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OSCE Chronic Visual Loss

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👁️ OSCE Station – Chronic Visual Loss

Candidate Instructions 📋

You are a final-year medical student in the GP clinic. A 72-year-old patient attends complaining of gradual visual deterioration over the last year. Take a focused history, perform an appropriate examination (as directed), and discuss your likely differential diagnosis and initial management plan.

Key History Points 📝

⏱️ Onset & Progression: Gradual or stepwise? Symmetrical or asymmetrical?
📍 Laterality: One eye vs both eyes.
🔎 Quality: Blurring, central vs peripheral loss, glare/halos, distortion (metamorphopsia).
⚡ Associated Symptoms: Floaters, flashing lights, eye pain, night blindness, photophobia.
📜 PMHx: Diabetes, hypertension, glaucoma, previous eye surgery or trauma.
💊 Drugs: Steroids (can cause cataracts & glaucoma).
👪 Family history: Glaucoma, macular degeneration, retinal disease.
⚖️ Functional impact: Driving, reading, falls risk.

Focused Examination 👀

🎯 Visual acuity (Snellen chart).
🖐️ Visual fields (confrontation or perimetry).
💡 Pupillary reflexes (afferent defect?).
🔬 Fundoscopy (lens opacities, optic disc cupping, retinal changes, macular degeneration).

Key Differentials ⚖️

Condition	Clues	Notes
Cataract	Gradual painless blurring, glare/halos, reduced night vision, absent red reflex	Most common worldwide cause of blindness; surgery usually curative
Primary Open-Angle Glaucoma	Insidious peripheral field loss, "tunnel vision"	Often asymptomatic until advanced; cupped optic disc
Age-Related Macular Degeneration (AMD)	Central vision loss, distortion, difficulty reading	Dry (atrophic) vs wet (neovascular) – wet needs urgent anti-VEGF
Diabetic Retinopathy	Fluctuating vision, floaters, progressive loss	Microaneurysms, haemorrhages, exudates; sight-threatening if proliferative
Chronic Uveitis	Blurred vision, floaters, possible redness	Associated with autoimmune conditions; needs ophthalmology input
Optic Atrophy	Pale disc, loss of colour vision	Late stage of optic neuropathies (MS, compression, ischaemia)

Investigations 🔬

🧪 Bloods: HbA1c (diabetes), ESR/CRP if suspect inflammatory disease.
👁️ Ophthalmic tests: Optical coherence tomography (OCT), intraocular pressure, slit-lamp exam.
🧠 Imaging (MRI/CT) if optic nerve compression or atypical features.

Management 💊

Cataract: Refer for cataract surgery when daily life is affected.
Glaucoma: Lifelong treatment – topical prostaglandin analogues (e.g. latanoprost), sometimes surgery.
AMD: Dry → lifestyle (smoking cessation, diet); Wet → urgent referral for intravitreal anti-VEGF injections.
Diabetic Retinopathy: Strict glycaemic & BP control, laser therapy or anti-VEGF for proliferative disease.

Examiner’s Marking Guide 📋

Identifies chronic, progressive course and functional impact.
Covers key sight-threatening differentials: cataract, glaucoma, AMD, diabetic retinopathy.
Performs focused eye exam (acuity, fields, fundoscopy).
Recognises when urgent vs routine ophthalmology referral is needed.
Explains management sensitively, addresses patient concerns (driving, independence).

🧑‍⚕️ Case Examples — Chronic Visual Loss

Case 1 (Cataract): 👁️‍🗨️ A 72-year-old woman complains of progressive, painless blurring of vision over 2 years. She struggles with night driving due to glare from headlights. Fundoscopy is difficult because of lens opacity. Diagnosis: Age-related cataract. Teaching point: Painless, gradual decline in vision with glare and faded colours; treatment is surgical lens replacement.
Case 2 (Primary Open-Angle Glaucoma): 🌫️ A 68-year-old man presents with gradual loss of peripheral vision, often described as “tunnel vision.” Intraocular pressure is raised and optic disc cupping is seen. Diagnosis: Chronic open-angle glaucoma. Teaching point: Insidious, bilateral disease causing peripheral field loss; managed with prostaglandin analogues or surgery to lower intraocular pressure.
Case 3 (Diabetic Retinopathy): 🍬 A 60-year-old man with poorly controlled type 2 diabetes presents with gradual worsening of vision. Fundoscopy reveals microaneurysms, dot-and-blot haemorrhages, and cotton wool spots. Diagnosis: Diabetic retinopathy (background proliferative changes). Teaching point: Regular screening and tight glycaemic/BP control are key; advanced disease may require laser or intravitreal therapy.
Case 4 (Age-Related Macular Degeneration – Wet type): 🌅 A 75-year-old woman reports distortion of central vision (straight lines appear wavy) and difficulty reading. Fundoscopy shows subretinal fluid and haemorrhage at the macula. Diagnosis: Neovascular (wet) AMD. Teaching point: Central vision loss with distortion suggests macular disease; treat wet AMD with intravitreal anti-VEGF injections.
Case 5 (Optic Atrophy from Multiple Sclerosis): 🧠 A 45-year-old woman with a history of relapsing-remitting MS reports gradual visual decline in one eye after previous episodes of optic neuritis. Fundoscopy shows a pale optic disc. Diagnosis: Optic atrophy secondary to demyelinating disease. Teaching point: Past optic neuritis can leave residual optic atrophy; vision loss is usually irreversible, but relapse prevention is key.

PLEASE NOTE LEGAL ADVICE: The contents are under continuing development and improvements and may contain errors of omission or fact. Feedback vital and always welcome at drokane at gmail.com. This is not to be used for the assessment, diagnosis or management of patients. It should not be regarded as medical advice. It is only for educational purposes. Please adhere to your local protocols. If you are unwell please seek healthcare advice from your doctor. This does not replace senior or specialist advice. If you do not accept this then please do not use the website. If you need medical advice, please consult a doctor or other appropriate medical professional. If you are a medical professional and you need advice then speak to your senior or colleagues.

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