Gradual Change in or Loss of Vision Station

Presenting Complaint: 

Alan reports gradually worsening vision in both eyes over the past year, particularly affecting his ability to drive at night and read.

He states —“My eyesight’s been going downhill slowly, but I really noticed it a few months ago when I struggled to read road signs at night. Everything just seems a bit cloudier.”

Symptoms (SOCRATES)

• Site: Both eyes – “The blurry vision is in both of my eyes.”
• Onset: Gradual, over 6 months – “It’s been slowly getting worse over the last six months.”
• Character: Cloudy, fuzzy vision – “It looks like there’s a fog or smudge over my vision in both eyes.”
• Radiation: No radiation – “The problem is just with my eyes, not spreading anywhere else.”
• Associated symptoms: Glare, halos around lights, difficulty with night driving – “Bright lights have halos around them, and driving at night is really difficult with both eyes.”
• Timing: Constant – “The blurriness is always there, it doesn’t come and go.”
• Exacerbating factors: Dim light and night time – “It feels worse when it’s darker, especially when I’m driving at night.”
• Relieving factors: None – “Nothing really makes it better.”
• Severity: Moderate vision impairment – “It’s bad enough that I’m struggling to read and see things clearly.”

Negative findings:

• No diplopia – “I don’t see double.”
• No photophobia – “I’m not sensitive to light.”
• No eye pain or discomfort – “My eyes don’t hurt.”
• No flashes or floaters – “I haven’t noticed any flashes or floaters.”
• No history of eye trauma or surgery – “I haven’t hurt my eyes or had any operations.”

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

Past Medical History

• Hypertension – Diagnosed 8 years ago, well controlled on medication- “I take tablets for my blood pressure, but it’s been stable for years.”
• Hyperlipidaemia – Managed with statins. “My cholesterol was high before, but it’s come down since I started treatment.”
• No previous eye trauma, surgery, use of prescription glasses or laser treatments- “I’ve never had any procedures on my eyes before or needed any glasses.”

Drug History

• Amlodipine 5 mg once daily (for hypertension) - “I take one tablet every morning for my blood pressure.”
• Atorvastatin 20 mg once daily (for hyperlipidaemia) - “I also take a cholesterol tablet at night.”

Allergies

• No known drug or food allergies

Family History

• Father was diagnosed with cataracts in his 60s - “My dad had cataracts and had them removed when he was around 65.”
• No family history of glaucoma, macular degeneration, or retinal conditions - “No one else in the family had serious eye problems apart from my dad’s cataracts.”

Social history

• Lifestyle: lives with his wife and is a retired bus driver
• Activities & Hobbies: Enjoys gardening, reading, and watching football
• Driving: Stopped driving recently due to vision - “I’ve given up driving lately—it’s too difficult with the glare and cloudy vision.”
• Smoking: Never smoked.
• Alcohol:  Drinks occasionally - “I’ll have a pint or two on the weekend, but nothing heavy.”
• Recreational Drugs: Never used 
• Exercise: Light walking and gardening regularly

 Ideas, Concerns, and Expectations:

• Ideas: “I think it’s just part of getting older—my eyes have probably just worn out a bit.”
• Concerns: “I’m starting to worry that this might be something more serious, like glaucoma or going blind.”
• Expectations: “I’m hoping you can tell me what’s going on and if there’s something that can fix my sight, like new glasses or surgery.”

 Observations:

- Respirations (Breaths/min): 16

- Oxygen Saturation (%): 98%

- Air or Oxygen: Air

- Blood Pressure (mmHg): 134/78

- Pulse (Beats/min): 76

- Consciousness (AVPU): A

- Temperature (Celsius): 36.7

NEWS Total Score: 0

Eye examination:

Inspection (show image below)

Image sourced from Neoretina Eyecare institute, available at https://www.neoretina.com/blog/nuclear-cataracts-symptoms-causes-treatment/

• Right Eye: Normal external appearance, no redness or swelling; lens appears cloudy/opaque on direct visualisation through the pupil
• Left Eye: Normal external appearance, no redness or swelling; lens appears cloudy/opaque on direct visualisation through the pupil

Visual Acuity (Snellen chart – each eye separately)

• Right Eye (OD): 6/18 unaided, no improvement with pinhole
• Left Eye (OS): 6/18 unaided, no improvement with pinhole

 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 (OD): Full visual fields bilaterally
• Left Eye (OS): Full visual fields bilaterally

 Eye Movements

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

Fundoscopy:

• Right eye (OD): Red reflex is reduced. The lens appears diffusely cloudy, making it difficult to visualise the fundus clearly. Retinal details, including the optic disc and vessels, are poorly defined due to lens opacification.
• Left eye (OS): Red reflex is reduced. The lens appears diffusely cloudy, similarly obscuring a clear view of the fundus. Retinal structures are indistinct due to media opacity from the cataract.

Choose EITHER examiner viva questions OR patient communication questions

Communication Questions

1) “Will I go blind from this?”

2) “What causes cataracts?”

3) “How is a cataract treated?”

4) “Is there anything I can do to stop it getting worse?”

Exemplar answers

1) “If left untreated, cataracts can lead to a gradual decrease in vision and eventually blindness, however if treated promptly we can ensure this doesn’t happen..surgical replacement of the lens of the eye is very effective at restoring sight. It’s one of the most commonly performed procedures in the UK, with excellent outcomes in most cases.”

2) “Cataracts are usually caused by natural ageing of the eye. Over time, the proteins in the lens break down and clump together, making the lens cloudy. However, other factors can also contribute, such as:

-          Diabetes

-          Long-term steroid use

-          Smoking

-          Excessive UV exposure

-          Previous eye injury or surgery

-          Family history of cataracts

Cataracts are very common and not something you’ve done wrong.”

3) “The only definitive treatment for a cataract is surgery, where the cloudy lens is removed and replaced with a clear artificial lens (called an intraocular lens or IOL). The procedure is usually done under local anaesthetic as a day case and takes around 20–30 minutes. It’s very safe, and vision often improves significantly within days to weeks after the operation.”

4) “Unfortunately, there’s no proven way to stop or reverse cataracts once they’ve formed. However, protecting your eyes from UV light (e.g., wearing sunglasses), managing underlying conditions like diabetes, and avoiding smoking can help reduce the risk of cataracts worsening or developing in the other eye. Regular eye checks are also important.”

Examiner Questions

1) What conditions are in your differential diagnosis for gradual painless vision loss?

2) How do cataracts typically present in patients?

• Gradual, painless reduction in visual acuity (often bilateral)
• Glare and difficulty with bright lights (especially night driving)
• Halos around lights
• Faded colour perception
• Increased difficulty with near tasks (e.g. reading)
• Myopic shift (suddenly able to read without glasses – “second sight”)

3) How are cataracts managed in clinical practice?

• The presence of cataracts in itself doesn’t necessarily mandate surgical intervention, which depends on the degree of functional visual impairment. In addition, the presence of a cataract will not affect the health of the eye in most cases.
• Mild cases (i.e. no functional impairment of vision) may be managed with non-surgical measures such as updating spectacles or magnifying lenses, close glucose control in diabetics, and avoiding excessive exposure to UV radiation. However this is likely to be temporary as there are no effective non-surgical measures to prevent or treat cataracts. 
• Definitive treatment is surgery (phacoemulsification with intraocular lens implantation) - recommended if cataract is causing functional impairment of vision.
• Pre-op evaluation includes:
  • Visual acuity and slit-lamp exam
  • Biometry to determine correct lens power

• Post-op care: topical antibiotics and corticosteroids; regular follow-up to monitor for complications

4) What are the risks and benefits of cataract surgery?

Benefits: 

• Significant improvement in vision in >95% of cases 
• Improved quality of life and functional ability

Risks:

• Posterior capsule opacification (most common long-term)
• Infection (endophthalmitis – rare)
• Retinal detachment
• Cystoid macular oedema
• Intraoperative complications: posterior capsule rupture, vitreous loss
• Incorrect lens power (refractive error)