History Taking · Foundation · Ophthalmology

Gradual Vision Loss and Peripheral Defects

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

Clinical scenario

You are an FY2 doctor in primary care. Mrs Jessica Snow, a 64-year-old woman, has attended for routine blood pressure check. She casually mentions she has noticed her side vision seems to have gotten worse over the past 18 months. Please take a focused history of her vision loss and discuss referral for specialist assessment.

Background notes: PMH: Hypertension, Hypercholesterolaemia, Bilateral cataract surgery

What this station tests

  • Recognising insidious bilateral peripheral visual field loss as the hallmark of open angle glaucoma
  • Distinguishing from other causes of gradual visual loss: cataracts (already treated), macular degeneration (central, not peripheral)
  • Treatment does not restore lost vision but prevents further deterioration: this is the key message for the patient
  • Risk factor assessment: age, family history, ethnicity, myopia, hypertension, diabetes
  • DVLA implications: significant visual field loss may require notification and driving assessment

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

Open angle glaucoma is often detected incidentally because it is painless and progressive. The candidate must recognise the significance of gradual peripheral visual field loss, arrange appropriate referral, and communicate the importance of treatment to a patient who does not feel unwell. Mrs Snow is 64, attending for a BP check, who casually mentions her side vision has been getting worse for 18 months. Open with: 'Mrs Snow, you mentioned your side vision has changed. That is actually something I want to explore further. Can you tell me more about what you have noticed?'

Core approach

Characterise the visual field loss. Gradual, bilateral, peripheral vision loss over 18 months. Her husband noticed before she did (bumping into things on the side). Central vision preserved. No pain, no redness, no floaters, no flashes. This painless, insidious, bilateral peripheral field loss is the hallmark of open angle glaucoma. She is not concerned because she attributes it to ageing.

Risk factors: age over 40 (yes, 64), family history of glaucoma (ask), Afro-Caribbean ethnicity (higher risk), myopia (short-sightedness), diabetes, hypertension (she has both hypertension and hypercholesterolaemia). Previous cataract surgery (she has had bilateral cataracts operated).

She has not had an eye pressure check or formal visual field test. Her optician checks were for glasses prescription and cataracts, not glaucoma-specific assessment. This is a common pathway: patients assume optician visits cover everything.

Distinguish from other causes of gradual visual loss: cataracts (already treated), macular degeneration (central vision, not peripheral), optic nerve compression (unilateral, progressive).

Closing and safety netting

Explain the concern clearly but without alarm. 'The gradual loss of side vision over 18 months is something that needs specialist assessment. One possible cause is a condition called glaucoma, where the pressure inside the eye damages the optic nerve. It is very common and very treatable, but it does need to be diagnosed and managed by an eye specialist.'

Arrange urgent optometry or ophthalmology referral. She needs: intraocular pressure measurement (tonometry), formal visual field testing (perimetry), optic disc assessment. If confirmed: treatment is usually eye drops (prostaglandin analogues like latanoprost) to lower intraocular pressure. Treatment does not restore lost vision but prevents further deterioration.

Address the key message: 'Glaucoma does not give you warning symptoms. The fact that you have noticed changes means it is important to act now to prevent further loss.' DVLA: if visual fields are significantly affected, she may need to notify DVLA. Safety net: 'If you notice sudden vision loss, eye pain, or flashing lights, come in urgently.' Follow-up after ophthalmology review.

How examiners mark this station

Examiners will focus on the thoroughness and structure of your history taking for open angle glaucoma. 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: Peripheral field loss characterised (bilateral, gradual, painless). Risk factors assessed. Other causes considered and excluded. Functional impact assessed. Driving assessed.

Costs marks: Dismissing as ageing. Not assessing risk factors. Not considering other causes.

Domain 2: Clinical Management Skills (Primary focus)

Scores well: Urgent ophthalmology referral. Correct investigations listed (tonometry, perimetry, disc assessment). Treatment principle explained (prevent further loss). DVLA mentioned.

Costs marks: No referral. Not knowing the investigations. Not explaining treatment principle. Missing DVLA.

Domain 3: Interpersonal Skills (Throughout)

Scores well: Taking her casual mention seriously. Explaining significance without alarming. Empowering her to act now. Correcting the 'just ageing' assumption respectfully.

Costs marks: Dismissing her concern. Being alarmist. Not explaining why this matters. Letting her leave without referral.

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. Dismissing the visual field loss as normal ageing. Gradual bilateral peripheral visual field loss is not normal ageing. Candidates who reassure without investigating miss a treatable cause of blindness.
  2. Assuming optician visits covered glaucoma screening. Routine optician checks for glasses do not always include tonometry or visual field testing. Candidates who say 'your optician would have found it' provide false reassurance.
  3. Not explaining that treatment prevents further loss but does not restore vision. Patients need to understand that early treatment preserves current vision. Delay means permanent, irreversible loss.

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 do I approach the consultation in this open angle glaucoma station?

Open angle glaucoma is often detected incidentally because it is painless and progressive. The candidate must recognise the significance of gradual peripheral visual field loss, arrange appropriate referral, and communicate the importance of treatment to a patient who does not feel unwell. Mrs Snow is 64, attending for a BP check, who casually mentions her side vision has been getting worse for 18 months.

What does a strong performance look like to the examiner in this station?

Strong performances show: Peripheral field loss characterised (bilateral, gradual, painless). Risk factors assessed. Other causes considered and excluded. Functional impact assessed. Weak performances: Dismissing as ageing. Not assessing risk factors. Not considering other causes.

What is the biggest pitfall in this open angle glaucoma station?

Dismissing the visual field loss as normal ageing. Gradual bilateral peripheral visual field loss is not normal ageing. Candidates who reassure without investigating miss a treatable cause of blindness.

How should I prepare for open angle glaucoma if I have never seen it in practice?

This station rewards process over personal experience. The skill being assessed: Distinguishing from other causes of gradual visual loss: cataracts (already treated), macular degeneration (central, not peripheral). Use the domain breakdown on this page to target your preparation, then practise the station aloud so your structure survives exam pressure.

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