History Taking · Foundation · Ophthalmology

Sudden Painful Red Eye - Vision Loss

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

Clinical scenario

You are an FY2 doctor in the emergency department. Mr Nigel Jones, a 58-year-old man, has presented with acute-onset right eye pain, blurred vision, and haloes around lights starting 3 hours ago. Please take a focused history and discuss emergency management.

Background notes: PMH: Hypertension, Myopia from childhood

What this station tests

  • Recognising the acute angle closure triad: severe eye pain, blurred vision, haloes around lights
  • Mid-dilated fixed pupil as the key distinguishing sign from other causes of acute red eye
  • Emergency pressure-lowering treatment: pilocarpine, timolol, IV acetazolamide
  • Laser peripheral iridotomy as definitive treatment and prophylactic treatment of the fellow eye
  • Distinguishing from anterior uveitis (small pupil), corneal ulcer (fluorescein), and scleritis (deep boring pain)

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

Acute angle closure glaucoma is an ophthalmic emergency. The candidate must recognise the triad (severe eye pain, blurred vision, haloes around lights), initiate pressure-lowering treatment, and arrange emergency ophthalmology review. Mr Jones is 58, presenting with 3 hours of acute right eye pain, blurred vision, and haloes. Open with: 'Mr Jones, sudden eye pain with vision changes is something we treat as urgent. Tell me exactly what happened.'

Core approach

The presentation is classic. Sudden onset right eye pain (severe, 8 to 10/10), blurred vision in that eye, rainbow haloes around lights, headache (can mimic migraine or even subarachnoid haemorrhage), nausea and vomiting (autonomic response to high intraocular pressure). The unilateral pain with visual disturbance distinguishes this from a headache disorder.

Expected examination findings: red eye (conjunctival injection), hazy cornea (oedema from high pressure), mid-dilated pupil that is fixed or sluggishly reactive, reduced visual acuity. The affected eye feels firmer than the other on palpation (though intraocular pressure measurement by tonometry is definitive).

Distinguish from other causes of acute red eye with pain. Anterior uveitis: photophobia prominent, small pupil (miosis), ciliary flush. Corneal ulcer: fluorescein uptake, history of contact lens use. Scleritis: deep boring pain, sectoral redness. Acute glaucoma: mid-dilated fixed pupil, hazy cornea, severe pain with nausea.

Ask about precipitants: dim lighting (pupil dilation), medications (anticholinergics, sympathomimetics), and whether it has happened before.

Closing and safety netting

This is an emergency requiring immediate treatment. Initiate pressure-lowering drops: pilocarpine 2% (constricts pupil, opens drainage angle), timolol 0.5% (reduces aqueous production), apraclonidine (reduces aqueous production). IV acetazolamide 500mg (systemic pressure reduction). Anti-emetic for nausea. Lie patient supine (can help open the angle).

Arrange emergency ophthalmology review. Definitive treatment: laser peripheral iridotomy (creates drainage pathway, prevents recurrence). The other eye is also at risk and may need prophylactic iridotomy.

Reassure: 'With prompt treatment, the pressure in your eye can be brought down and your vision should recover. The most important thing is that you came in quickly.' Safety net: the treatment pathway is in-built as he is being referred immediately.

How examiners mark this station

Examiners will focus on the thoroughness and structure of your history taking for acute angle closure 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: Classic triad identified. Pupil abnormality noted (mid-dilated, fixed). Corneal haze recognised. Differentials distinguished. Precipitants checked.

Costs marks: Not examining the eye. Attributing to migraine. Not checking the pupil. Not distinguishing from uveitis.

Domain 2: Clinical Management Skills (Primary focus)

Scores well: Emergency pressure-lowering initiated (pilocarpine, timolol, IV acetazolamide). Emergency ophthalmology referral. Iridotomy as definitive treatment. Fellow eye risk mentioned. Anti-emetic.

Costs marks: Not initiating treatment. Delayed referral. Not knowing pressure-lowering agents. Not mentioning fellow eye.

Domain 3: Interpersonal Skills (Throughout)

Scores well: Reassuring about vision recovery with prompt treatment. Acknowledging his fear of blindness. Explaining what is happening in plain terms.

Costs marks: Not addressing blindness fear. Being vague about prognosis. Not explaining the treatment.

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. Attributing the headache and nausea to migraine or SAH. Acute glaucoma causes severe headache and vomiting through autonomic response to high IOP. Candidates who investigate for neurological causes without examining the eye miss the diagnosis.
  2. Not initiating treatment before ophthalmology review. Pressure-lowering drops and IV acetazolamide should be started immediately. Candidates who refer without initiating treatment allow ongoing optic nerve damage.
  3. Not mentioning the fellow eye. The other eye is anatomically predisposed and may need prophylactic iridotomy. Candidates who treat one eye without mentioning bilateral risk demonstrate incomplete understanding.

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

What is the best way to take an acute angle closure glaucoma history in PLAB 2?

Acute angle closure glaucoma is an ophthalmic emergency. The candidate must recognise the triad (severe eye pain, blurred vision, haloes around lights), initiate pressure-lowering treatment, and arrange emergency ophthalmology review. Mr Jones is 58, presenting with 3 hours of acute right eye pain, blurred vision, and haloes.

Where are marks won and lost in this acute angle closure glaucoma station?

Examiners reward: Classic triad identified. Pupil abnormality noted (mid-dilated, fixed). Corneal haze recognised. Differentials distinguished. Precipitants checked. Candidates are penalised for: Not examining the eye. Attributing to migraine. Not checking the pupil. Not distinguishing from uveitis.

Where do candidates most often go wrong in this station?

Attributing the headache and nausea to migraine or SAH. Acute glaucoma causes severe headache and vomiting through autonomic response to high IOP. Candidates who investigate for neurological causes without examining the eye miss the diagnosis.

Can I do well in this station without real-world experience of acute angle closure glaucoma?

Structure beats experience here. Focus on mid-dilated fixed pupil as the key distinguishing sign from other causes of acute red eye. 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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