Written Qualifying Exam:  Content Breakdown

As mentioned on the ABO website, the written qualifying exam (WQE) assesses the following topics (in alphabetical order):

  • Cataract and Anterior Segment
  • Cornea and External Disease
  • Glaucoma
  • Neuro-Ophthalmology and Orbit
  • Oculoplastics and Orbit
  • Ophthalmic Pathology and Oncology
  • Pediatric Ophthalmology and Strabismus
  • Refractive Management and Optics
  • Retina and Vitreous
  • Uveitis

Fortunately, the AAO's Basic and Clinical Science Course sections are organized in a very similar topical arrangement.  The ABO even provides a content outline for your personal use to get a sense of what topics you should review.  So while the ABO's outline should be a more-than-sufficient start to your review, this article will focus more on what sections in the BCSC are helpful to review.  The ABO's outline specifies in detail the individual testable items (each section has more items than the total number of questions possible on the test).  While it should be mostly common-sense, I know I wish I had an easy-to-reference list of chapters/topics that I could use to review the material.

*Disclaimer:  I don't remember test questions on the written exam (it's been a few years), so please don't take my reading suggestions as fully comprehensive.  I'm sure that there will be topics that I will recommend to focus on that won't show up on the test at all, and there will be questions on the test that aren't in my list of things to know.  When in doubt, use the ABO's content outline!

*Note:  I have not gotten a chance to update this page for the most recent edition of the BCSC, so some of the chapters and topic divisions will not be entirely accurate.

Cataract and Anterior Segment:  BCSC Section 11 (Lens and Cataract)

Basic Info

  • This section comprises 10% of the test (25 questions).
  • As one might expect, every aspect of the workup for cataracts, systemic and special causes for cataracts, management of cataracts (surgical and nonsurgical), and post-surgical complications is important to review.  While hopefully the basic anatomy and physiology of the lens and anterior segment are quick reviews, it would still be a smart idea to re-familiarize yourself with them.

Chapter Breakdowns

Chapters 1-5

  • The first few chapters of the Lens and Cataract book deal with anatomy, embryology, physiology, and pathology.
  • The outline is not very specific about what to know about these sections; based on my common sense inference, I think that the focus should be directed towards the clinically applicable material.
  • Chapter 5 is pretty short - the main takeaway should be the risk factors for cataract formation.
  • Conceptual examples:  How does glucose metabolism affect lens clarity?  What biochemical changes are responsible for cataract formation?
  • Other topics of focus to consider:  congenital cataracts and lens abnormalities, secondary causes of cataracts (drugs, trauma, radiation, etc.), lens-induced diseases (phacomorphic glaucoma, phacoantigenic uveitis/glaucoma, etc.).

Chapters 6-9

  • The last 4 chapters of the Lens and Cataract book address evaluation of cataracts, cataract surgery, post-surgical complications, and considerations for special cases of cataract surgery.
  • Between the first 5 chapters and the last 4 chapters, I would recommend focusing more on these last 4 chapters, which are more clinically relevant and are essential for the comprehensive ophthalmologist.
  • Conceptual examples:  What aspects of the clinical history are important to consider in all cataract patients?  What are the variables used in the calculation of IOL lens power?  What happens to the fluid dynamics within the eye when changing various variables during phacoemulsification?  What are the possible post-operative complications with cataract surgery, how do they present, how are they diagnosed, and how do you manage them?
  • Other topics of focus to consider:  systemic considerations for cataract surgery, ocular disease in cataract surgery, etc.

Cornea and External Disease:  BCSC Section 8 (Cornea and External Disease)

Basic Info

  • This section comprises 11% of the test (27-28 questions).
  • I think one of the major differences between the WQE and the OKAP is in the number of questions about rare diseases.  Where it used to be pretty common for the OKAP to throw in a question or two about some corneal dystrophy or other obscure topic, it seemed to me that the WQE tended to shy away from those types of questions.  The challenge in the questions is more related to answering complex questions about common diseases, or in being able to recognize a disease from a very obscure piece of information.

Chapter Breakdowns

Chapters 1 & 2

  • The first 2 chapters of the Cornea book deal with anatomy, embryology, and physiology, and clinical exam techniques.
  • While a decent portion of the clinical exam techniques are likely concepts we use on a daily basis, for some people it may be helpful to review slit lamp techniques and when to use them.
  • Conceptual examples:  What diseases would specular microscopy be helpful in diagnosis?  What diseases can affect each component of the tear film?
  • Other topics of focus to consider:  diagnostic tests for the cornea (e.g., Schirmer's test), indications for diagnostic testing, interpretation of diagnostic test data, etc.

Chapters 3-9

  • These next 7 chapters cover the core of corneal disease - dry eyes/ocular surface disease, infectious keratitis, non-infectious keratitis, neoplasias, and congenital anomalies.
  • If you only have time to review a small subsection of the book, these 7 chapters would be where I would spend most of my time reviewing, because this covers the bulk of corneal disease.
  • Depending on your experience and level of comfort with the material, you may want to budget your time to reflect your level of knowledge, rather than uniformly dedicate the same amount of review time to dry eyes as you do ocular surface neoplasia.
  • Definitely take the time to know and understand the Herpes Eye Disease Study (HEDS).  Since it answered many questions about the management of anterior segment manifestations of herpetic disease, it's very practical to know.
  • Conceptual examples:  How do you evaluate and manage stromal keratitis?  What is the difference between primary acquired melanosis (PAM) with atypia and melanoma in situ?  What are all of the possible treatments available for the treatment of dry eyes, and what would be a reasonable order for treatment?
  • Other topics of focus to consider:  systemic associations with ocular surface disease (e.g., conjunctival lymphoma and systemic lymphoma, Peters-plus syndromes, blue sclera, autoimmune causes of scleritis, etc.)

Chapters 10-12

  • While I've lumped these three chapters together (corneal dystrophies, ectasias, metabolic diseases, corneal degenerations), there are definitely some sections within these chapters that shouldn't take up much of your time.
  • There are only a few key corneal dystrophies you need to know (pretty much the ones we understand the most and the ones that are most commonly seen clinically).  Know how to identify them and how to manage their complications.
  • Corneal ectasias are fairly common (especially that keratoconus one).  Obviously there are quite a few things that we understand about keratoconus; this section may be useful to review with the pathology text as a guide.
  • Metabolic diseases involving the cornea, for the most part, are not listed on the ABO outline as essential study material.  I still included chapter 11 in this section, because I think it's important to review the more common conditions (for example, calcific band keratopathy, enlarged corneal nerves, etc.).  But the obscure stuff?  Learn it for bonus points if you have time.
  • Corneal and conjunctival degenerations are plentiful - but the ones you probably need to know for the exam are also the ones that are the most commonly seen.  The questions are likely going to be higher-order in nature, rather than simple identification of the lesion.
  • Conceptual examples:  What corneal dystrophies present as recurrent corneal erosions?  How do you manage corneal disease?  What are the differences between a dystrophy and a degeneration?
  • Other topics of focus to consider:  surgical and nonsurgical management of corneal ectasias, pathology of corneal dystrophies, etc.

Chapters 13-16

  • These last few chapters cover corneal trauma/injury and surgery of the cornea and external surface.
  • Again, common sense would state that the more commonly encountered conditions will be more likely to be tested.  I have no reason to believe otherwise.
  • Being well-versed in options for management is one of the important aspects of being a good ophthalmologist.  While we don't have to become a master surgeon in all fields, we do have to be able to recognize the appropriate treatment options available to accurately counsel our patients.
  • Conceptual examples:  What specific components of the eye exam should be examined in greater detail when someone comes in with a chemical injury to the eye?  What are the sequelae of blunt trauma to the eye, and what conditions may require surgical intervention?  What are the advantages/disadvantages to corneal transplantation?
  • Other topics of focus to consider:  techniques for pterygium surgery (and the advantages/disadvantages), indications for surgery, management of corneal complications, etc.

Glaucoma:  BCSC Section 10 (Glaucoma)

Basic Info

  • This section comprises 12% of the test (30 questions).
  • While I think it would be smart to know the major glaucoma studies (both for the test and for clinical practice), any questions that address the findings of those studies will likely be framed within the context of a clinically-applicable situation.  So don't waste your time memorizing the number of subjects or specific details like that, spend more time using the studies to develop a strong evidence-based approach to managing glaucoma.
  • That being said, you are expected to know the following studies:  Ocular Hypertension Treatment Study (OHTS), Early Manifest Glaucoma Treatment (EMGT), Collaborative Initial Glaucoma Treatment Study (CIGTS), Advanced Glaucoma Intervention Study (AGIS), Collaborative Normal Tension Glaucoma Study (CNTGS), Glaucoma Laser Trial (GLT), Fluorouracil Filtering Surgery Study, and Tube Versus Trabeculectomy Study (TVT Study).
  • Because of how important glaucoma management is to ophthalmology, it will be really challenging to do well if you take the approach of "it's ok if I miss a few questions in this section" - since most everyone should know something about glaucoma, one missed question may drop you from the 99th percentile down to the 90th (this is hypothetical; obviously, this result will largely depend on how everyone else taking the test does).
  • For such a short book, there is a lot of key elements to review.  For this reason, there will be less chapters that you can "skip" in this book.  Still, it should be short enough that you can review everything in a little amount of time.

Chapter Breakdowns

Chapters 1-3

  • The first 3 chapters cover anatomy and physiology, terminology, and examination techniques.
  • The genetics of glaucoma should probably be memorized.  I think I remember there being a few practice questions about the various genes for specific types of glaucoma (congenital glaucoma, pseudoexfoliation, Axenfeld-Rieger syndrome, etc.)
  • Risk factors for glaucoma are easily testable; now that I mention it, risk factors for any disease are easily testable.  Probably should look into that.
  • So much has been studied about aqueous dynamics and physiology, and much of what we attempt to accomplish treatment-wise is born out of the understanding we have of how the aqueous humor is produced and eliminated.  From concentrations of different ions to the equations that describe intraocular pressure, I am using several ways to say, this stuff is probably pretty important to know.
  • IMHO, chapters that describe examination techniques are always challenging to read initially, because they often provide examples of diseases that are described later on in the book.  However, they're great for review, because the examples help us understand the usefulness of those exam techniques.
  • This section is where the BCSC provides the most detailed content about visual field testing and interpretation.  Since visual fields are a vital component to the assessment of vision and eye function, knowing the details of these tests is pretty important.
  • Conceptual examples:  What is the clinical definition of glaucoma?  What genes and proteins have been found to be associated with the development of glaucoma?  What are the 3 components to aqueous production, and how do they work?  What part of the angle (name both the main structure and the segment) is most responsible for aqueous outflow resistance?  What factors can affect applanation tonometry?
  • Other topics of focus to consider:  visual fields, aqueous humor ion concentrations, gonioscopy, visualization of the optic nerve, ancillary tests that evaluate optic nerve anatomy, etc.

Chapters 4-6

  • The next 3 chapters cover the different glaucomas, divided into open angle glaucomas, angle closure glaucomas, and childhood glaucomas.
  • I suggest that you spend a great deal of time making sure you are very familiar with all of the different possible glaucomas.  The questions should make it pretty simple for you to recognize the type of glaucoma being tested, but recognition is typically only the first step; you also need to know probably at least 2-3 different things about each glaucoma (sometimes more).
  • Figure out ways to group different topics together.  For those who like mnemonics, create a mnemonic that lists all of the glaucomas in which pilocarpine is contraindicated (and share it with us!).  Or list the glaucomas in which laser trabeculoplasty may be more efficacious.
  • Like I said before, knowing how to apply the major glaucoma studies is probably more important than memorizing the statistics.
  • There are TONS of great histopathology slides that may be used in a question stem about glaucoma.  We'll be covering some of that when we get to pathology, but it might not be a bad idea to have the Pathology text open while you review this section.
  • Conceptual examples:  What are the risk factors for developing open angle glaucoma, and what studies determined those risk factors?  What are the differences between normal/low-tension glaucoma and primary open angle glaucoma?  What are the different lens-associated glaucomas, and how do each of them look histopathologically?  What are causes of increased episcleral venous pressure?  What is the mechanism for primary angle-closure glaucoma?  What is the mechanism for aqueous misdirection glaucoma, and how is it treated?
  • Other topics of focus to consider:  trauma-associated glaucoma, surgery-associated glaucoma, glaucomas associated with retinal disease, pediatric glaucomas, etc.

Chapters 7 & 8

  • The last 2 chapters discuss the medical and surgical management of glaucoma, respectively.
  • While individual drugs probably won't be tested, classes of drugs probably will.
  • Speaking of drugs, it'd probably be smart to know indications and contraindications, especially those pertaining to pregnancy and children and other special conditions (trauma, inflammation, etc.).
  • Mechanisms of action are pretty key too, since understanding that will determine the appropriate indications for use.
  • Adverse reactions are also important to recognize, since glaucoma meds are so widely prescribed.
  • There is probably more detail about the various glaucoma meds in the BCSC Fundamentals book (Section 2), so while you might not need to open that book if you're pretty knowledgeable about glaucoma meds, it might still be a good reference.
  • In regards to surgical correction, it's important to know the appropriate indications for surgery, and choosing the appropriate technique.
  • Medical decision-making is very testable.  Keep that in mind as you review.
  • Laser settings are definitely testable, but potentially less high-yield than other facts.  I may be wrong about this, so if you come across a laser setting question, don't curse me too much, and let us know!
  • Conceptual examples:  What glaucoma medications should be avoided in children?  What are the contraindications for selective laser trabeculoplasty?  What are the potential post-operative complications for aqueous shunt surgery?
  • Other topics of focus to consider:  goals for IOP lowering, mechanisms to decrease systemic absorption, etc.

Neuro-Ophthalmology and Orbit:  BCSC Section 5 (Neuro-Ophthalmology)

Basic Info

  • This section comprises 10% of the test (25 questions).
  • There will be a little bit of overlap in topics with Neuro-Ophthalmology and Oculoplastics in regards to orbital disease.
  • Neuro-Ophthalmology also discusses assessment of strabismus, which is also covered in Pediatric Ophthalmology.  However, surgical management of strabismus is reserved for the Pediatric Ophthalmology and Strabismus section.
  • Neuro-Ophthalmology also discusses visual field techniques and interpretations, which overlaps with Glaucoma.

Chapter Breakdowns

Chapter 1

  • There is no way around it - Chapter 1 is incredibly dense, long, and extremely detailed.  It covers every neurological pathway, all the orbital bones, and all of the vascular supply of the eye and visual pathways.
  • If you feel sufficiently confident in your neuroanatomy, you can skip this section.  Yay!
  • Another way to study might be to use Chapter 1 as a reference, and as you study all of the different neuro-ophthalmic diseases, you review the pertinent anatomy for those diseases.
  • Conceptual examples:  What conditions would cause a first-order Horner's syndrome?  What is the mechanism of a relative afferent pupillary defect?
  • Other topics of focus to consider:  vascular supply to the optic nerve, cranial nerve pathways, facial nerve pathway, bony anatomy, etc.

Chapters 2-3

  • The next 2 chapters discuss the evaluation of neuro-ophthalmic disease through imaging studies and clinical examination.
  • Again, if you're comfortable understanding the indications for CT and MRI, and have the neuro-ophthalmic exam figured out, it'd be perfectly fine to skip these chapters.  Or, at the very least, skim these chapters.
  • However, because it's important to know this (and I'm not just saying this because I'm a neuro-ophthalmologist), if you're in the least bit unsure of these topics, it would probably be smart to at least skim the material.
  • Conceptual examples:  What types of conditions are better visualized on CT than MRI?  What questions should be asked when assessing double vision?  What tests are helpful in assessing functional vision loss?  What are different methods available for assessing color vision?
  • Other topics of focus to consider:  pupil exam, ocular motility examination, methods for assessing visual fields, etc.

Chapter 4

  • Chapter 4 is a very long chapter and covers diseases of the entire afferent visual pathway, from anterior segment to occipital cortex.  As such, I decided this should be a separate section to discuss.
  • If you don't review any other chapter in the BCSC Neuro-Ophthalmology book, review this one.  While the ABO only expects you to know about the most common visual pathway diseases, each disease is distinctly detailed.
  • Look at the content outline to know which optic neuropathies are essential to know.  Chiasmal disorders are also commonly tested, but retro-chiasmal visual fields tend to be pretty basic (after all, we learned it in medical school), so if they test on a lesion posterior to the chiasm, it will probably be combined with some other visual or systemic symptoms to force you to localize the lesion more.
  • Believe it or not, the only 2 studies you need to know for neuro-ophthalmology are the Optic Neuritis Treatment Trial (ONTT) and the Ischemic Optic Neuropathy Decompression Trial (IONDT).
  • Conceptual examples:  What is the workup for papilledema, and how do you treat it?  What are the causes of bilateral cecocentral scotomas?  What do the visual fields look like in a lateral geniculate body lesion, and how do each visual field pattern correspond based on the blood supply?
  • Other topics of focus to consider:  optic neuritis, ischemic optic neuropathy, optic nerve sheath meningioma, pituitary adenoma, etc.

Chapter 5

  • In contrast to chapter 4, chapter 5 is short; but in terms of yield, I would say that this is another chapter worth looking at.
  • The main things to know in this chapter are the vascular causes of transient visual loss, as well as how to distinguish by history the different causes of vision loss.
  • Conceptual examples:  What are the differences between transient visual obscurations and amaurosis fugax?  What are the various types of emboli that can affect the eye, and where do they originate?  What are the causes of bilateral transient visual loss?
  • Other topics of focus to consider:  ocular ischemic syndrome (which is also going to be covered in retina), ocular migraine, etc.

Chapters 6-7, 9

  • These three chapters are a bit more obscure.  Chapter 6 is about illusions and hallucinations and the like, chapter 7 is about supranuclear motility disorders, and chapter 9 is about nystagmus.
  • In terms of how much time one should spend learning the ins and outs of these sections, I am going to say, precious little.
  • In fact, I might dare say that it would be just fine to skip these three chapters (gasp!) and keep on moving.  The content outline does list higher cortical function disorders as a topic that you need to know, but unless you're aiming for a perfect score in Neuro, you might want to spend more time reading through one of the other sections.

Chapters 8, 10-14

  • The last few chapters in the Neuro-ophthalmology text are pretty important to review, with diplopia (chapter 8), pupils (chapter 10), and systemic manifestations of neuro-ophthalmic disease (chapter 14) being of the highest yield.
  • Keep in mind that there's only a handful of causes of diplopia that you need to know.  So don't panic!
  • There just isn't a whole lot of detail to be found in the headache, facial disorders, and functional vision loss chapters.  Don't spend too much time memorizing the minutiae.
  • Systemic manifestations of neuro-ophthalmic disease.  Know it.  That is all.
  • Conceptual examples:  How should someone evaluate anisocoria?  What are the features of dorsal midbrain syndrome?  What is the most common cause of a cranial VI palsy?  What are the indications for steroid use in neuro-ophthalmic conditions, and what are the appropriate dosages for each disease?
  • Other topics of focus to consider:  myasthenia gravis, multiple sclerosis, giant cell arteritis, thyroid eye disease, orbital inflammatory disease, etc.

Oculoplastics and Orbit (BCSC Section 7:  Orbits, Eyelids, and Lacrimal System)

Basic Info

  • This section comprises 10% of the test (25 questions).
  • This is another fairly short book that has quite a few questions.  There are many different eyelid/skin and orbital lesions, some of them quite rare and others are somewhat common but don't have a whole lot of description in the book.
  • I would strongly recommend using supplemental material, such as Kanski's Clinical Ophthalmology or The Wills Eye Manual for additional images of the different lesions.  You can also check out the various online resources out there to become facile at figuring out all of those eyelid lesions.
  • Keep in mind that common, life-threatening, and sight-threatening lesions are going to be more likely tested than obscure, rarely seen, benign lesions.

Chapter Breakdowns

Chapters 1-2, 9, 12

  • The first 2 chapters of the Oculoplastics book deal with anatomy, clinical exam techniques and terminology.  I lumped chapters 9 and 12 in here because they deal with facial and eyelid anatomy, and lacrimal anatomy and physiology, respectively.
  • There is another review of appropriate indications for various types of neuroimaging, similar to chapter 2 in the Neuro book.
  • On the whole, these chapters are pretty light on content; if you're pressed for time, you could probably skip these.
  • That being said, the content outline does expect you to know anatomy, so keep that in mind.

Chapters 3-5

  • Chapters 3-5 discuss orbital lesions, starting with congenital orbital disorders, then addressing inflammatory and infectious orbital disease, then finishing with orbital tumors.
  • This is a pretty high-yield set of chapters, but even within these sections there are a few items you can probably skim (look at the content outline for reference).
  • There are quite a few systemic diseases that can produce orbital lesions.  It would behoove you to know these (yes, I said behoove).
  • This is another section where having the pathology book open can be very helpful.  Some lesions are only distinguishable histologically, so knowing when to biopsy, how to do it, and what technique you need to use is quite important.
  • A helpful exercise for me was to categorize the lesion by its distinguishing feature.  For example, thyroid eye disease is the most common cause of eyelid retraction in adults, or fibrous histiocytoma is the most common mesenchymal orbital neoplasm.
  • Considering management of thyroid eye disease is a pretty long section in the outline, I would suggest knowing this disease intimately (it's gotta be a popular test item, since it's a multidisciplinary disease, both within ophthalmology and extending to medicine in general).
  • Conceptual examples:  What are the orbital manifestations of Wegener's granulomatosis?  What are the different subtypes of rhabdomyosarcoma, what do they look like histologically, and how do they differ in presentation and prognosis?  What are clinical findings suspicious for orbital cellulitis, and what are the criteria for observation vs. surgical intervention?
  • Other topics of focus to consider:  fungal infections of the orbit, vascular tumors, systemic inflammatory diseases, AIDS-associated orbital diseases, etc.

Chapters 6-8

  • These 3 chapters (orbital trauma, orbital surgery, and anophthalmic socket) are pretty short and sweet.
  • Orbital surgery may be a bit more important to review than the other chapters, as surgical management of orbital disease is pretty testable.
  • Conceptual examples:  What surgical approaches are appropriate for orbital decompression in thyroid eye disease?  What are the surgical approaches for optic nerve sheath decompression?
  • Other topics of focus to consider:  types of orbital fractures and how to manage them, surgical complications, techniques/approaches to enucleation and evisceration and exenteration, indications and contraindications for surgery, etc.

Chapters 10-11

  • This is another dense but high-yield section.  Eyelid disease questions can be pretty challenging, because you have to recognize the gross appearance of the lesion, the clinical presentation, the histopathology, and the management.  "When in doubt, cut it out" doesn't always work on the test, sadly.
  • It's probably safe to say that you're going to need to know all of the skin cancers.  Just know them.
  • The cosmetic procedures had a surprisingly larger section in the content outline than I would have expected.  I don't know if that will translate to at least 1 question regarding cosmetic facial and eyelid procedures, but it does seem to indicate skipping this section might be detrimental.  But don't take my word for it.  (Cue the music from Reading Rainbow)
  • Conceptual examples:  What skin conditions are associated with malignancies elsewhere in the body?  What are the differences in pigmented skin lesions?  How should actinic skin lesions be managed?  What are the gross and histological differences between molluscum contagiosum and keratoacanthoma?
  • Other topics of focus to consider:  congenital eyelid lesions, cosmetic surgery, infectious eyelid lesions, eyelid surgery techniques, etc.

Chapter 13

  • This section deals with lacrimal system abnormalities.
  • There are a few key diseases to know.
  • It is absolutely vital to know the appropriate management approach in every disease.  Remember what we were taught in medical school:  least invasive to most invasive, common things are common, rule out the dangerous stuff.
  • Conceptual examples:  What is the proper approach to evaluating and then treating nasolacrimal duct obstruction (congenital vs. acquired)?  What are the causes of acquired nasolacrimal duct obstruction?  What is the appropriate workup and management of canaliculitis?  What is the differential diagnosis for medial canthal lesions?
  • Other topics of focus to consider:  surgical techniques for lacrimal system, infectious and inflammatory diseases of the lacrimal system, etc.

Ophthalmic Pathology and Oncology:  BCSC Section 4 (Ophthalmic Pathology and Intraocular Tumors)

Basic Info

  • This section comprises 8% of the test (20 questions).
  • This is one of the sections where, if you do well, you can really add points to your raw score.  I know that sounds pretty self-explanatory, but hopefully you get my meaning - because not every residency program has an emphasis in ophthalmic pathology and oncology, I think most people do somewhat poorly on this section.  Since your final score is based on the total number of questions you get correct, it would follow that getting several more questions correct in this section would, in turn, significantly help your score, far more than getting that extra question in Glaucoma would.  Bottom line, for many/most people, this is a section that has a lot of potential for improvement.
  • Even though there are not very many ophthalmic pathologists out there, there are tons of great resources to help prepare you for this section.
  • Like I've said in many other places on this site, the ophthalmic pathology section is a great review for the other sections.

Chapter Breakdowns

The chapter breakdowns in this book are a bit different, since the pathology section is divided into the different anatomical parts of the eye (which are covered in other sections).

Chapters 1-4

  • The first 4 chapters cover a basic introduction to the field of pathology - how pathology slides are created, what stains are used, what special tests are used for diagnosis, etc.  Wound healing is also addressed, specifically within the context of ophthalmology.
  • Because I didn't take histology seriously in medical school and forgot virtually everything about it, a significant portion of this was almost completely new to me.  I was blessed to have an outstanding ophthalmic pathologist in residency (who incidentally contributed a great deal to the BCSC pathology book), and through his excellent teaching, I discovered the exciting world of ophthalmic pathology.
  • While pathology itself is a smaller section on the WQE, there are tons of topics in other subjects that will probably have some pathology tie-in.  So by understanding the histopathology of the eye, you can often arrive at the correct answer when you otherwise wouldn't.  I don't know why I'm trying to sell you all on learning pathology; I think it's because I wish I had been convinced of its importance earlier on in my education.
  • There's a small chance you will be tested on the various stains used in pathology.  At the very least, I would recommend learning the most common stains and their corresponding tissues/diseases.
  • I think a more common way stains will show up (and I've mentioned it before), is that a histopathology slide will be shown revealing a structure that you should recognize, with a stain that is not labeled.  You should then be able to determine based on the image the disease being addressed and answer any random question about that disease.
  • Wound healing is another section worth reviewing well.  Even though many of the principles are fairly straightforward, the definitions of the terms and concepts may be testable.  Just sayin'.
  • Conceptual examples:  What structures does PAS stain?  What are the stains for iron?  What are the indications for frozen section?  How does the lens heal in response to trauma?
  • Other topics of focus to consider:  types of inflammation (including what types of immune cells are involved), pathology terminology, the stages of phthisis bulbi, immunohistochemistry, fixative agents, etc.

Chapters 5-15

  • This is the meat of the Pathology book.  It walks through every layer of tissue in the eye, with a very structured format (I bet you can see why I like this book so much):  topography (normal tissue appearance, embryology, anatomic correlation), congenital anomalies, inflammations/infections, degenerations/dystrophies, and neoplasia.
  • I highly suggest that you tackle this book and this section alongside the corresponding volumes.  While the information contained within the Pathology book is generally unique to pathology, I think it really needs to be processed within the context of the entirety of ophthalmic knowledge.  Makes for a great review, and helps to tie everything together (like the Force!).
  • I would pay close attention to the pictures in the Pathology book, and utilize the hard work of so many great pathologists online to look at as many examples of each tissue and disease as possible.  For me, my downfall in Pathology my first year taking the OKAP test was flipping through the pictures, figuring that the answer would always be obvious regardless of the picture.  I underestimated how similar everything would look in a test situation.
  • There are some pathognomonic descriptors of tissues and disease that you absolutely should memorize.  While they may not necessarily be worded in a test the same way, you should be able to immediately recall that elastotic degeneration of the conjunctiva refers to either a pinguecula or pterygium.  Sort of like how apple-green birefringence on Congo Red staining automatically makes you think of amyloid deposits.
  • Conceptual examples:  There really are too many examples to list here.  If you're having trouble figuring out what things to focus on, send me an e-mail and I'll try to be more specific.

Chapters 17-20

  • I'm purposefully skipping chapter 16, because it's simply an introductory chapter and doesn't have any specific information that you need to review.  Feel free to read it if you want, though.  I'm not stopping you.  :)
  • The last section covers the major intraocular tumors that you need to know.  Of course, throughout the pathology section (chapters 5-15), there were other neoplasias that you reviewed.  However, these chapters focus specifically on melanocytic tumors, angiomatous tumors, retinoblastoma, and ocular manifestations of systemic malignancies.
  • Surprisingly, the content outline does not state that you need to know the Collaborative Ocular Melanoma Study (COMS) in detail.  However, ocular melanoma is still on the list of things you need to know, and since COMS taught us a lot about how to appropriately manage ocular melanoma, it would make sense to know it well enough to choose management options.
  • Same thing with retinoblastoma - it's just one of the many diseases we need to know about, but there is a lot that we've learned about genetic counseling, prognosis, and management.  So while there isn't much in the content outline that would suggest that there will be more than one question about retinoblastoma (I wouldn't be surprised if some tests don't even cover retinoblastoma one year), it's obviously still an important disease to know and review.
  • Conceptual examples:  What are the clinical factors that suggest high-risk melanoma?  What are appropriate management options for a medium-sized melanoma?  What are the treatment options for a retinal angioma, and what are the potential complications/sequelae?  What systemic tests should be performed in a patient with more than one retinal angioma, and why (i.e., what are the most common causes of death)?
  • Other topics of focus to consider:  ocular manifestations of malignancy, lymphoma, phakomatoses, etc.

Pediatric Ophthalmology and Strabismus:  BCSC Section 6 (Pediatric Ophthalmology and Strabismus)

Basic Info

  • This section comprises 11% of the test (27-28 questions).
  • Some of the discussion of strabismus is already covered in Neuro-Ophthalmology.  However, strabismus surgery and management of non-neurological strabismus has not been discussed yet, and will be in this section.

Chapter Breakdowns

Chapters 1-4

  • The first four chapters of the Pediatric Ophthalmology and Strabismus book provide definitions for terminology, discuss the anatomy and physiology of ocular motility and binocular visual perception, and describe sensory tests.
  • If you're like me, this was one of the most challenging sections to understand upon first read, and if you don't deal with strabismus on a regular basis, reviewing this material can be equally challenging.
  • Honestly, I don't know that mastering this information would be all that useful to you in a testing situation, but at the very least you should master the terminology.
  • Most of the sensory tests are not listed on the ABO's content outline.  Take that for what it's worth.
  • Conceptual examples:  What is the difference between vergence movements and version movements?  What are examples of violations of Sherrington's Law?  Of Hering's Law?  What are anatomical considerations in strabismus surgery?  What are the adaptive mechanisms for strabismus, and how can they be tested?
  • Other topics of focus to consider:  visual developmental milestones, fusional amplitudes, etc.

Chapters 5-6

  • The next 2 chapters discuss amblyopia and testing of strabismus and amblyopia.
  • Amblyopia is a VERY important topic to know.  Know the different types of amblyopia, how quickly they can develop, how to treat it, etc.  The Amblyopia Treatment Studies are testable material.  It's worth taking the time to review.
  • In terms of assessment techniques, you need to be able to determine AC/A ratios (and know what is normal/abnormal), perform and interpret Worth 4-dot tests, perform and interpret stereoacuity, test corneal light reflex and red reflex, and perform and interpret the three-step test for cyclovertical muscle palsies.
  • Conceptual examples:  What are some causes for refractive amblyopia?  What are the options for treating amblyopia, and how do you determine effectiveness of therapy and timeframe for follow-up?  What muscles are you testing with right head tilt?
  • Other topics of focus to consider:  Amblyopia Treatment Studies, cycloplegic medications, etc.

Chapter 7-12

  • This is the bulk of the strabismus pathology, as well as discussion of treatment of strabismus.
  • Use the content outline to focus on the specific conditions you need to know best within the strabismus section.  Again, some strabismus has already been covered in Neuro-Ophthalmology, but if you're like me and had a hard time with strabismus in residency, it never hurts to review this stuff again.  Sadly, I had to do a fellowship in Neuro-Ophthalmology and Strabismus to become comfortable with evaluation, diagnosis, and management.
  • Conceptual examples:  What is angle kappa, and what does it mean when there is a positive angle kappa?  What is the appropriate plan for management of childhood esotropia, and how does it change for refractive and non-refractive accommodative esotropia?  What are some ocular associations with esotropia in childhood?  What is a skew deviation?  What are the basic surgical treatment options for strabismus?
  • Other topics of focus to consider:  ocular complications for strabismus surgery, nonsurgical management of strabismus, special cases of strabismus, etc.

Chapter 13

  • Chapter 13 (Chemodenervation Treatment of Strabismus and Blepharospasm Using Botulinum Toxin) is really just a discussion of Botox and the indications and complications of use.
  • Because it is a common-enough treatment option, I would recommend familiarizing yourself with the mechanism of action as well as the indications, complications, and methods for injection.
  • Conceptual examples:  What are common side effects of ophthalmic use of Botox?  What is the onset and the duration of action of Botox?
  • Other topics of focus to consider:  use in the management of strabismus, its effect on extraocular muscles following injection, etc.

Chapter 14

  • Chapter 14 describes the normal growth and development of the eye, and lists some terminology that describes abnormal growth and development.
  • While the various dimensions of the eye may still be test fodder, to me it seems less likely to be tested on than other, more clinically relevant, pieces of information.
  • I personally created a timeline to help me remember the different visual milestones.  Sadly, it didn't stick well enough with me to recall when my son was born.  Now that he's almost 5 months old, I can say that, assuming his eyes are developing normally, he shouldn't be having intermittent strabismus, he should have some fusional convergence and accommodation, and his vision should be becoming closer to 20/20 in each eye.  Doubtful you'll be seeing my son as a test question, but each of those milestones is definitely testable.
  • Frankly, there's not enough content in this short chapter to provide enough meaningful examples.  Knowing differences between infant eyes and adult eyes is important.

Chapters 15-29

  • These chapters cover the bulk of pediatric ophthalmology.  Reference the content outline to know what conditions you absolutely need to know.
  • The Pediatrics section is another great quick review of every other subject, similar to the Pathology section.
  • You are expected to know the CRYO-ROP trial and the ETROP trial.  While there are many ongoing studies about ROP and the more recent findings may continue to shape how we decide to treat ROP, these two trials defined a lot of terminology and categorized ROP in a way that helped us determine treatment options.
  • Conceptual examples:  With such a wide breadth of topics in this section, I can't provide enough examples to give this a fair shake.
  • Other topics of focus to consider:  everything in the content outline.  :)  Chapter 29 might not even have anything worth spending time studying.

Chapters 30 & 31

  • These last two chapters cover ocular trauma in childhood and management of decreased vision.
  • Sadly, there are many ways children can injury their eyes and periocular tissue.  Not all of them are accidental.  Because it is so important to recognize accidental causes and distinguish them from non-accidental causes, I think this is a very important section to know.
  • Evaluating children with poor vision requires recognition of what is considered normal vision and what constitutes poor vision.  Milestones are good to know, but I don't know how testable they are.
  • There's not much to discuss here, so I'll be lazy and not provide any examples.

Refractive Management and Optics (BCSC Section 3:  Clinical Optics, and BCSC Section 13:  Refractive Surgery)

Basic Info

  • This section comprises 8% of the test (20 questions).
  • For as small of a section as it is, there is often quite a bit of angst generated by clinical optics.  Keep in mind that refractive surgery is also sorted into this section, which should dilute the total number of optics problems you see on the test.
  • I personally used Dr. David Hunter's Last Minute Optics book instead of the BCSC for learning and review optics.  While it works great for most general optics conceptual and calculating problems, there were still a handful of questions that delved into conceptual optics that were a bit more technical than there was in the book.  I think it may have dropped my raw score by a couple of points at the most, so if you're going for perfection, I would suggest knowing the BCSC, and if you're going for not failing, I think Last Minute Optics should work out just fine for you.

Chapter Breakdowns:  Clinical Optics

Chapters 1-3

  • The first 3 chapters cover an introduction to and discussion of optics (physical optics, geometric optics, and optics of the eye).
  • For those who don't remember much of optics, there's a lot of good conceptual information in these sections.
  • There always seems to be at least one or two questions dealing with the basic concepts of optics.  I always just guessed at them, so you might not necessarily want to take my approach.
  • While any equations listed are fair game, I would imagine that on the whole the actual equations are not as important as the concepts that the equations describe, especially in the physical optics section.
  • Terminology definitions are probably good optics test questions, as well as examples of those terms.
  • Most of the dreaded optics calculations are found in the geometric optics section.  Personally I found working problems to be more effective than simply reading about the concepts.
  • Conceptual examples:  What is coherence?  What is interference?  How does an excimer laser work on a molecular level?  How do telescopes work?  What is the lensmaker's equation, and how can it be applied to determining the power or focal length of a lens?
  • Other topics of focus to consider:  prisms, mirrors, diffraction, polarization, spherical and chromatic aberration, astigmatism, treatment and prevention of refractive errors, pupil size and its effect on visual resolution, etc.

Chapters 4-8

  • The next chapters cover the applications of optics to ophthalmology, ranging from the evaluation and management of refractive errors, to the optics of different ophthalmic instruments.
  • Depending on the amount of time you want to spend, you could easily become a wizard at optics, or spend less time and still do fairly well.
  • Conceptual examples:  What is the expected accommodative amplitude at age 40?  What is the difference between image jump and image displacement?  How do progressive lenses work?  What are the methods for calculating rigid gas permeable contact lens power?
  • Other topics of focus to consider:  telescopes, intraocular lenses, streak retinoscopy, etc.

Chapter 9

  • The last chapter is about visual rehabilitation.
  • I would say that most ophthalmologists prefer not to do a lot of visual rehabilitation, but it is a service that at the very least should be considered for many of our patients, given the many different pathologies that can cause low vision conditions.
  • While we may not necessarily have to screen/fit people for low vision aids, we definitely need to understand many of the low vision principles - I confess that, to some degree, I will often refer patients to a low vision clinic and expect some magical wizardry to happen and aid people's vision.
  • Conceptual examples:  What is the Kestenbaum rule, and how does it apply to low vision?  What components to vision can affect the quality of visual perception?
  • Other topics of focus to consider:  use of prisms in low vision, resources and tools available to aid low vision conditions, etc.

Chapter Breakdowns:  Refractive Surgery

Chapters 1 & 2

  • The first two chapters discuss the basic science of refractive surgery and patient evaluation.  I think there always seems to be a science of refractive surgery question on every practice test or OKAP test I've taken, though I generally just guess at the answer.  In terms of high-density information, this section is not; but, if you're aiming for a perfect score, there will probably be something tested from this section.
  • Conceptual examples:  What are wavefront aberrations?  What do the terms oblate and prolate mean, and how do they relate to the cornea?  What is coupling?  How does each different type of refractive surgery laser (excimer, femtosecond, etc.) achieve the goals of refractive surgery?
  • Other topics of focus to consider:  indications and contraindications for refractive surgery, risks with steep or flat corneas, etc.

Chapters 3-11

  • The rest of the book discusses the different refractive surgery techniques, pre-op and post-op considerations, and management of complications.
  • While the actual step-by-step procedure for refractive surgery techniques may not necessarily be tested, the principles and indications are definitely fair game.  Systemic and ocular diseases that may affect patients seeking refractive surgery would be an area I would consider making up test questions.
  • Conceptual examples:  What are the complications associated with LASIK?  With PRK?  With femtosecond laser-guided LASIK?  What considerations should be added to LASIK evaluation in patients with diabetes?  HIV/AIDS?  Rheumatoid arthritis?
  • Other topics of focus to consider:  intracorneal refractive surgery, non-cataract intraocular lenses, etc.

Retina and Vitreous:  BCSC Section 12 (Retina and Vitreous)

Basic Info

  • This section comprises 14% of the test (35 questions).
  • Stating the obvious here, retina has the most questions out of all the subspecialties in ophthalmology.  If there's going to be one subject that you know better than any other, retina would be a good one to know.

Chapter Breakdowns

Chapters 1-3

  • As you've probably figured out by now, the first chapters discuss anatomy and physiology, as well as describe the pertinent diagnostic tests used to evaluate the structure (in this case, the retina).
  • While you may get lucky and have a question or two of straight anatomy recall, more likely you'll have to interpret diagnostic tests as part of answering a particular question, or recall some detail of the actual test.  Since most ophthalmologists have to be somewhat capable of interpreting OCTs and the like, it's pretty important to make sure you have a comfortable level of knowledge of these chapters.
  • Conceptual examples:  What are the functions of the RPE?  What are the functions of choroidal circulation?  What are the contraindications for fluorescein angiography?  For indocyanine green angiography?
  • Other topics of focus to consider:  OCT, ERG, EOG, fundus autofluorescence, color vision, etc.

Chapters 4-15

  • This is the main portion of the Retina book.  Not much to say here, except to just follow the content outline.
  • While there may be a few questions on the rare stuff, primarily I would focus on the common diseases, those conditions that are associated with systemic manifestations, sight-threatening or life-threatening diseases, and diseases we understand really well (i.e., lots of studies or characteristic data about it).
  • Interestingly, no retina studies were listed as "need to know" on the content outline.  Perhaps it's because there are too many to list?  Regardless, for evidence-based clinical practice it's probably expected that you will know most of the major retina studies out there.
  • Conceptual examples:  There really are too many examples to list here.  If you're having trouble figuring out what things to focus on, send me an e-mail and I'll try to be more specific.

Chapters 16-17

  • The last two chapters of the retina book discuss the role of lasers and surgery in management of retinal disease.
  • Because medical decision-making is pretty important (I don't know where they get that idea), I would guess that questions about these chapters would revolve around the indications for treatment.
  • Conceptual examples:  What are appropriate indications for laser photocoagulation?  What are the potential complications for laser photocoagulation?  In what situations would intraocular gas be preferable to silicone oil, and vice versa?  What are the indications for pars plana vitrectomy?  What are complications associated with pars plana vitrectomy?
  • Other topics of focus to consider:  transpupillary thermotherapy, photodynamic therapy, etc.

Uveitis:  BCSC Section 9 (Intraocular Inflammation and Uveitis)

Basic Info

  • This section comprises 6% of the test (15 questions).
  • This is the smallest section of the test.  While it may be less "important" in the sense of less test questions, it still has some important information that you need to know as a comprehensive ophthalmologist.
  • On the whole, the uveitis book is very wordy in comparison with the other books.  This means that there are definitely parts of the book you can skim.

Chapter Breakdowns

Chapters 1-4

  • The first 4 chapters are a review of basic immunology.
  • You probably won't find a whole lot of testable-type material in this section that you wouldn't find in other sections.  So for brevity, you could probably get by skipping these chapters without missing out on too many questions.
  • If you just really want to learn this stuff well, here are some conceptual questions you might want to know.
  • Conceptual examples:  What are the different types of immune cells, and what are their roles?  What is innate immunity, and what are some clinical examples?  What is adaptive immunity, and what are some clinical examples?
  • Other topics of focus to consider:  hypersensitivity reactions, all clinical examples, immune responses within the eye, animal models of uveitis and what human diseases they mimic, etc.

Chapters 5-11

  • When it comes to the rest of the Uveitis book, the content outline should help you narrow down the conditions you need to study and know well.
  • You can relax that you probably won't be tested on Chikungunya fever or other less common causes of uveitis.  Even with white dot syndromes, you will only need to know the most well-known.
  • I would try to find images to help illustrate what some of these basic uveitides look like.  Since many forms of uveitis will look similar, often the test questions are going to be asking differential diagnosis or management-type questions.  If there is a uveitis that has a characteristic appearance, that may be a good test question.
  • Thankfully, you don't absolutely need to know any studies (though the Endophthalmitis Vitrectomy Study is pretty important).
  • Conceptual examples:  There really are too many examples to list here.  If you're having trouble figuring out what things to focus on, send me an e-mail and I'll try to be more specific.

Hope this is helpful!  Do you have any other tips, comments, or suggestions?  Contact me and I'll add it to the article!