You are an FY2 in a GP surgery
Personal Details:
Name: George Miller
Age: 60
Medical Record:
Past medical history: Hypertension (well-controlled). Cataract surgery in the right eye 2 months ago.
Regular medication: Ramipril.
Allergies: None known.
Notes:
A 60-year-old man presents with a vision problem
Task:
1. Take a focused history of his visual symptoms.
2. Perform a relevant eye examination.
3. Explain the suspected diagnosis and the need for immediate referral.
Opening Sentence: “Doctor, something’s wrong with my right eye. It’s like a curtain is coming across my vision.”
Open History (to give freely): “It started two days ago. I suddenly saw a shower of black dots, like little floaters, and then it was like a dark shadow or a curtain started to spread across the side of my vision. It’s not painful, but it’s very frightening.”
Cues to give: “I had my cataract done in that eye a couple of months ago. Could it be related to that?”
ICE (Ideas, Concerns, Expectations):
Ideas: “I have no idea what’s happening. I thought my vision was meant to be better after the cataract surgery.”
Concerns: “Am I going to be blind? What is happening to me?”
Expectation: “I need you to tell me what’s wrong and what can be done about it.”
How to Act: You are very anxious and scared of losing your sight.
More History (only if asked): The shadow is on the side of your vision closest to your nose. You have not experienced flashing lights. There is no pain, redness, or discharge. You have had no head injury. Your other eye is fine.
Social History: You are a retired accountant. You are a driver.
Questions to ask:
“What do you mean, the back of my eye has come away?”
“What will happen if I don’t go to the hospital?”
Examination findings:
Reduced visual acuity on the right eye
Opening & Focusing on the Emergency:
Thank you for coming in. Tell me exactly what’s been happening with your eye.
History of Presenting Complaint: You mentioned flashing lights. Are they in one eye or both? What about the floaters? Are these new? Are there lots of them, like a shower of spots?
Tell me more about this curtain or shadow. Where did it start? Which way is it moving? Is your central vision, what you see when you look straight ahead, affected?
Have you had any pain in the eye or any injury to your head or eye?
Risk Factors: “Do you wear glasses? Have you ever had any eye surgery in the past?
ICE (Ideas, Concerns, Expectations): “What were your own thoughts about what could be causing this? What is your biggest worry? What were you hoping I could do for you today?
Examination: Assess visual acuity, visual fields (confrontation), and perform fundoscopy (looking for the detached retina and assessing for an abnormal red reflex).
Explain the possible diagnosis:
Thank you for coming in so promptly. This sounds very alarming, and you’ve done the right thing by coming straight here.”
(After examination) (general external eye examination, fundus examination, visual acuity)
Your vision is reduced in the right eye, and when I looked into the back of the eye, the normal red glow we expect to see was abnormal. Based on your symptoms – the sudden floaters and the curtain-like shadow – I am very concerned that you have a condition called retinal detachment. This is where the thin, light-sensitive layer at the very back of your eye, the retina, has started to peel away from the wall of the eye.
Addressing and answering the patient’s ICE:
You’re asking if you’re going to go blind. This is a very serious, sight-threatening condition that needs to be treated as an emergency. If we don’t act quickly, you could permanently lose the vision in your right eye. However, if we get you to the eye specialists immediately, they have surgical treatments that can reattach the retina and save your sight.
Next Steps:
I am going to call the on-call ophthalmologist at the eye hospital right now. You need to go directly to the hospital today for an urgent assessment by the specialists. They will perform a more detailed examination and will likely arrange for surgery to fix the detachment, possibly as soon as today or tomorrow.”
Driving advice until assessed
“You must not drive. You should arrange for someone to take you to the hospital. While you are waiting, it’s best to rest and avoid any strenuous activity or jerky head movements.
You asked if this is related to your cataract surgery. Yes, it can be. Cataract surgery is a known risk factor for developing retinal detachment in the months or years following the procedure. It doesn’t mean the surgery went wrong, but it is a recognised complication.
Addressing ideas, concerns, and expectations: Provide a clear, suspected diagnosis. Be direct and honest about the seriousness of the condition and the risk of blindness to ensure compliance.
The management is a single, critical action: an immediate, same-day emergency referral to the on-call ophthalmology team. Provide clear instructions: go directly to the hospital, do not drive.
What is the scenario testing: This case tests the candidate’s ability to recognise a sight-threatening emergency. It requires focused history-taking, basic ophthalmological examination skills, and the ability to communicate the urgency of the situation to the patient to ensure they go to the hospital immediately. The key is conveying seriousness without causing undue panic.