By Dr. Jignesh M. Gala — Vitreoretinal & Cataract Surgeon, Crystal Clear Eye Clinic, Andheri West, Mumbai
In 2016, after a multi-stage examination process that tested my knowledge of visual sciences, optics, instruments, clinical ophthalmology, and live clinical decision-making, I was admitted as a Fellow of the International Council of Ophthalmology — entitling me to use the post-nominal letters FICO after my name.
This is, in my view, one of the more unusual qualifications a working ophthalmologist can hold. Most medical postgraduate examinations are national: they certify competence within the standards of a single country’s healthcare system. The FICO is different. It is, as the ICO itself describes, the only worldwide medical-specialty examination — a single examination standard, sat in over 80 countries, that does not belong to any one nation’s training apparatus.
This post is about that examination — what it is, why it exists, and what it tested.
What the International Council of Ophthalmology Is
The International Council of Ophthalmology (ICO) is the global representative body for ophthalmology. Founded to connect ophthalmologists worldwide and to harmonise standards of eye care across countries, it serves as the international counterpart to the various national ophthalmological societies and royal colleges. Its examinations are unique in modern medicine: they are independent of any single national training system, can be taken in the candidate’s own country at over 80 examination centres worldwide, and are free of the geographic or political constraints that affect almost every other medical-specialty examination.
In practice, this means that an ophthalmologist sitting the ICO examinations in Mumbai is taking the same examination as a candidate sitting in São Paulo, Cairo, Manila, Lagos, or Toronto on the same day. The questions are identical. The marking standard is identical. The pass mark is identical.
This is part of what gives the FICO its weight as a credential. It is, by design, a level playing field.
The Pathway to the FICO
To be admitted as a Fellow of the ICO, a candidate must successfully pass:
- Part A — Visual Sciences (one of the ICO Standard Examinations)
- Part B — Optics, Refraction and Instruments (Standard)
- Part C — Clinical Ophthalmology (Standard)
- The Advanced ICO Examination (the “Advanced 115”) — only available to candidates who have cleared all three Standard parts
- A local face-to-face ophthalmology examination recognised by the ICO
Only candidates who pass every one of these components — including the in-person clinical assessment — are entitled to use the FICO designation. Here is what each component involved.
Part A — Visual Sciences
The Visual Sciences examination is the gateway. It is a 120 multiple-choice question paper, single best answer from four options, testing the basic-science underpinnings of ophthalmology:
- Anatomy and embryology of the eye, orbit, and visual pathway
- Physiology of vision, including phototransduction and binocularity
- Biochemistry of the lens, cornea, and tear film
- Ocular microbiology and immunology
- Genetics relevant to inherited eye disease
It is the part of the examination that most reflects undergraduate-style learning, and for many candidates it is the first proper test of whether they truly understand the foundations of the discipline they have chosen.
Part B — Optics, Refraction, and Instruments
The second written examination tests the applied physics of ophthalmology. Optics is, in many ways, the part of medicine that ophthalmologists are uniquely required to master — no other specialty depends so completely on understanding lenses, light, refraction, and the optical performance of clinical instruments.
The syllabus covers geometric and physical optics, the design and use of clinical instruments (slit lamps, ophthalmoscopes, retinoscopes, perimeters, OCT machines), refraction techniques, and the principles behind intraocular lens calculation and refractive surgery. For a candidate who has spent more time on retina than on retinoscopy, this examination demands serious revision.
Part C — Clinical Ophthalmology
The third examination is the most demanding of the three Standard papers. 200 multiple-choice questions over a four-hour examination period, single best answer from four options, covering the full breadth of clinical ophthalmology:
- Cornea and external eye disease
- Cataract and refractive surgery
- Glaucoma
- Uveitis and ocular inflammation
- Medical and surgical retina
- Neuro-ophthalmology
- Oculoplastic and orbital disease
- Paediatric ophthalmology and strabismus
- Ocular oncology
The ICO describes the examination’s purpose as testing whether candidates have “acquired the breadth and depth of knowledge of the clinical sciences related to ophthalmology to enable them to recognise and treat diseases of the eye which they will come in contact with in day-to-day practice.”
Passing this examination on its own is a meaningful achievement. It is, however, not yet enough for the FICO.
The Advanced Examination
After passing all three Standard parts, candidates become eligible to sit the Advanced ICO Examination. This is a separate written examination — more challenging in question structure, integrative across subspecialties, and designed to confirm that the candidate’s clinical knowledge is consistent at a high level across every area of ophthalmology, not only within the parts where they happen to have done their specialty training.
Combined with a local face-to-face ophthalmology examination — a clinical or oral assessment recognised by the ICO — successful candidates are then entitled to use the post-nominal FICO.
A Note on the ICO–Glasgow Pathway
One feature of the ICO examinations worth mentioning is that, by formal agreement between the ICO and the Royal College of Physicians and Surgeons of Glasgow, candidates who pass the ICO Standard Examinations become eligible to apply for the final clinical FRCS Ophthalmology examination of RCPSG — bypassing the first two parts of the FRCS pathway. The two bodies have, for years, partnered to recognise this equivalence.
For me, this collaboration mattered. The ICO process that culminated in my FICO in 2016 was, in many ways, the foundation on which my FRCS (Glasgow), completed two years later in 2018, was built. The two qualifications, although awarded by different bodies, are linked by a shared commitment to standardising what an internationally competent ophthalmologist should know — and the journey from the first to the second is, for many candidates around the world, a deliberate sequence rather than two unrelated qualifications.
Why the FICO Matters
In a world of national medical examinations, the FICO offers something genuinely rare: a single, transparent, geography-neutral standard of ophthalmic competence that is recognised across countries and continents. For patients, the meaning is straightforward. An ophthalmologist who holds the FICO has been examined against the same benchmark as ophthalmologists in eighty other countries — and has passed every part of that examination.
For me, sitting the ICO examinations forced a kind of intellectual discipline that I had not, until then, fully experienced. The Standard exams demanded a rebuilding of basic-science knowledge from the ground up. The Advanced exam demanded I demonstrate that knowledge consistently, under timed conditions, across every subspecialty of the eye. And the face-to-face clinical examination demanded I do all of this while examining a patient, in real time, under examiner scrutiny.
I came out of the process a more rigorous clinician. Nearly ten years on, I still feel the influence of that preparation in the way I approach unfamiliar cases at Crystal Clear Eye Clinic today.
About the Author
Dr. Jignesh M. Gala is a vitreoretinal and cataract surgeon based at Crystal Clear Eye Clinic, Andheri West, Mumbai. He holds FICO (London) from the International Council of Ophthalmology (2016), MRCS (Edinburgh) and FRCS (Glasgow) — dual Royal College surgical qualifications from the United Kingdom (both 2018). He completed dual fellowships in Comprehensive Ophthalmology and Medical & Surgical Retina at L V Prasad Eye Institute, Hyderabad, and served as a Resident Physician with the Department of Ophthalmology, Woodlands Health (NHGEI), Singapore (2021). He has been a peer reviewer for BMJ Case Reports since November 2019.
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