Presenting Complaint:

• Amina reports seeing flashing lights and multiple black floaters drifting across her right visual field. She also describes a dark shadow or curtain affecting the lower part of her vision.
• She states, “I’ve been seeing bright flashes and little black spots floating about in my right eye. Now it feels like a shadow’s creeping over the bottom of my vision, and I’m really worried.”

Symptoms (SOCRATES):

• Site: Right eye, mainly affecting the right visual field – “It’s mostly in my right eye and mostly on the lower side.”
• Onset: Sudden onset 2 days ago – “The lights started suddenly two days ago and the black spots came on shortly after.”
• Character: Flashes described as bright, flickering streaks; floaters as small black dots and cobweb-like shapes drifting in vision – “It’s like I keep seeing little bursts of light, almost like flickers or sparks, especially in the side of my eye. And there are these tiny dark spots or threads that float around when I move my eyes.”
• Radiation: No radiation – “The symptoms are only in the right eye; they don’t spread.”
• Associated Symptoms: Noticed a shadow or curtain effect inferiorly in the right eye; no pain, no redness or discharge – “There’s a dark shadow creeping across the bottom of my sight, but no pain or redness.”
• Timing: Symptoms persistent and progressively worsening over 2 days – “The lights and spots haven’t gone away, and the shadow seems to be getting bigger.”
• Exacerbating and Relieving Factors: No clear triggers or relief – “Nothing seems to make it better or worse; it just stays there.”
• Severity: Moderate distress and concern – “It’s quite frightening, and I’m worried I might lose my vision.”

Systemic Symptoms:

• Fatigue: No 
• Fever: No 
• Night Sweats: 
• Unintended Weight Loss: No 
• Chest or Shoulder Tip Pain: No 
• Shortness of Breath or Cough: No 
• Peripheral Oedema: No 
• Rashes or Skin Changes: No 
• Headache: No
• Change in Bowel Habits: No 
• Urinary symptoms: No

Relevant Positive and Negative Findings:

Positive findings:

• Presence of photopsia (flashes) – “Bright flashes have been popping up in my vision.”
• Multiple floaters – “Lots of black spots and cobweb shapes drifting across my sight.”
• Visual field defect/shadow inferiorly – “There’s a dark curtain moving across the lower part of my right eye vision.”

Negative findings:

• No diplopia – “I don’t see double.”
• No pain or redness reported.
• No headache, neurological symptoms, or weakness.
• No systemic symptoms like fever or weight loss – “I feel fine otherwise.”
• No history of recent eye trauma or surgery – “I haven’t hurt my eye or had any operations.”
• No changes to the left eye – “My left eye is completely fine.” 

Past Medical History:

• High myopia (short-sightedness) since early adulthood – “I’ve needed glasses since my twenties.”
• No prior ocular surgery or trauma – “No previous eye operations or injuries.”
• Well-controlled hypertension, diagnosed 5 years ago – “I take tablets for blood pressure.”

Drug History:

• Lisinopril 10mg once daily – “I take one pill every morning.”
• No missed doses or compliance issues – “I’m good at taking my medication.”

Allergies:

• No known drug or food allergies.

Family History:

• Mother has glaucoma diagnosed in her 70s – “My mum has glaucoma.”
• Father has type 2 diabetes – “My dad has diabetes.”

Social History:

• Lifestyle: Works as a school librarian and lives with her husband and two adult children. Independent and self-caring.
• Activities and Hobbies: Enjoys gardening, knitting, and reading.
• Smoking: Never smoked.
• Alcohol: Does not drink alcohol.
• Recreational Drugs: Never used.
• Exercise: Goes on walks 3-4 times a week for 30 minutes.

 Ideas, Concerns, and Expectations:

• Ideas: “I’m worried the flickers of light mean there’s something seriously wrong inside my eye.”
• Concerns: “I’m scared I might go blind if this isn’t treated quickly.”
• Expectations: “I want urgent treatment to save my vision and clear information about what’s happening.”

Observations:

• Respirations (Breaths/min): 14
• Oxygen Saturation (%): 98
• Air or Oxygen?: Air
• Blood Pressure (mmHg): 130/78
• Pulse (Beats/min): 78
• Consciousness (AVPU): A
• Temperature (Celsius): 37.1

NEWS Total Score = 0

Eye examination:

Inspection:

• Right eye: Normal appearance, no redness or swelling.
• Left eye: Normal appearance, no redness or swelling.

Visual Acuity (Snellen chart – each eye separately):

• Right eye (OD): 6/12 with correction.
• Left eye (OS): 6/9 with correction.

Pupillary Reflexes:

• Right eye (OD): Direct and consensual light reflexes normal.
• Left eye (OS): Direct and consensual light reflexes normal.
• Relative Afferent Pupillary Defect (RAPD): Absent

Swinging light test should be demonstrated or verbalised.

Visual Fields (by confrontation):

• Right eye: Inferior visual field defect noted on confrontation testing.
• Left eye: Full visual fields bilaterally.

Eye Movements

• Full range of movement in both eyes, no diplopia or restriction noted.

Fundoscopy

• Verbalise fundoscopy findings from right eye (image below):

Image sourced from Department of Ophthalmology and Visual Sciences. Available at https://webeye.ophth.uiowa.edu/eyeforum/tutorials/retinal-detachment-med-students/index.htm#gsc.tab=0 (Figure 3)  

• Right eye: Elevated, detached retina visible in the superior and temporal retina; grey, typical corrugated appearance; no haemorrhage noted.
• Left eye – Normal optic disc and macula, no retinal abnormalities.

Choose EITHER examiner viva questions OR patient communication questions

Communication Questions:

1)  “What exactly is causing these flashes and floaters in my eye?”

2)  “Is this condition serious? Will I lose my vision?”

3)  “What kind of treatment will I need and how soon?”

Example answers:

1)  “The flashes and floaters happen because the gel inside your eye (called the vitreous) is tugging on the retina at the back of your eye, which normally detects light. This can sometimes cause a tear, letting fluid slip underneath the retina and cause it to detach. That’s why you’re seeing sudden flashes and floaters.”

2)  “Yes, retinal detachment is serious. Without prompt treatment, it can cause permanent vision loss. The sooner it’s treated, usually with surgery, the better the chances of saving your sight.”

3)  “You need urgent assessment by an eye specialist. Treatment usually involves surgery to reattach the retina, which should happen within days to prevent further vision loss.”

Examiner Questions:

1) What are your differential diagnoses and which is the most likely?

2) What are the main risk factors for retinal detachment?

• Age over 50 years.
• High myopia (severe short-sightedness).
• Previous eye trauma or surgery (e.g., cataract removal).
• Previous retinal detachment or tears in the other eye.
• Family history of retinal detachment.
• Posterior vitreous detachment (PVD).

3) What investigations would you perform to confirm the diagnosis?

• Dilated indirect ophthalmoscopy with slit lamp examination to visualise the retina.
• Optical coherence tomography (OCT) to check retinal layers and macula involvement.
• B-scan ultrasound if the view of the retina is obscured (e.g., by vitreous haemorrhage).
• Visual acuity and confrontation visual field testing as adjuncts.

4) How would you manage this patient acutely?

• Immediate referral to ophthalmology emergency services for assessment and management.
• Advise the patient to avoid heavy lifting and sudden head movements.
• Position the patient appropriately to reduce progression of detachment.
• Discuss surgical options: pneumatic retinopexy, scleral buckle, vitrectomy with silicone oil replacement or gas bubble vitrectomy depending on the case.
• Pain relief if necessary (usually mild discomfort).

5) What complications should you be aware of following retinal detachment surgery?

• Cataract development, especially after vitrectomy.
• Raised intraocular pressure or secondary glaucoma.
• Recurrence of retinal detachment.
• Infection (endophthalmitis).
• Persistent vision impairment despite surgery.

6) What advice would you give to the patient regarding symptoms to watch for in the other eye?

• Seek urgent medical attention if you experience new flashes, floaters, or any shadow/curtain over your vision.
• Regular eye check-ups if you have risk factors such as high myopia or previous retinal problems.