DNB practical exam is a time-bound test of knowledge, presentation skills, swiftness and presence of mind. In the exam, a candidate usually gets 4 long cases with 20 mins per case (a whole 2 minutes more than you can taketo write each answer in the theory exam). That usually includes 2 anterior and 2 posterior segment cases. Although 2 posterior segment cases may seem like a daunting task, there are ways to excel the viva; otherwise, the sheer stress of exam often changes the performance, pace and quality and a lot of brilliant minds start fumbling under stress. The 20 minutes that are provided are for not just taking the case (which includes history taking and examination) but alsowriting the case sheet and in retina cases- a good diagram or illustration preferably on the Amsler-Dubois chart. Here are 10 simple tips for presenting a retina-based case in a DNB practical exam.
1. Don’t screw the basics:
In the exam, unlike in the clinics of most DNB hospitals (where we have an optometrist to help), you will be expected to take the uncorrected and best-corrected visual acuity (BCVA), the intraocular pressure (IOP) and refraction/retinoscopy by yourself.These are fundamentals; hence you need to make sure you don’t grossly mess up here. For example, in a case of macula off retinal detachment, the BCVA usually does not improve with pinhole or glasses. This is a simple accepted fact that your examiner already knows; hence, if you speak haywire here, your examiner might get muddled with your basic findings and might not leave a good first impression.
2. Be the sailor of your ship:
DNB examiners do not come to the center with a set of questions; they just have an answer key to your case findings. Hence, they will ask you questions depending on how you answer. Thus, if you’re sure of an entity and have deep knowledge about the same, you can press on that fact in the viva. On the other hand, if you’re unsure of something, it's better to say, “I am not very sure/I haven’t read about it/I can’t recall at the moment” rather than boasting about it. Nothing irritates the examiner more than the pseudo-confidence swag of the candidate. The students who fare well in these exams always know how to direct their viva. For example, suppose if there is a case of retinal detachment, the intraocular pressure is usually on a lower side. This might be a good point to pen down and noticeably speak during the viva (provided you know the causes of lows and highs).
3. Take aid from your common sense:
Most of the time, it is known to the candidate - either by the exam coordinator saying that it is a posterior segment case or by indirect hints like if Amsler chart is provided. Each specific retinal pathology has very directive symptoms and signs. Hence, loitering around with unnecessary words in a retina-based case never helps. Better elicit and speak those symptoms rather than wasting time on something usual that the patient has randomly spoken. For example, once you know it is a case of retinal detachment, you can ask about preceding flashes, floaters, injury, myopia, history of the previous laser, etc. Or when it’s a case of CSCR, a history of stress, smoking, tobacco usage, steroids, sleeping pattern can be very useful and is necessary to mention.
4. Examine in entirety:
There is no reason to hurry through the anterior segment or systemic examination in a retina-based case. Unlike in MS exam, the DNB retina case holds equal weightage for complete ocular and systemic examination. Cases like CRVO and DR have a significantly crucial systemic history. Therefore, all such findings must be documented and spoken distinctly. Also, a brief knowledge of the systemic condition and its general management always fetches credit points. For example, one of the retina cases in my DNB was a patient with retinitis pigmentosa, which had an associated Bitot spot on the conjunctiva. I could see that I gained brownie points from the examiner when I mentioned it, as that finding was absent in their answer key or findings list, and they called the patient and cross-examined. Key anterior segment findings that aid the diagnosis, management, and prognosis,must be emphasized - sometimes in summary also (discussed later), including angle findings like neovascularization, phakic status and lens clarity, and presence of strabismus if any, etc.
5. Documentation and drawing are the keys:
Once you finish history and examination (which should not take more than 8-10 minutes per case), dedicate 6-8 minutes to do the following things.
Step1 - Write and document history points and examination findingsneatly
Step 2 - Draw your diagrams with accurate color coding (including Amsler)
Step 3 - Write provisional diagnosis, differentials, summary, and plan of action
For example, during my presentation, I forgot to mention that I did notice NVA in the gonioscopy, which I performed in a case of CRVO with NVG. The examiner asked me if I had penned down the same. Luckily, my gonio findings were neatly documented in my case sheet, and on seeing that, it indeed laid a good imprint on his mind.
Also, never speak abbreviations. You might pen down “FFA” in your sheet, which is okay, but when you are speaking in the viva, you should speak “Fundus fluorescein angiography”. Always utter the full forms.
6. Trust your findings:
There may be some help and hints flowing in the room, either from seniors or from fellow candidates. It’s not always true that they would be correct. Hence, trust your own findings if you are confident enough over all of that. Always be assured that the examiners will cross-check the patient if there are gross discrepancies. For example, the senior coordinator told me that it’s a case of retinal detachment and there are multiple opened lattices and a small tear in the inferior periphery. I could see the lattices but not the tear. I tried searching it up with scleral depression, however, I couldn’t locate the tear. Hence, I didn’t mention it up. To my luck, the examiner checked the fundus himself and couldn’t find the tear either that was mentioned in his answer key. Hence, it was a win-win!
7. Sum it up:
If you are the first candidate of the day or there is somethingparticularly interesting about you or yourcase, the examiner will listen to your entire case. But that seldom happens. Often examiners will interrupt to ask you for positive findings only, or basically a summary. Therefore, it is a good habit to start practicing highlighting the positive findings in the case sheet (either by underlining or putting a star bullet or writing a few statements summary). The summary must convey your thought process to the examiners. For example, a typical summary at the end of your case sheet should read like “This is a case of a 17-year-old healthy myopic boy, with history of blunt trauma with a cricket ball in the right eye before 10 days, with history of a gradual decrease in vision over 1 week preceded by flashes and floaters. Vision in the right eye is 6/60 and IOP is 8 mmHg. On examination, there is a total rhegmatogenousretinal detachment in the right eye with breaks at 12 and 2 o clock position, with no PVR changes, while the left eye has 3 lattices in the inferior half of the retina beyond the equator. The right eye needs surgical intervention under guarded visual prognosis and the left eye needs laser barrage.” Ideally, use the Amsler-Dubois chart. But if it is not provided, use a round object to make large neat circles and depict all findings with the correct color coding with labeling.
8. What next?
This is one of their favorite questions; examiners will begin with “what will you do next?” The best way to go about here is to divide the answer into parts, namely, investigations and management. Cases such as diabetic retinopathy or vein occlusion willcertainly require you to discuss investigations. You must not only divide them into groups of systemic vs ocular investigations but also investigations that aid in diagnosis vs. those used for documentation of baseline. For example, in a diabetic macular edema case, even though you may be doing OCT in all cases in your DNB days, in the exam when clinically the edema is evident, it is wise to say that OCT should be done for documentation of baseline features before initiation of treatment so that response can be monitored. You can also mention investigations that you will do at a later date - such as in vein occlusion cases -FFA at a later date once hemorrhages resolve to look for neovascularization or foveal avascular zone. Again, don’t be afraid to display the knowledge that you are confident of. You can smartly direct your viva into areas you have read well - clinical trials, recent advances, etc. Answer to the point, precisely, but not in one word. When you are asked what investigations are indicated, you should not only mention the name but also why it is indicated and what findings are expected. For example, in an eye that has PDR in one eye and severe NPDR in the other eye, FFA is done to establish the presence of NVE that may not be seen clinically and the presence of NVE will appear as leaks or hyper-fluorescent areas,increasing in intensity with fuzzy margins. Allow the examiner to interrupt and ask the next question. If your answer ends and the next question has not been shot at you, you may not have answered as completely as to the expectation of the examiner - allowing you to quickly alter or add to your answer. Always give the management/treatment plan for both eyes. If the other eye is seemingly normal, do mention the need for follow-up sos.
9. Be street-smart, but simultaneously respectful:
The older and newer generations of examiners have quite an abundance of differences in questioning in the viva. A street-smart candidate would see and assess the situation. For example, a candidate got a case of vitreous hemorrhage (with no evident traction on B scan) secondary to PDR, which was two weeks old. His examiners were apparently two comprehensive ophthalmologists, a senior professor of 60 years and a young, dynamic surgeon of 40 years. When he was asked about the management, he smartly replied that there can be two approaches. Approach 1 is to observe, give head end elevation position and follow up weekly, and once the vitreous hemorrhage seems resolving, initiate PRP laser. Approach 2 is to advise surgical vitrectomy with a pre-op Anti VEGF injection. Both the examiners were smartly catered to what they wanted to hear. Instead of going ahead with the viva, they started discussing amongst themselves their ways to do it, and this candidate was totally enjoying their conversation!
10. Wisdom from experience:
When the case viva is segmented, as in, you finish taking one or two cases and finish the viva of it before proceeding to the next cases; do not let the post viva mood (melancholy or exuberance) affect the next two cases. Remember, one case is enough to change your day or score and moreover, there is absolutely no time to waste in reflecting upon it while the exam is going on! For example, my first case was a case of exotropia and I did not fare well in the viva. I assumed they might not even give me passing grades. Trying not to be disheartened, I went to take history of the next two cases which were retina-based cases. To my luck and fortune, the viva there went extremely lucid. Had I been depressed with the first one, I don’t think I could have aced the next two.
To sum it up, retina-based cases are high-scoring cases for two reasons: 1. The answers are very case-specific and direct and there is not much to beat around the bush. 2. If a general ophthalmologist would be an examiner (which commonly is the case), you can build your viva on the basics of the retina rather than going into thorough depths and intricacies of newer advances. Preparation for the viva should be staunch. Ask a senior or fellow to perfect your examination technique as you may be asked to demonstrate in the exam, or you may be watched from a distance. Discuss cases every day with your batchmates and seniors and have a mock viva in your own institute- it builds mental reserve. Make your basics strong, Set your temperament and smile right and be the best version of yourself on the exam day!