The clinical scenarios in ophthalmology selection are pitched at a junior registrar who must recognise an eye emergency and act, often at night and often with the patient in front of them before any investigation. In a recorded interview there is no probing, so the answer must be complete in one timed pass. This guide covers the scenarios that recur and the structure that scores.
The structure
Recognise the emergency and name the diagnoses that must not be missed. Assess: the history that matters, the visual acuity, the pupils, the pressure, the examination. Treat what must be treated now. Refer or escalate: the ophthalmology consultant, theatre, the subspecialist. Explain to the patient. Say what you would do if the first step failed. In two minutes, in order.
Sudden painless loss of vision in one eye
The differentials that must not be missed: central retinal artery occlusion, which is a stroke of the eye and a vascular emergency; central retinal vein occlusion; retinal detachment; vitreous haemorrhage; giant cell arteritis causing ischaemic optic neuropathy in the older patient. The assessment: the time of onset, the acuity, the pupils for a relative afferent defect, the fundus, and for the older patient the symptoms of giant cell arteritis and the inflammatory markers. For the artery occlusion, the urgent measures within the window and the stroke pathway, because the patient is at risk of a cerebral stroke. For giant cell arteritis, high dose steroids started on suspicion before the biopsy, to protect the other eye. Say that you would involve the consultant immediately.
The red, painful eye with nausea and a fixed mid dilated pupil
Acute angle closure glaucoma until proven otherwise. The pressure measured, the treatment to lower it started now (the topical and systemic agents in the hospital's protocol), the patient kept nil by mouth and the pain and nausea managed, the urgent ophthalmology involvement for the definitive laser treatment, and the other eye considered. Say that delay costs vision.
The chemical injury
Irrigation immediately and for a long time, before anything else, with whatever clean fluid is available and then saline, until the pH is neutral and stays neutral. Then the history of the agent, with alkalis the more dangerous. Then the examination after irrigation: the acuity, the cornea, the limbus, the pressure. Then the referral and the treatment to protect the cornea. Say that you would not stop irrigating to examine, and that you would check the pH again after a pause.
The patient with diabetes and no eye check in five years
What you are looking for: diabetic retinopathy and macular oedema, the grading, the risk of sight loss, and the treatments that prevent it if caught. How you would organise care: the dilated examination, the imaging, the follow up interval by the grading, the treatment pathway, and the conversation with the patient about control of their diabetes and blood pressure. Mention the particular burden in Aboriginal and remote communities and the screening programmes.
The child with a white pupil reflex
Leukocoria is retinoblastoma until proven otherwise, and the other causes (cataract, retinopathy of prematurity, Coats disease) are also serious. Urgent referral to a paediatric ophthalmologist, the examination under anaesthesia, and the conversation with the parents that is honest about the urgency without giving a diagnosis you cannot yet make. Say that you would not reassure.
The driving standard
Not an emergency but a scenario that recurs: the patient whose visual fields are below the driving standard and insists on driving. The standard and why it exists, the patient's responsibility to notify the licensing authority, your obligations in your state, the alternatives, the documentation, and respect for the patient's loss.
What the assessors score
Recognition of the diagnoses that must not be missed, the assessment that confirms them, treatment started without delay where delay costs sight, the right escalation, honest communication, and the plan for failure. The common failures are examining before irrigating the chemical injury, reassuring the parents of the child with leukocoria, and missing giant cell arteritis in the older patient with vision loss.
Preparing
Learn the hospital's protocols for each emergency. Talk each scenario through aloud in two minutes, then record it against the clock and watch it. The recorded format means a complete, ordered answer with nothing left for a probe to draw out, and that is a skill that practice builds quickly.