History Taking · Foundation · Ophthalmology

Flashing Lights and Shadow in the Eye

Practise this PLAB 2 history taking station on Retinal Detachment. 8-minute voice AI simulation with feedback on all 3 marking domains.

Clinical scenario

You are an FY2 doctor in a GP surgery. Mr Obi Osei, a 62-year-old man, has come to see you urgently complaining of sudden onset flashing lights and floaters in his left eye. He has also noticed a dark shadow or curtain in his peripheral vision. Please take a focused history and discuss your management plan with the patient.

Background notes: PMH: High myopia since teenage years (approximately minus 6 dioptres)

What this station tests

  • Recognising the retinal detachment triad: flashes (photopsia), floaters, and shadow/curtain (progressive visual field loss)
  • High myopia as the strongest risk factor for retinal detachment
  • Same-day emergency ophthalmology referral: time-critical, especially if macula is still attached
  • Macular status determining visual prognosis: macula-on detachment has better outcome if repaired within 24 hours
  • Practical advice while waiting: keep head still, no sudden movements, no heavy lifting

How to use your 8 minutes

  • 0-1 min — Introduction: Introduce yourself, confirm identity, open question. 'What's brought you in today?'
  • 1-4 min — Systematic History: Presenting complaint detail (SOCRATES for pain, timeline, severity). Systems review. PMH, medications, allergies.
  • 4-6 min — Context and ICE: Social history (smoking, alcohol, occupation, living situation). Family history. Ideas, Concerns, Expectations.
  • 6-7 min — Summary and Plan: Summarise findings back to patient. Share differential/working diagnosis. Outline investigation and management plan.
  • 7-8 min — Closing: Safety netting with specific red flags. Arrange follow-up. Check for questions.

Consultation approach

The opening

Retinal detachment is an ophthalmic emergency. The classic triad is flashes, floaters, and a shadow or curtain across the vision. The candidate must recognise this immediately and arrange same-day ophthalmology referral. Mr Osei is 62, high myopia, presenting with sudden flashes, floaters, and a dark shadow in his left eye this morning. Open with: 'Mr Osei, those symptoms need urgent assessment. Tell me exactly what happened this morning.'

Core approach

The presentation is textbook. Sudden onset this morning: flashing lights in the left eye (photopsia from vitreous traction on retina), followed by a shower of dark floaters (pigment released from retinal tear), then a dark shadow or curtain appearing in the peripheral vision and progressing (detaching retina). Vision in the central field may still be preserved (macula not yet involved) or already affected. No pain (retinal detachment is painless).

Risk factors: high myopia (minus 6 dioptres) is the strongest risk factor for retinal detachment. Age over 50 (vitreous liquefaction increases risk). Ask about recent trauma (none), previous eye surgery (cataract surgery increases risk), family history of detachment.

The urgency depends on macular involvement. If the macula is still attached (central vision preserved), surgery within 24 hours gives the best visual outcome. If the macula has detached (central vision lost), surgery is still urgent but prognosis for central vision is worse. This makes time critical.

Do not delay for examination. In primary care, the priority is recognition and referral, not detailed fundoscopy.

Closing and safety netting

Arrange same-day emergency ophthalmology referral. 'Mr Osei, the combination of flashing lights, floaters, and the shadow across your vision strongly suggests a retinal detachment. This needs emergency assessment and very likely surgery today or tomorrow. I am contacting the eye hospital now.'

While waiting: advise him to keep his head still and avoid sudden movements (to prevent further detachment). No heavy lifting or straining. The ophthalmologist will determine the surgical approach (vitrectomy or scleral buckle).

Address his fear: 'Retinal detachment is treatable with surgery. The sooner it is repaired, the better the chance of preserving your vision. That is why we are acting so quickly.' Safety net: 'If the shadow spreads to cover more of your vision while waiting, go directly to the eye casualty.' Do not delay for routine investigations.

How examiners mark this station

Examiners will focus on the thoroughness and structure of your history taking for retinal detachment. Domain 1 (Data Gathering) carries the most weight: expect marks for systematic coverage of presenting complaint, red flags, PMH, medications, social and family history. Domain 2 (Clinical Management) requires a clear differential, appropriate investigations, and a safe management plan with safety netting. Domain 3 (Interpersonal Skills) is assessed throughout: genuine exploration of ICE, active listening, empathic responses, and clear communication without jargon.

Domain 1: Data Gathering, Technical and Assessment Skills (Primary focus)

Scores well: Triad recognised immediately (flashes, floaters, shadow). Risk factors identified (high myopia). Macular status assessed (is central vision preserved?). Onset timing noted (this morning, hours matter).

Costs marks: Not recognising the triad. Not identifying myopia as risk factor. Not assessing macular status. Delayed recognition.

Domain 2: Clinical Management Skills (Primary focus)

Scores well: Same-day emergency ophthalmology referral. Practical interim advice (head still, no straining). No delay for investigations. Eye casualty safety netting if worsening.

Costs marks: Routine referral. Attempting examination instead of referring. Delaying for investigations.

Domain 3: Interpersonal Skills (Adapted to emergency)

Scores well: Explaining why urgency matters (macula preservation). Providing hope about surgical treatment. Calm, decisive manner. Acknowledging his fear of vision loss.

Costs marks: Being vague about urgency. Not providing hope. Causing panic without action plan.

Common examiner feedback (and how to fix it)

Did not gather sufficient information to make an adequate assessment of the patient's condition

Fix: Use a consistent framework for every history. After covering the presenting complaint, systematically move through PMH, drug history, social history, family history, and ICE. Keep a mental checklist.

Did not identify the patient's problems and/or did not develop a management plan adequately

Fix: Reserve the final 2 minutes to summarise your findings, share your working diagnosis with the patient, and outline your investigation and management plan including safety netting.

Common mistakes in this station

  1. Attempting detailed examination instead of referring immediately. In primary care, the priority is recognition and same-day referral, not fundoscopy. Candidates who spend time examining delay the referral.
  2. Not recognising the triad. Flashes, floaters, and a shadow/curtain is retinal detachment. Candidates who investigate these as separate symptoms rather than recognising the pattern miss the emergency.
  3. Arranging routine or next-day referral. If the macula is still attached, delay of even hours worsens the visual outcome. Same-day ophthalmology assessment is mandatory.

Resitting PLAB 2?

If you have previously struggled with history taking stations, focus on building a consistent systematic framework that you apply to every case. Practise structuring your history into clear phases (presenting complaint, systems review, PMH, social, ICE) so that even under pressure, you cover all domains. Many resitters lose marks not on knowledge but on organisation and time management.

Example opening

Good morning/afternoon, my name is Dr [Name], I'm one of the doctors here today. Could I confirm your name and date of birth please? Thank you. So, what's brought you in to see me today?

Frequently asked questions

How should I structure the retinal detachment history in this PLAB 2 station?

Retinal detachment is an ophthalmic emergency. The classic triad is flashes, floaters, and a shadow or curtain across the vision. The candidate must recognise this immediately and arrange same-day ophthalmology referral.

What are examiners marking in this retinal detachment station?

Marks are won for: Triad recognised immediately (flashes, floaters, shadow). Risk factors identified (high myopia). Macular status assessed (is central vision preserved?). Marks are lost for: Not recognising the triad. Not identifying myopia as risk factor. Not assessing macular status. Delayed recognition.

What is the most common mistake candidates make in this retinal detachment station?

Attempting detailed examination instead of referring immediately. In primary care, the priority is recognition and same-day referral, not fundoscopy. Candidates who spend time examining delay the referral.

How do I prepare for this station if I have not managed retinal detachment in clinical practice?

This station rewards process over personal experience. The skill being assessed: High myopia as the strongest risk factor for retinal detachment. The written guidance on this page covers the full approach, and practising the consultation aloud builds the fluency the examiner is listening for.

Related cases