Zuhaib Ehsan

OSCEs are time-pressured environments where students are expected to recall examination sequences, communicate confidently with both patients and examiners, and accurately interpret their clinical findings.

Ophthalmology can feel unfamiliar to medical students because the amount of undergraduate exposure varies considerably between medical schools (1). Ophthalmology teaching can also be limited within undergraduate curricula, leaving students and newly qualified doctors less confident in assessing common ophthalmic problems (2).

The equipment can also feel unfamiliar and having little opportunity to practise with tools such as the ophthalmoscope or slit lamp can make the whole process seem overwhelming at first. Undergraduate ophthalmology education varies considerably in both its organisation and teaching methods, highlighting the importance of making the most of opportunities for practical exposure (1,3).

The good news is that ophthalmology OSCEs are often much more manageable than they initially appear. Many of the marks come from demonstrating a clear, structured approach and getting the fundamentals right. Once you become familiar with the common examination sequences and know what the examiner is looking for, the stations become far less daunting. With that in mind, here are 10 common mistakes students make in ophthalmology OSCEs and, more importantly, how to avoid them.

1. Forgetting to introduce yourself

When students are nervous and working under time pressure, it is easy to overlook the basics and introducing yourself is often one of the first things to be forgotten. It can be tempting to pick up the equipment and start the examination straight away, but basic communication skills still matter in ophthalmology stations.

Before beginning, introduce yourself, confirm the patient’s identity, explain what you are going to do and obtain consent. This takes only a few seconds but demonstrates professionalism and helps the patient understand what to expect. To make this easier to remember under pressure, use a simple sequence before handling any equipment such as introduce, identify, explain and obtain consent.

2. Forgetting to gain consent

Consent can sometimes feel like a small detail during an OSCE, but it is an essential part of any clinical examination. This is particularly important in ophthalmology, where examinations may involve getting close to the patient’s face or using equipment near the eye. Before beginning, briefly explain what you are going to do and check that the patient is happy for you to proceed. This reassures the patient, demonstrates professionalism and ensures that they understand what the examination will involve.

Rather than treating consent as a separate step that you might forget under pressure, incorporate it into your introduction from the beginning. Once you have introduced yourself and explained the examination, simply confirm that the patient is happy for you to proceed. This makes obtaining consent feel natural and ensures it becomes a consistent part of your OSCE routine.

3. Forgetting to ask about contact lens use

Contact lens history is particularly important when assessing a patient with a red or painful eye. Students can become so focused on identifying the cause of the redness that they overlook a simple question about whether the patient uses contact lenses. This is particularly relevant because poor lens hygiene and overnight or extended contact lens wear can increase the risk of microbial keratitis (4,5). Identifying contact lens use can therefore provide an important clue when assessing a potentially sight-threatening corneal problem.

If the patient does wear contact lenses, ask about how long they have been wearing them, how they clean and store their lenses, how frequently they replace them, and whether they sleep or swim while wearing them. These questions can help identify behaviours that may increase the risk of infection (4,5).

To avoid forgetting this in an OSCE, make contact lens use a routine part of your history when assessing any patient with a red or painful eye. It takes only a few seconds to ask but can make a significant difference to your assessment.

4. Testing visual acuity incorrectly

Visual acuity is one of the most fundamental ophthalmic assessments, yet students can easily lose marks through simple errors in technique. One common mistake is testing both eyes together. Visual acuity should generally be assessed one eye at a time, allowing you to identify any difference in vision between the two eyes.

Before starting, establish whether the patient normally wears glasses or contact lenses and follow the station instructions regarding whether their usual visual correction should be used. If the patient is unable to read the largest letters on the chart, you should also know how to proceed with alternative methods of assessing visual acuity.

To avoid missing this step under pressure, think of the right eye and left eye as two separate assessments. Test each eye individually, record the findings, and then compare them. Rather than simply asking the patient to read the chart with both eyes open, make testing each eye separately part of your routine approach.

5. Forgetting to examine the pupils accurately

Pupillary examination is another area where students may know what they are expected to do but rush through the assessment when working under pressure. This can result in important findings, such as a relative afferent pupillary defect (RAPD), being missed.

A systematic approach is essential. Assess the size, shape and symmetry of the pupils, followed by their direct and consensual responses to light. Where appropriate, perform the swinging-light test to assess for a RAPD. However, knowing how to perform the test is only part of the skill. You should also understand what RAPD represents, and which conditions can cause one. RAPD indicates an asymmetry in the afferent visual pathway and can be associated with significant optic nerve or retinal pathology.

To avoid losing marks, don’t simply memorise the steps of the swinging-light test. Make sure you understand what you are testing, what a normal response looks like and how you would interpret an abnormal finding. This will make the examination much easier to perform confidently under OSCE pressure.

6. Performing visual fields with poor technique

Visual field testing can appear relatively straightforward, which can lead students to underestimate the importance of good technique. However, small errors in positioning can make the assessment less reliable and may cost valuable OSCE marks.

A common mistake is sitting too far away from the patient. In confrontation testing, you and the patient should be positioned appropriately so that you can use your own visual field as a rough comparison. The patient should cover one eye while you cover your corresponding eye, allowing you to compare what you can see with what the patient can see.

You can then introduce a target from the periphery towards the centre and ask the patient to indicate when they first see it. This should be repeated in the relevant areas of the visual field to identify any obvious defects.

Poor positioning can make the comparison less reliable, so it is important to practise the technique rather than simply memorising the steps. To avoid this mistake, make positioning part of your routine. Before starting, check that you and the patient are sitting at an appropriate distance and that you are covering the correct eyes. With enough practice, the positioning and technique should become automatic, allowing you to focus on identifying and interpreting any visual field abnormalities.

7. Forgetting to assess eye movements

Eye movements are easy to overlook, particularly when a station appears to be focused on visual acuity or examination of the anterior eye. However, they are an important part of a general ophthalmic examination and can provide valuable information about the extraocular muscles and cranial nerves.

When assessing eye movements, ask the patient to follow your finger or another target while you move it through the appropriate positions of gaze. As you do this, observe the patient’s eyes carefully rather than simply moving your finger through the examination pattern. Look for restriction of movement, diplopia, nystagmus or any asymmetry.

It is also important to ask the patient whether they experience diplopia, as this can provide an important clue when interpreting any abnormal eye movements.

To avoid forgetting this assessment, incorporate eye movements into your routine whenever you are performing a general ophthalmic examination, unless there is a clear reason not to. The aim is to make it part of your normal sequence rather than something you have to remember separately under OSCE pressure.

8. Assuming every red eye is conjunctivitis

Students often see a red eye and immediately think conjunctivitis. While conjunctivitis is a common cause of a red eye, it is important to remember that not every red eye is conjunctivitis. Conditions such as keratitis, anterior uveitis and acute angle-closure glaucoma can also present with a red eye, and some require urgent assessment and treatment.

When assessing a red eye, it is important not to focus on the redness alone. Instead, consider the associated symptoms and clinical findings. Ask about pain, photophobia, changes in vision and discharge. Contact lens use is also particularly important, as it can increase the risk of corneal infection (4,6).

A useful approach is to ask yourself four key questions: Is the eye painful? Is vision affected? Is there photophobia? Could this be sight-threatening? These features should prompt you to think beyond a simple diagnosis of conjunctivitis and consider more serious causes.

Developing this habit will help you avoid making assumptions based on redness alone. More importantly, it demonstrates good clinical reasoning in the OSCE and helps ensure that potentially sight-threatening conditions are not overlooked.

9. Failing to summarise and suggest the next step

Another common mistake is completing the examination and then stopping. Students can become so focused on performing the examination correctly that they forget to demonstrate what they would do with the findings.

An OSCE is not just about showing that you can perform an examination. You also need to demonstrate that you can interpret your findings and apply them clinically. The examiner wants to see that you can move beyond simply identifying an abnormality and understand what it might mean for the patient.

At the end of the station, summarise your findings clearly and, where appropriate, give your most likely diagnosis or a relevant differential diagnosis. You should then explain what you would do next. Depending on the scenario, this could involve performing a further examination, arranging additional investigations, starting treatment or referring the patient for specialist ophthalmic assessment. A concise summary also gives the examiner an opportunity to see that you understand the clinical significance of your findings, rather than simply following a memorised examination sequence.

To finish the station confidently, develop the habit of moving from your findings, to their clinical significance, and finally to the appropriate next steps. This demonstrates both your examination skills and your clinical reasoning.

10. Not knowing the common ophthalmology stations

Finally, students can sometimes make ophthalmology harder than it needs to be simply because they are unfamiliar with the types of stations that commonly appear in OSCEs.

Although the exact stations will vary between medical schools, there are several recurring themes that are worth becoming familiar with. These include visual acuity, pupillary examination and RAPD assessment, visual fields, eye movements, fundoscopy, red eye presentations, and the interpretation of ophthalmic images or clinical findings.

Ophthalmology OSCEs can assess both clinical skills and clinical reasoning, including history taking, examination and generating appropriate differential diagnoses (7). Becoming familiar with these common components can therefore help you approach stations in a more structured way.

You should also be comfortable recognising and discussing common ophthalmic conditions such as cataracts, glaucoma and diabetic retinopathy.You do not necessarily need to know every detail about these conditions, but you should understand their key clinical features, how they present and what the appropriate next steps would be.

Rather than trying to memorise hundreds of individual facts, focus on developing a structured approach to the common stations. Knowing what to do when you walk into a station will make the examination feel much less daunting and reduce the likelihood of forgetting important steps.

Practise the examination sequences repeatedly, ideally out loud and with a partner. Make sure you know what normal findings look like before moving on to recognising abnormalities. Then, for each important abnormal finding, develop an understanding of its clinical significance, possible causes and the appropriate next steps in management. The aim is not simply to memorise a checklist. It is to develop a consistent approach that allows you to remain calm, structured and clinically focused, even when you are under pressure.

Final thoughts

Ophthalmology OSCEs can seem overwhelming when you first encounter them. The equipment can look unfamiliar, the examinations can feel highly specialised and there is a lot of terminology to learn. The biggest improvement usually comes from repetition. Once the basic examination sequences become familiar, the equipment becomes much less intimidating and you can focus on interpreting what you actually see.

References

1. Baylis O, Murray PI, Dayan M. Undergraduate ophthalmology education: a survey of UK medical schools. Med Teach. 2011;33(6):468-471. doi:10.3109/0142159X.2010.540594.
2. Chadha N, Gooding H. Twelve tips for teaching ophthalmology in the undergraduate curriculum. Med Teach. 2021;43(1):80-85. doi:10.1080/0142159X.2020.1758649.
3. Hill S, Dennick R, Amoaku W. Present and future of the undergraduate ophthalmology curriculum: a survey of UK medical schools. Int J Med Educ. 2017;8:389-395. doi:10.5116/ijme.59ac.f69b.
4. Linaburg TJ, Hammersmith KM. Contact lens-related corneal infections. Infect Dis Clin North Am. 2024;38(4):795-811. doi:10.1016/j.idc.2024.07.010.
5. Stapleton F, Keay L, Edwards K, Naduvilath T, Dart JKG, Brian G, et al. The incidence of contact lens-related microbial keratitis in Australia. Ophthalmology. 2008;115(10):1655-1662. doi:10.1016/j.ophtha.2008.04.002.
6. Dart JKG, Radford CF, Minassian D, Verma S, Stapleton F. Risk factors for microbial keratitis with contemporary contact lenses: a case-control study. Ophthalmology. 2008;115(10):1647-1654. doi:10.1016/j.ophtha.2008.05.003.
7. Patil NS, Bal M, Khan Y. Medical student competence in ophthalmology assessed using the Objective Standardized Clinical Examination. Indian J Ophthalmol. 2023;71(5):2218-2221. doi:10.4103/ijo.IJO_2108_22.