start with ant vitreous, examiner said nice proceed, disc
odematous, slight venous tortousity, CSME, PRP laser, what about
arterioles?/ attenuated AV cross)
• Dx?
(I want to examine the other eye, proceed, the same findings). PDR
treated with PRP+ CSME, disc odema may be 2ry to active nv
leakage, I will ask for FFA
• How to ttt ocular condition?
According to FFA, OCT → if still active NV augment PRP + anti VEGF

21. Posterior segment station
2. Case 2: young female, give me indirect, examine Rt eye.
(asymmetrical red reflex, there is post choroidal scar, examiner said
describe, it is sub retinal pigmented lesion within it hypopigmented
areas, it is located between disc and macula)
• What do you think about dx?
(toxoplasma scar or 2ry to trauma), I did not mention CHRPE
because it is usually in periphery but I had to mention it as a DD of
pigmented fundus lesion.

22. Posterior segment station
3. Case 3: middle age female, examine fundus with 90D.
(epimacular tractional whitish membranes, PRP laser marks), I
continued, macula I cannot comment on it.
• Dx?
(I asked to examine the other eye, the same → high risk PDR + laser
marks PRP)
Ttt?
(refer to VR surgeon for PPV as membranes threaten macula ± anti
VEGF preoperative).

23. Neuro-motility station
1. Case 1: young female, examine.
(apparent exodeviation of rt eye, manifest XT with angle about 40
degree with Hirschburg) → I want to do cover/ uncover in near/far,
with/without glasses, in PP/ all gazes). Do please (I performed N/F,
wih/out glasses, there is no significant difference in angle, slightly
more in F)
• Complete your ex?
(I want to examine motility). Do please.. V pattern, no limitation, no
over or underaction.
• You Dx ? (alt constant XT, V pattern)
• Ttt?
(Refer, Bilateral LR recession ± transposition to superior), Why
bilateral?! (due to large angle!!)

24. Neuro-motility station
2. Case 2: adult female, examine.
(pt has fair skin, lash & brow hair, nystagmus with daiphonous iris)
(horizontal, pendular, low amplitude, fast frequency) → I want to assess it
with convergence, ok (slightly decreased), I want to do cover test, why (to
assess manifest latent nystagmus), ok →no latent. I will assess EOM
motility, ok → increase nystagmus in horizontal temporal gazes.
• Dx?
(Horizontal pendular nystagmus mostly congenital associated with
oculocutaneous albinism)
• What other ocular finding with albinism you will find?
(refractive error, zonulysis, iris & fundus hypopigmentation, foveal
hypoplasia, VF abnormalities due to ↑ uncrossed fibers)
• Cause of ↓ vision? (foveal hypoplasia). Is ↓ vision progressive? (No
stationary & nystagmus decrease with age). What do you expect vision
here? About 6/36. Ttt? (conservative with tinted glasses, treat EOR)

25. Oculoplasty station
1. Case 1: adult female.
(by observation lt droppy UL just below pupil margin with slight head tilt to lt,
absent crease), ok continue ex→ I want to assess ptosis measurement, I measured
all 4 in both eyes. LFT were 15 & 10 mm which is moderate in Lt. she asked what is
normal? ( more than 12-16mm)
• What to examine else?
(I asked to perform all examination while she was observing me→ MG fatigue
test/ she asked for? 30 sec. I performed cogan lid twitch for MG/normal,
Shake/ she said free,
Jaw movement/no winking,
Motility/ she said normal
Bell phenomen/ intact
No lagophthalmos on closure
Elevate droppy lid lid for other eye ptosis/ no
• Your Dx? (lt ptosis with moderate LFT mostly congenital due to absent crease)
• TTT? (counsel, Refer, levator resection). If LFT is poor what is the surgery?
(frontalis suspension)

26. Oculoplasty station
1. Case 2: adult female.
(by observation rt apparent proptosis & dystopia) I examined her from side & behind.
• How to assess?
(while starting to measure it with ruler, she asked is there another method? I said Hertel
and she gave me it and I felt as she is saying it is mandatory to use it.
My mistake I learned from it that I had to ask again for using a ruler. I used Hertel twice only
and knew the technique well but not expert in using it.
Ay way I started to use it and widened it, but while I was searched for the scale, I realized
that I hold it upside down and the examiner said there is something wrong.
Measurements were 28/25. He asked what is normal ? (not more 20mm)
He asked is it unilateral or bilateral, kept silent. He asked examine dystopia? (I performed it
horizontal& vertical/ no dystopia).
What is the type of proptosis here? (axial)
He asked what else to examine? Bell, lagophthalmos, motility, I forgot to do LID SIGNS!
DD? (I said most common cause is thyroid dis., orbital tumour).Time was out.

27. Anterior segment station
All my cases in anterior segment station bilateral and nearly symmetrical..
1. Case 1: old age male, examine Rt eye using slit lamp, narrate your
finding during ex.
(keratoprothesis, interrupted sutures, exposed knots of two of them with
Ahmed valve shunt, explant subconjunctival superiorly surrounding
corneal scarring and vascularization, limbal stem cell ↓)
• Ok, do you know the name of it? (yes, Boston)
• What is the indication? (recurrent graft failure, rejection)
• What may be the cause? (I want to examine the other eye), examine
(the same finding but the shunt is not observed in AC, I detected it
through the explant superiorly). The cause may be due recurrence of
herbetic eye dis over the graft/ graft rejection/ OCP,SJS / dystrophy
recurrence over the graft, trauma but usually unilateral. What else
cause stromal scarring? I said syphilis. What else?!!... I don’t know what
is the specific cause she want to hear!.

28. Anterior segment station
2. Case 2: adult age femlae, examine Rt eye using slit lamp.
(superonasal dislocation of clear lens about 6 hrs, tremulous iris, pt
has No marfanoid features)
• Cause? (I want to examine the other eye which has the same
findings/ I must exclude systemic & ocular associations 1st). Like
what? (Homocystinuria, Weil-Marchasani, Marfan but Marfan has
superotemporal dislocation)
• Ok, how to manage?
(conservative with glasses) if failed? (CTR with scleral fixation as it is
progressive, IOL scleral fixation or iris claw)

29. Anterior segment station
3. Case 3: adult female, examine.
(by observation apparent bilateral mild ptosis). what else by observation? Nothing!
• Ok, examine with slit lamp? (nystagmus is detected once I switched on slit lamp light,
cornea showing superficial scarring, aniridia of both eyes). Level of corneal scarring?
(anterior stromal). Cause? (limbal stem cell ↓ associated with aniridia)
• Other association? (I will start with FH to exclude systemic association with SPORADIC
cases 1st by screening /WAGR, Wilms). What is Wilm? (hypernephroma). Other
hereditary modes? (AD, AR)
• Ocular association? (dryness MG ↓, limbal stem cell↓, zonulysis, glaucoma, other
coloboma in fundus)
• How to manage? (tinted glasses, painted Cl, treat glaucoma with shunt if failed medical,
surgery if zonulysis or cataract with scleral fixation). How to treat aniridia surgical ( iris
prothesis but according to my knowledge It will deteriorate glaucoma!). He finshed
discussion saying ok it is a sporadic aniridia, thank you.
Thanks Allah, parents, family, professors and colleagues
finished and passed the exam.