Vinesh Mistry 1* (Ranked #6, 2025) and Oluwaseun Akinniranye 2* (Ranked #8, 2024)
* Joint first authors
1 Anglia Ruskin University, School of Medicine, Chelmsford, UK
2 Princess Alexandra Hospital NHS Trust, Harlow, UK
Introduction
The Duke Elder Undergraduate Prize Examination is commonly regarded as the most prestigious ophthalmology exam available to medical students. Run annually by the Royal College of Ophthalmologists (RCOphth), the examination attracts candidates from across the UK and increasingly from overseas, many of whom undertake it despite having had limited formal exposure to ophthalmology (1).
The exam is a virtual, 2-hour, 90-question multiple-choice examination with a syllabus extending well beyond undergraduate teaching; all candidates receive a numerical score and national ranking after results are published- this determines the assessment outcome for each student (1). Questions are mostly based on clinical ophthalmology, but other areas covered include ocular physiology, anatomy, pharmacology, basic science, statistics, pathology, embryology, genetics and socio-economic medicine relevant to ophthalmology (2).
The core clinical topics include (2):
- Cornea and external eye disease
- Cataract
- Glaucoma
- Medical retina & vitreo-retinal surgery
- Strabismus & paediatric ophthalmology
- Neuro-ophthalmology
- Ocular adnexal & orbital disease
- Refractive errors & optics
Ophthalmology remains one of the most competitive specialties in the UK. In 2025, there were 2,197 applicants for 102 specialty training (ST1) posts, giving a competition ratio of 21.54:1 (3). In this context, early portfolio differentiation is increasingly important.
In the ST1 Ophthalmology portfolio, national undergraduate prizes awarded through competitive examination can score up to 3 points (4):
- 1st place → 3 points
- Top 10% → 2 points
- Top 20% → 1 point
Crucially, for a prize to count, applicants must demonstrate that the exam is national and that over 400 candidates sat it (4). This requirement is rarely met by undergraduate prizes, making the Duke Elder examination one of the very few reliable opportunities for medical students to score portfolio points at this level.
Preparing for the Duke Elder exposes you to the full breadth of ophthalmology, far beyond clinic taster weeks. Many students only realise during revision whether they genuinely enjoy areas such as optics, neuro-ophthalmology, and visual science. For both of us, Duke Elder preparation was pivotal in confirming that ophthalmology was the right career choice.
A retrospective study published in Eye (2011) analysed Duke Elder exam performance between 1989-2005 and subsequent careers (5). Approximately 30% of top-20 candidates entered ophthalmology training, with higher rates among repeat top-20 performers(5). While the exam alone does not determine career progression, it functions as a meaningful academic signal rather than a superficial prize.
In 2025, approximately 650 candidates sat the exam. This is less than previous years and can partly be explained by the rising cost to sit the exam. In 2022, the exam cost £25; in 2023-2024, the exam cost £50; in 2025 and now 2026, the exam cost £65. With rising costs and lower total number of students in the top 20% bracket, it seems it is becoming even more difficult to make the time and effort spent on the exam worthwhile. Having both sat the exam and ranked in the top ten internationally, we present this article as a complete, step-by-step guide on the optimise performance in the Duke Elder exam.
Historically, the Duke Elder exam was held in March, making preparation difficult alongside university exams. However, since 2024, it has moved to September, a major advantage that allows candidates to use the summer period strategically for focused revision. A 3-6 month preparation window is realistic for most students. This article will be assuming the whole 6-month period is used for preparation, however this can be altered depending on your speed of learning, prior ophthalmology knowledge, as well as your other commitments.
Timeline
Months 1-2 (March-April): Build foundations
A common mistake is jumping straight into difficult question banks. A graduated approach works best. You don’t have to go all out here; just making sure you have a strong understanding of the undergraduate ophthalmology curriculum. Your medical school Ophthalmology slides as well as the traditional online question-banks (Passmed/ Quesmed) are more than sufficient at this stage (6,7).
Months 3-4 (May-June): Duke Elder-specific learning
Now is the best time to begin the more focussed revision. Beginning this now can ensure that, even with summer plans/ possible medical elective, you won’t need to rush your preparation and compromise your relaxation.
The Moorfields Duke Elder Revision Course is a great place to start. It typically runs in mid-June (e.g. mid-June 2025) and is delivered over Zoom as a 2-day course, making it an ideal mid-point anchor to identify high-yield topics early (8). It is normally ~£25, however is highly praised due to the how much high yield content is normally covered. The lecturers selected would have all ranked in the top-24 candidates, meaning you are getting the advice from students who recently have achieved what your goal is. The course recording is normally released to attendees, meaning the content can be rewatched closer to the time of the exam.
To structure your revision over summer, there many good textbooks and resources for this exam that are mentioned in the Duke Elder Candidate Info Pack (2). From personal experience, both authors agree that the “The Duke Elder Exam of Ophthalmology: A Comprehensive Guide for Success” textbook, which can be purchased on Amazon, reaches a good level of depth whilst covering a suitable range of topics (9,10). Using a textbook to structure your revision throughout Summer is a smart idea for distributing learning and making it feel manageable.
Supplementing your textbook revision with the courses led by university societies, can improve engagement. These courses normally run virtually however have the advantage that they are usually free. Many societies will run some kind of course over summer for the exam, however, the University of Cambridge Ophthalmology Society Course showed the most potential from our personal experience; it was well-structured, ran by clinicians, and offered a spread-out, reliable, supplemental learning (11).
Months 5-6 (July-August): High-yield questions and mock exams
July is a great chance time to start integrating active learning, to begin solidifying your knowledge. This can be achieved through a combination of flashcards and practice questions.
As you work through textbooks and teaching courses, actively identify topics you repeatedly struggle with. Converting these into flashcards, especially any high-yield material highlighted in courses or frequently tested questions, enables targeted, spaced repetition. Tools such as Anki are particularly effective, automating spaced review so difficult concepts are revisited efficiently without overwhelming your schedule (12).
Questions should make up the bulk of your learning at this point. PREP Duke Elder Question Bank is an excellent place to start testing yourself (13). PREP Duke Elder costs ~£60 and focusses on high yield questions, however it is important to note that it isn’t as difficult as some of the later resources and is not fully representative of the real exam. Despite this, it is an excellent stepping stone from flashcards/ textbook to active learning. PREP Duke Elder includes an online textbook that makes learning from your mistakes much more manageable.
Once you have completed enough questions that you feel reasonably comfortable with PREP Duke Elder, Eyedocs is the next step (14). This resource is renowned for being very similar to real exam. Similar to the PREP Duke Elder question-bank, it costs ~£60. It asks high-yield, difficult questions that represent the exam very accurately. Don’t be put-down if your marks aren’t as high as you expected; remember, the thresholds for top decile aren’t as high as you may expect.
In order to perfect your performance under timed conditions, it is suggested to complete the below, recommend mocks in the exact same exam-conditions as the real assessment. There are multiple which prove representative of the exam, and can be found on Amazon:
- 180 MCQs for the Duke Elder Examination (15)
- 300 MCQs For The Duke Elder Ophthalmology Exam (16)
- End of Book Mock on “The Duke Elder Exam of Ophthalmology: A Comprehensive Guide for Success” (9)
A week before the exam, you will be contacted for system testing and reminded of the regulations enforcing the exam.
On-the-Day Exam Strategy
The Duke Elder exam is sat remotely from home as an online proctored examination (2). Ensure that:
- You have re-familiarised yourself with the regulations.
- You are in a quiet, familiar environment
- You have strong Wi-Fi, with a mobile hotspot backup
- You are on time
- You have the photographic evidence mentioned by RCOphth
- Your laptop/desktop camera and phone camera are correctly positioned for the invigilator
The exam is notoriously unpredictable, with unfamiliar content appearing every year. This is expected and affects everyone equally; do not let it unsettle you. Remember, you do not need an exceptionally high percentage to score well. Previous years suggest that ~65% has often been sufficient to place candidates in the top 10%. Given the volume of content, candidates often perform better by being calm and well-rested, rather than overstressed.
Conclusion
The Duke Elder exam is challenging but highly rewarding. It offers rare and high-value portfolio points, early insight into ophthalmology as a career, and a strong academic foundation for future training. With strategic preparation, any motivated student can score highly. Best of luck!
References
1. Duke Elder Undergraduate Prize Examination [Internet]. The Royal College of Ophthalmologists. [cited 2025 Dec 27]. Available from: https://www.rcophth.ac.uk/examinations/duke-elder-undergraduate-prize-examination/
2. THE ROYAL COLLEGE OF OPHTHALMOLOGISTS.
3. NHS England | Workforce, training and education | Medical Hub [Internet]. [cited 2025 Dec 27]. 2025 Competition ratios | Workforce, training and education | NHS England. Available from: https://medical.hee.nhs.uk/medical-training-recruitment/medical-specialty-training/competition-ratios/2025-competition-ratios
4. Evidence Folder – Severn PGME [Internet]. [cited 2025 Dec 27]. Available from: https://www.severndeanery.nhs.uk/recruitment/vacancies/show/oph-st1-26/evidence-folder-lib
5. Joshi L, Shanmuganathan VA, Kneebone RL, Amoaku W. Performance in the Duke–Elder ophthalmology undergraduate prize examination and future careers in ophthalmology. Eye [Internet]. 2011 Aug [cited 2025 Dec 27];25(8):1027–33. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC3178229/
6. Quesmed [Internet]. [cited 2025 Dec 27]. Quesmed: UKMLA, MRCP & PLAB Question Bank Platform. Available from: https://quesmed.com/
7. Passmedicine [Internet]. [cited 2025 Dec 27]. Available from: https://www.passmedicine.com/#
8. Duke Elder preparatory course [Internet]. [cited 2025 Dec 27]. Available from: https://checkout.moorfields.nhs.uk/product?catalog=Duke-Elder
9. Khalil M, Kouli O, editors. The Duke Elder Exam of Ophthalmology: A Comprehensive Guide for Success. Boca Raton: CRC Press; 2019. 248 p.
10. The Duke Elder Exam of Ophthalmology: A Comprehensive Guide for Success eBook : Khalil, Mostafa, Kouli, Omar: Amazon.co.uk: Books [Internet]. [cited 2025 Dec 27]. Available from: https://www.amazon.co.uk/Duke-Elder-Exam-Ophthalmology-Comprehensive-ebook/dp/B07RYN68KP
11. X (formerly Twitter) [Internet]. [cited 2025 Dec 27]. Cambridge Ophthalmology Student Society (@cam_ophthal_soc) / X. Available from: https://x.com/cam_ophthal_soc
12. Anki – powerful, intelligent flashcards [Internet]. [cited 2025 Dec 27]. Available from: https://apps.ankiweb.net/
13. Complete digital textbook and question bank – PREP Duke Elder [Internet]. [cited 2025 Dec 27]. Available from: https://prepdukeelder.com/
14. Eyedocs [Internet]. [cited 2025 Dec 27]. The Online Ophthalmology Community – Welcome to Eyedocs. Available from: https://www.eyedocs.co.uk/
15. 180 MCQs for the Duke Elder Examination eBook : Blackburn, Benjamin , Kanda, Mumta, Sprogyte, Lina: Amazon.co.uk: Books [Internet]. [cited 2025 Dec 27]. Available from: https://www.amazon.co.uk/180-MCQs-Duke-Elder-Examination-ebook/dp/B082K99P3G
16. 300 Mcqs For The Duke Elder Ophthalmology Exam: Amazon.co.uk: Patel, Anmol, Abdulhussein, Dalia, Kalkat, Harkaran, Sim, Peng Yong: 9789811233050: Books [Internet]. [cited 2025 Dec 27]. Available from: https://www.amazon.co.uk/MCQs-Duke-Elder-Ophthalmology-Exam/dp/9811233055