“My eye’s agony, doctor” — a red, painful eye

Candidates: do not open until you have consulted.

Persona and manner

• Margaret Quinn, 64, retired bookkeeper; married to Peter, who drove you here and is in the waiting room. Two grown-up children; a grandson you look after on Wednesdays.
• Sitting hunched with your right hand cupped over your right eye, eyes screwed up against the light; you speak in short sentences and occasionally retch into the bowl. You are frightened — you have never had anything wrong with your eyes.

Opening line — say this verbatim

• “My eye’s agony, doctor — the right one. Since last night. Everything’s got a halo round it and I’ve been sick twice. Can you turn that light off?”

Volunteer freely if given the space

• It started about nine last night, in the cinema — you were watching a film in the dark with Peter and the eye started aching and the screen went blurry with coloured rings round the lights. By the time you got home it was a deep ache like toothache behind the eye and down the side of your head.
• You took two paracetamol and went to bed; you could not sleep; you were sick at about two and again this morning. The eye is red and the vision in it is “like looking through a steamed-up window”.
• You rang the surgery at eight.

Only if asked

• The vision: the right eye is a fog; you can see Peter’s shape but not his face. The left is fine. No flashes, no floaters, no curtain coming across. You have had two or three short episodes over the last month — an ache and blurred vision with rings round the lights in the evenings, gone by morning — “I thought it was my glasses”.
• Pain: deep, constant, 9 out of 10, worse in the light; the whole right side of your head aches. No pain on chewing, no scalp tenderness, no jaw pain. No rash on your face. No fever, no stiff neck.
• Nothing went in the eye; no injury; no contact lenses — you have worn glasses for being long-sighted since your forties and need them for reading too. No discharge, no sticky lids. No previous eye trouble, no eye operations. Nobody in the family has glaucoma that you know of.
• Medicines: ramipril for years. Only if asked about any other or new medicines, including anything from another doctor, a walk-in centre or a pharmacy: a tablet for sleep from the walk-in centre doctor three weeks ago — amitriptyline, 10 mg at night; it is not on your practice record. If asked only “are you on anything apart from the blood-pressure tablet?” say “Not from here.” Otherwise keep it for the ‘anything to add’ moment. Nothing over the counter, no eye drops, no cold remedies. No allergies.
• Health: blood pressure only. No diabetes, no arthritis, no bowel or back problems, no mouth ulcers. No headaches normally. No migraine.
• You are not sure whether the eye has felt hard — you have not dared touch it.
• You drove yourself nowhere — Peter brought you. You cannot see well enough to walk out on your own.

Impact on daily life — home and work (only if asked)

• You have your grandson tomorrow and cannot see to look after a three-year-old.
• You do the accounts for your son’s business; you cannot look at a screen.
• Peter does not drive at night; you are the driver.

Ideas, concerns and expectations

• Idea: migraine — a neighbour gets rings round lights with her migraines — or that it is your glasses.
• Concern: that you are going blind in that eye; and, if the doctor mentions the hospital, that it will mean an operation.
• Expectation: painkillers, something for the sickness, and “some drops”.

Cues to deliver, timed

• Minute 2: flinch from the window — “Can we close the blind? The light’s unbearable.”
• Minute 4, if the earlier evening episodes have not come out and the doctor has not asked about previous similar symptoms: “It did something like this a couple of times last month, only it went off by morning.”
• Minute 6, if the doctor has not said what they think it is or what happens now: “Is it a migraine? My neighbour gets rings round lights.”

If the doctor summarises and asks whether you want to add anything

• If the amitriptyline has not come up: “I don’t know if it matters — the walk-in centre doctor gave me a tablet for sleep three weeks ago. Amitriptyline. It was after that it started playing up in the evenings.”
• If it has: “Will I lose the sight in it?”

How to respond to the doctor

• If the doctor explains that the pressure inside the eye has risen sharply and is squeezing the nerve, that it is an emergency for the eye but treatable, and that you need to be seen at the eye hospital today — now — and is arranging it by phone: frightened but compliant — “Will they be able to save it?”
• If the doctor asks you to lie flat while they telephone: do so.
• If the doctor offers painkillers and something for the sickness while you wait: grateful.
• If the doctor says it is migraine, conjunctivitis or “a bit of inflammation” and gives drops or tablets to take home: “Are you sure? It’s never been like this.” — and, if sent home, say you will go to A&E yourself.
• If the doctor suggests you drive yourself or go by bus: “I can’t see out of it. Peter’s here.”
• If the doctor says the amitriptyline may have set it off and must be stopped: “I’ll never take it again.”
• If the doctor asks whether an eye patch or a dark room would help: say you do not know (do not lead).
• If jargon is used (“angle closure”, “intraocular pressure”, “iridotomy”, “mydriasis”): “What does that mean?”
• If the doctor explains honestly that sight can be lost if treatment is delayed, but that treated promptly most people keep useful vision: “Then let’s go.”

Do not

• Volunteer the walk-in centre sleeping tablet unless asked about other or new medicines — or until invited to add anything (apart from the minute-4 cue about the earlier episodes).
• Describe flashes, floaters, a curtain, discharge, a rash or an injury — there were none.
• Name the diagnosis. If the doctor asks what you think it is, say “migraine” or “my glasses”.

Findings to give the candidate — only if asked for

If the candidate asks to examine you, or asks for observations or examination findings, read these out. Do not offer them otherwise. (Where a separate examiner is present, the examiner reads them.)

Domain marks — with the key facts that earn a 4 at this station

Domain score (educational construct):

This 1–4 domain score and its descriptors are an Acumen educational construct: the GMC publishes the three marking domains and the four-mark maximum, but not the descriptors its examiners use, and it does not publish station mark sheets. See Legal & Regulatory.

Marks are 1 to 4 in each domain; the generic descriptor for each mark is on the mark scheme page, and the structure of the eight minutes is on the 8-minute station page. The full standard for this case is in section 3 and the GMC feedback statements, with examples from this case, are in section 4. The examination findings that the role player gives — only if the candidate asks for them — are at the end of section 1.

The top row is the full picture of what a competent FY2 could do at this station, including the working diagnosis with its justified differentials, the safety-net and the follow-up; lower rows describe how performance falls away. It is a debriefing aid, not a checklist to recite: nobody says every line in eight minutes, and a 4 is a judgement that the essentials — the italic key facts on the mark sheet — were done well, in plain language and at the patient’s pace. Acumen training standard — the GMC does not publish station mark sheets.

A feedback statement marks where underperformance was identified in the consultation. With PLAB 2 results the GMC may attach any combination of the ten statements to a station — none, one or several. The right-hand column shows what each one looks like at this station. Record the statements that applied in the practice log.

Points of fact the examiner should have to hand

1. NICE CKS Glaucoma (last revised July 2025) — recognising acute angle closure: suspect it in a person with an acute, painful red eye, particularly with risk factors or a history of previous episodes of blurred vision, headache or eye pain with nausea and haloes around lights, typically in the evening and relieved by sleeping, or a precipitant such as watching television in a darkened room, a semi-prone position, an adrenergic drug (for example phenylephrine) or an antimuscarinic drug (for example a tricyclic antidepressant). Typical features: severe eye pain with headache, nausea and vomiting; a red eye; blurred vision with haloes from a hazy oedematous cornea; a semi-dilated fixed pupil, classically vertically oval; and a tender, hard eye — palpate very gently. Intermittent (subacute) angle closure gives the same symptoms more mildly, resolving on lying supine and closing the eyes or after sleep.
2. CKS management: if acute angle closure is suspected, admit immediately for specialist ophthalmology assessment and treatment. If immediate admission is not possible, start emergency treatment in primary care: let the person lie flat, face up, head not supported by pillows (this may relieve some pressure on the angle); if the drugs are available give pilocarpine eye drops — one drop of 2% for blue eyes or 4% for brown eyes — acetazolamide 500 mg orally to reduce aqueous production (if not contraindicated), analgesia and an antiemetic. Anyone with suspected intermittent or chronic angle closure is referred to an ophthalmologist. (Acetazolamide is a sulfonamide — check allergy, renal function and electrolytes; CKS says to start these when immediate admission is not possible; in practice an FY2 would check with the supervising GP or the ophthalmologist.)
3. Why no dilating drops, patch or dark room: pupillary dilatation — by darkness, an eye pad, topical mydriatics, or systemic drugs with antimuscarinic or adrenergic effects — crowds the iris into a narrow drainage angle and precipitates or worsens closure; the first treatment is the opposite, pupil constriction with pilocarpine (CKS lists a darkened room and adrenergic or antimuscarinic drugs as precipitants; avoiding a patch and dimming rather than darkening the room is standard practice, not a CKS statement). Antiemetics: avoid cyclizine and prochlorperazine, which the BNF cautions in susceptibility to angle-closure glaucoma; ondansetron or metoclopramide are suitable. Steroids: do not start topical corticosteroids or steroid-antibiotic combinations for an undiagnosed painful red eye in primary care — herpes simplex keratitis can progress to ulceration and perforation; steroid drops are an ophthalmology decision (standard teaching, not a CKS statement). Drugs implicated include tricyclic antidepressants, some antihistamines and cold remedies, antimuscarinic bladder and Parkinson’s drugs and, less often, SSRIs (CKS; BNF cautions “angle-closure glaucoma” on these drugs); topiramate causes a different, non-pupil-block type of angle closure in which pilocarpine is not used — a specialist matter (CKS; RCOphth 2022). A drug that may have precipitated an attack is stopped and recorded.
4. Risk factors (CKS, background information): age — the lens thickens and the anterior chamber shallows; female sex (two to three times more common); Asian ancestry (prevalence highest in East Asia); short, hyperopic (long-sighted) eyes — rare in myopia; and family history. Mrs Quinn is long-sighted, 64 and female, and started a tricyclic three weeks ago.
5. NICE CKS Red eye (last revised March 2026) — red flags that may indicate a serious or sight-threatening cause: reduced visual acuity; moderate to severe pain; headache; photophobia; significant ciliary injection; fluorescein staining showing a corneal defect or ulcer; unequal or misshapen pupils or abnormal pupillary reactions; pain on pupillary constriction; loss of the red reflex; corneal haze; hyphaema or hypopyon. Refer for same-day ophthalmology assessment if a red flag is present, if a serious cause such as acute glaucoma or a corneal ulcer is suspected, after chemical injury (after immediate irrigation) or trauma — the referral urgency table of the College of Optometrists is the reference. Document acuity and the negative findings. CKS tiers: same-day for a red flag, suspected acute glaucoma or corneal ulcer, chemical injury or trauma; urgent (within 24 hours) for suspected anterior uveitis or scleritis; do not palpate the eye if perforation is suspected.
6. The differentials of a painful red eye (CKS Red eye): acute angle closure (as above); anterior uveitis — dull ache, photophobia, a small or irregular pupil, ciliary flush, cells in the anterior chamber, often with ankylosing spondylitis, inflammatory bowel disease or sarcoidosis; keratitis and corneal ulcer — foreign-body sensation, watering, fluorescein uptake, contact-lens wear, herpes simplex dendrite; scleritis — severe deep pain worse at night, bluish-red sclera, associated rheumatoid arthritis or vasculitis; episcleritis — mild, sectoral, blanches with phenylephrine; conjunctivitis — gritty, discharge, normal acuity; subconjunctival haemorrhage — painless, measure the blood pressure. Herpes zoster ophthalmicus (rash in the ophthalmic division, Hutchinson’s sign on the nose) and giant cell arteritis (over 50, headache, scalp tenderness, jaw claudication, visual loss with a white eye) are the two headache-with-eye emergencies not to miss.
7. Definitive treatment (Royal College of Ophthalmologists, Management of angle-closure glaucoma guideline, 2022): in hospital the pressure is lowered medically — oral or intravenous acetazolamide, topical beta-blocker, alpha-agonist and pilocarpine, with intravenous mannitol if needed — followed by laser peripheral iridotomy, which the College recommends promptly for the affected eye and the fellow eye once acute symptomatic angle closure has occurred; lens extraction is an alternative in some. NICE NG81 covers chronic open-angle glaucoma and ocular hypertension, not acute angle closure. Untreated, acute angle closure damages the optic nerve within hours to days; the fellow eye carries a high risk of a later attack until it is treated.
8. Driving: she must not drive with acuity of 6/60 in one eye and in pain; after treatment the DVLA Group 1 standard is Snellen 6/12 with both eyes open (or in the only eye), reading a number plate at 20 metres (20.5 metres for older plates) in good daylight, and an adequate visual field (DVLA, Assessing fitness to drive, visual disorders, updated September 2025). Advise her not to drive until the ophthalmologist confirms she meets the standard.
9. Referral craft: a telephone referral to the eye casualty or on-call registrar with the six findings (acuity each eye, pattern of redness, corneal clarity, pupil, globe tension, fluorescein) and the precipitant, the time of onset, medicines and allergies, followed by a written summary; transport arranged so that she is not alone and does not drive; the practice records the referral time and checks the outcome. This is also what the mark scheme rewards as “acting on findings”.

Where candidates lose marks at this station

• “Probably a migraine — her neighbour gets haloes too.”
• Dilating the pupil to get a better look at the back of the eye.
• An eye pad and a dark room while she waits.
• A referral letter marked “urgent” — instead of a telephone call today.
• Never asking what medicine was started three weeks ago.
• Forgetting the other eye.

Guidelines for this station

• NICE CKS — Glaucoma: management of acute angle closure (revised July 2025)
• NICE CKS — Glaucoma: diagnosis of primary angle closure
• NICE CKS — Red eye: assessment and red flag features (revised March 2026)
• NICE CKS — Red eye: management and referral
• Royal College of Ophthalmologists — The Management of Angle-Closure Glaucoma (published June 2022; PDF)
• NICE NG81 — Glaucoma: diagnosis and management (chronic open-angle glaucoma and ocular hypertension)
• DVLA — Assessing fitness to drive: visual disorders

Record your three domain marks, your station total, the GMC feedback statements that applied (where underperformance was identified), and what you will keep and change. The form is already labelled with this case and its web address; a copy of your entry is emailed to you, so your practice log builds up in your inbox and can be downloaded.

Record my marks and reflection for P2-36