Cases/Neurology

Sudden Double Vision and A Droopy Eyelid — Free SCA Practice Case

Man with sudden double vision and a droopy eyelid

Station Timer

12:00

Golden Minute

Initial Introduction

•Introduce yourself

•Ask an open question — "How can I help you today?"

•Listen — don't interrupt

•Catch early cues

Data Gathering

History, ICE & Diagnosis

Clinical Management

Diagnosis, Plan & Decisions

Safety Net

Follow-up & Close

12:00

Golden Minute

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Materials for Candidate

Please review before starting the consultation

Patient Profile

Full Name

Dilip Mistry

Age

58 years

Consultation Type

Telephone

Age

Situation

Telephone Consultation. Same day appointment booked when he rang as the surgery opened.

Reason for Encounter

"Woke up seeing double this morning and my left eyelid is drooping. I've got a headache behind that eye as well. I've an eye test booked at the optician on Friday, so can I just wait for that?"

Medical Records

●PMH: Hypertension. No diabetes.
●Medications: Amlodipine 5 mg once daily.
●Allergies: NKDA.
●Social: Smoker, about 20 a day. Area sales representative, drives a company car.
●Last review, 5 months ago: BP 136/82. HbA1c 38 mmol/mol, eGFR 84.

Patient Script

For the friend playing the patient role

Character Overview: You are Dilip Mistry, a 58 year old area sales representative for a company that supplies industrial fixings to builders' merchants and factories. You drive about 25,000 miles a year in a company car. You live with your wife Rekha in a terraced house. Your daughter Hetal lives a couple of hours away. You are practical, polite and a bit gruff, and you hate making a fuss. Apart from blood pressure checks you have not seen a doctor in about ten years. You are ringing from your kitchen. Rekha works afternoons, so she is in the next room.

You woke this morning with double vision and a left eyelid that had come down. You are annoyed and inconvenienced, and you privately think it must be your eyes. You have been squinting at order sheets for months and your last eye test was about four years ago. You have an eye test booked at the optician on Friday and you are sure new glasses will sort it out, so you mostly want to hear that it is fine to wait. You are covering a colleague's patch this week with important customer visits tomorrow and the day after, and you do not want to let your short staffed manager down. You cancelled today's calls and have not driven since you woke up. You plan to drive tomorrow if you possibly can. You do not volunteer any of this until asked.

Underneath, the droopy eye and the headache bother you more than you admit, because they remind you of what happened to your uncle. You will only say so if the doctor takes time to ask how you are really feeling about it.

Opening Sentence: "Morning doctor. I woke up this morning seeing double, and my left eyelid's drooping, and I've got a headache behind that eye. I've got an eye test booked at the optician on Friday, so I was wondering if I can just wait for that."

History if Asked (Data Gathering Phase)

●The double vision: "I woke up this morning and there were two of everything. Two pictures, one sitting a bit above and off to the side of the other. It's been like that all morning and doesn't come and go. It's worse when I look over to my right. It's never happened before and it isn't worse when I'm tired."
●Covering one eye: "I tried that in the bathroom. Covering either eye, it goes back to one picture. It's only double with both open."
●The eyelid: "My left lid's come down about halfway. I can still see out of it, just. The right one's normal."
●The eye itself: If asked whether anyone has noticed anything about the eye: "Rekha says it looks different. She says it's sort of pointing off to the side."
●The pupil and light: If asked about the pupil, the black part of the eye, or the pupil sizes: "Rekha says the black bit in the middle of the left one looks bigger than the right one." If asked about bright light: "Yes, the window light bothers that eye more than the other one. I've been squinting."
●Sight itself: "I haven't lost any sight. If I cover one eye it isn't blurry. It's just double when I use both."
●The headache: "A dull ache behind my left eye. It started yesterday evening about seven while I was watching telly. I thought I was just tired. It's about four or five out of ten. Two paracetamol last night took the edge off and I had two this morning. It's still there."
●How the headache came on: If asked whether it was sudden or the worst ever: "No, it crept up on me. It's nothing like the worst headache I've ever had."
●Warning symptoms: "No stiff neck, no sickness, no temperature that I know of, no knock to the head."
●Other nerve and brain symptoms: "No weakness or numbness, my face feels normal apart from the eye, speech and swallowing are fine, I'm steady on my feet and not confused."
●Scalp, jaw and general symptoms: "My scalp isn't sore. Chewing is fine, I had toast. No aching in my shoulders or hips, no fever, no sweats, no weight loss. Apart from this I feel well."
●Other symptoms: If asked about pain moving the eye, a red or watering eye, flashing lights, floaters, an injury, or recent illness: "No, none of that."
●Eye history: "No eye problems or operations. I use cheap reading glasses from the chemist. My last proper eye test was about four years ago."
●Impact today: "I can't read an order sheet or my phone properly. I keep misjudging distances."
●Driving: If asked whether he has driven: "Not since I woke up. I rang the office and cancelled today's calls. But I need the car tomorrow and the day after, so I'm hoping this'll be sorted by then." If asked what he drives: "A company car. I've an ordinary car licence."

Ideas, Concerns, Expectations

Gating note: Not volunteered. These surface only when the candidate explores the patient's perspective.

●Ideas: He thinks it is his eyes. "I think I need new glasses. I've been squinting for months. Maybe I've strained them."
●Concerns: On the surface, a wasted day in A&E and letting his manager down. "If I'm sat in A&E all day I miss the visits and my boss won't be happy." If the doctor asks how he is really feeling about it, or takes time over his worries, his voice drops: "To be honest, I don't like the headache bit. And the eye all droopy like this, it reminds me of what happened to my uncle. I'd rather not think about it. I'd much rather it was just my glasses."
●Expectations: He wants to be told it is fine to wait until Friday, or to have a letter for the optician. "Can you write something so they look at it properly?"

If Asked: Medical History and Medications

●Blood pressure: "I've had high blood pressure about three years. I take one tablet in the morning, amlodipine. They checked it a few months ago and said it was fine. Just a bit of puffy ankles by the evening."
●Diabetes and other conditions: "No diabetes. They did a sugar test with my bloods and it was normal. No heart trouble, no stroke, nothing like that."
●Blood thinners and other medicines: "No aspirin or anything like that. Just the paracetamol the last day or so. No supplements."
●Allergies: "None."
●Family history: "My dad had a heart attack when he was 66. My mum has diabetes. My dad's brother, my uncle, had a stroke in his seventies. Nobody's died suddenly that I know of."

Social History and Lifestyle Impact

●Home: Rekha is at home now and has her own small car.
●Work: 14 years in the job, on the road most days. "If I can't drive, I can't do the job, and my manager's got nobody else to cover."
●Smoking: "About twenty a day, a packet. I started when I was 19."
●Alcohol: "A couple of pints on a Saturday."

Responses to Management (The Negotiation Phase)

●
If the Doctor suggests going to hospital today:
- ●Reaction: Surprised and resistant. "Today? To hospital, for a droopy eyelid? Can't it wait till Friday when I'm seeing the optician?" If told the optician cannot arrange the scans this needs: "Right. I hadn't thought of that. I thought they could do more." If A&E is mentioned: "I'll be sat there eight hours on a plastic chair." If told the hospital will be warned he is coming: "Well, if you ring ahead, that does help. All right."
●
If the Doctor explains the worry in plain words (a nerve to the eye being squeezed, possibly by a weak spot in a blood vessel at the base of the brain):
- ●Reaction: Alarmed. "A bleed? In my head? Hang on, you're scaring me now. Is that what you think it is?" He steadies if given an honest answer: it is not the most likely cause, but it must be ruled out today, and it can be treated if found early.
●
If the Doctor says it is probably nothing, or offers a routine referral, a two week referral, an appointment in a few days or an urgent optician appointment:
- ●Reaction: Relieved and quick to agree. "Oh good. So Friday's fine then? I'll keep the optician appointment."
●
If the Doctor asks how he will get there, or suggests an ambulance:
- ●Reaction: "Rekha's here, she can take me. She doesn't like the big roads to that hospital, mind, but she'll do it." If an ambulance is suggested: "An ambulance? I can walk and talk fine. That seems a bit over the top." He accepts it if the reason is explained.
●
If the Doctor tells him not to drive, or mentions the DVLA:
- ●Reaction: Dismayed. "Not drive? I need the car tomorrow. How long for? Will they take my licence off me? Do I have to tell the DVLA?" He settles if he hears that driving can start again once the double vision is controlled and the DVLA has been told. If a fit note is offered: "My manager will want one of those, yes."
●
If the Doctor asks him to look at his pupils, move his eyes, cover an eye or test his vision now:
- ●Reaction: Politely declines. "I wouldn't know what I was looking for. Can't someone look at it properly? Do I need to come in?"
●
If the Doctor gives safety netting, or asks him to repeat the plan:
- ●Reaction: If vague ("come back if it gets worse"): "Worse how? What would I be looking out for?" If specific: "Can you say that again slowly? I want to tell Rekha." Repeats the plan back correctly if it has been clear: "Right. Rekha takes me to the hospital now, I don't drive, I tell them the doctor rang ahead, and if the headache goes really bad or I feel sick or drowsy I ring 999. I'll ring my manager." If asked whether the practice will check on him: "Ring Rekha's mobile if I don't pick up."

Mark Scheme

Domain 1: Data Gathering and Diagnosis

0 / 16 indicators checked+0−0

Positive (0/8)

Negative (0/8)

Domain 2: Clinical Management and Medical Complexity

0 / 20 indicators checked+0−0

Positive (0/10)

Negative (0/10)

Domain 3: Relating to Others

0 / 14 indicators checked+0−0

Positive (0/7)

Negative (0/7)

Clinical Learning Points

The Core Dilemma and the Model Plan

●Dilip is 58, has treated hypertension, smokes 20 a day, and woke with double vision, a drooping left lid and a dull ache behind the left eye. His wife has noticed the eye turning out and a bigger pupil. He thinks he needs glasses and wants to wait for his optician on Friday.
●Model answer: a painful, probably pupil involving third cranial nerve palsy, until proven otherwise a compressing aneurysm, which needs emergency assessment and imaging of the brain and its arteries today. Recognise the pattern, explain it plainly, arrange safe travel now with a phone call ahead, tell him not to drive and to notify the DVLA, give specific 999 triggers, and check later that he arrived.
●Also acceptable: a lift from his wife or a 999 ambulance; the emergency department, or a direct call to on call ophthalmology or acute medicine if that team can arrange same day imaging (routes vary, so follow the local pathway); examining or seeing him in person first, provided the hospital referral still happens today; naming giant cell arteritis and leaving steroids to the hospital, or giving a one off steroid dose on ophthalmology advice.
●Not acceptable: waiting for Friday, an urgent optician appointment, a routine or two week referral, an outpatient scan, or relying on a pupil check by phone.

Recognising a Third Nerve Palsy

●The third nerve lifts the lid, moves the eye up, in and down, and constricts the pupil. Loss gives ptosis, an eye turned down and out, and a dilated pupil that reacts poorly. Dilip's diplopia is worse looking right because the left eye cannot move in.
●The double vision is binocular: it goes when either eye is covered. Monocular diplopia persists with one eye covered and points to an eye cause such as refractive error or cataract.
●Palsies can be partial. A 2026 systematic review found double vision (about 61%), ptosis (about 54%), pain (about 46%) and pupil involvement (about 41%), so no feature is always present.
●Over the phone you cannot examine the pupils, lid or eye movements. Use the history, including what his wife has seen. Do not ask him to test himself or rely on what he reports.

Why the Pupil Matters, and Why a Normal Pupil Does Not Reassure

●The pupil fibres run on the outside of the nerve, so a swelling aneurysm compresses them early, whereas ischaemic palsies tend to spare the pupil. A 2025 review of posterior communicating artery aneurysm palsies reports pupil involvement in about 98.6% and ipsilateral periorbital pain in more than half.
●The same review gives aneurysm as about 6% of acquired third nerve palsies and about 11% over 60, with ischaemic cerebrovascular disease the commonest cause. An aneurysm is not the likeliest cause but is the one that cannot be missed because of the risk of rupture. Smoking and hypertension are the main modifiable risk factors for aneurysm formation and rupture, and Dilip has both, so his vascular risk sharpens the concern rather than reassuring.
●Pupil sparing is not a safe reason to wait. In a 2026 series of 51 adults, 3 of 9 structural causes had a normal pupil, and the authors concluded that pupil sparing did not reliably exclude a significant lesion. Specialist reviews advise vascular imaging for everyone with a palsy as soon as possible.

The Differential and How the History Separates It

●Ischaemia of the nerve: the commonest cause, linked to hypertension, diabetes and smoking. Dilip has hypertension and smokes 20 a day. It is a diagnosis made only after structural causes are excluded.
●Posterior communicating artery aneurysm: pupil involving, often painful. Sudden severe headache, neck stiffness, vomiting or collapse would suggest a bleed has already happened; NICE NG228 covers subarachnoid haemorrhage.
●Giant cell arteritis: over 50, scalp tenderness, jaw claudication, visual loss, polymyalgia symptoms, fever or weight loss. Dilip has none, but delay can cost sight.
●Brainstem stroke: limb weakness, numbness, speech or swallowing change, unsteadiness.
●Myasthenia gravis: lid and double vision that fluctuate, worsen with tiredness and spare the pupil. His symptoms are constant and painful.
●Other: tumour or inflammation near the cavernous sinus, trauma, infection. The same imaging and specialist assessment cover these.

Same Day Assessment, Transport and Handover

●No NICE guideline or CKS topic covers isolated third nerve palsy. The emergency plan rests on specialist reviews and on the CKS rule for giant cell arteritis that double vision means immediate referral for same day ophthalmology assessment.
●He is alert with a gradually built headache, so a lift from his wife who can leave now is reasonable. An ambulance is better if there is no safe lift, if he worsens, or if travel would be delayed. He must not drive.
●Phone ahead and give age, vascular risk factors (hypertension and smoking 20 a day), a painful drooping lid with diplopia and a possible larger pupil, and the question: urgent vascular imaging for a possible aneurysm, with inflammatory markers because of his age.
●A check in the surgery is reasonable only if it does not replace or delay the hospital referral. A normal pupil in the surgery would not make waiting safe. A community optometrist cannot arrange emergency vascular imaging.
●Afterwards the practice should confirm that he arrived and review the outcome. If the cause is ischaemic, blood pressure, smoking cessation (he smokes 20 a day) and cardiovascular risk need review, and NICE NG136 supports his amlodipine as step 1 treatment at his age without diabetes.

Giant Cell Arteritis in a Man Over 50 With Double Vision

●NICE CKS on giant cell arteritis (revised January 2026) says to suspect it in a person aged 50 or over with new headache or acute visual disturbance such as double vision. With double vision, vision loss or field loss it advises referral to ophthalmology immediately for urgent same day assessment, and the specialist may recommend a one off high dose corticosteroid in primary care while he waits.
●Where giant cell arteritis is strongly suspected without visual symptoms, CKS advises immediate high dose prednisolone, with inflammatory markers taken before or just after the first dose and no delay to referral for results.
●Dilip has no features that make it strongly suspected, and the dominant concern is a compressive cause, so empirical steroids at home instead of assessment are not appropriate. The hospital will check inflammatory markers and decide.

Driving and the DVLA

●DVLA guidance on visual disorders (updated 26 September 2025) says that drivers with diplopia, car and motorcycle (Group 1) and bus and lorry (Group 2), must not drive and must notify the DVLA.
●For Group 1, driving may resume after the DVLA has received confirmation that the diplopia is controlled, for example by glasses or a patch with an undertaking to use it while driving. Exceptionally, stable uncorrected diplopia of 6 months or more may be licensable with a specialist report. Group 2 licences are refused or revoked for insuperable diplopia.
●Dilip drives a company car on a standard car licence (category B, up to 3,500 kg), so Group 1 applies. The duty to notify is the driver's, so tell him clearly, record that you did, and acknowledge what it means for his job. A fit note and help planning what to tell his manager are sensible extras.

Communication With a Reluctant, Practical Patient

●Start with his reasons. Waiting for the optician made sense from where he sat, and missing the customer visits matters to him.
●Explain in plain words: a nerve that lifts the lid and moves the eye is being squeezed or starved of blood, one cause is a weak spot on a blood vessel at the base of the brain that can bleed, it is not the commonest cause, but it can be treated if found early, so it must be ruled out today.
●Be honest about uncertainty. Do not say it is probably nothing, do not state it is certainly an aneurysm, and do not promise recovery.
●Ask how he feels. His fear is his uncle's stroke; naming it kindly makes agreement easier.
●Remove barriers: who drives, phoning ahead, the wait in A&E, what to tell his manager. Ask him to repeat the plan and involve his wife.

Common Mistakes in This Station

●Accepting Friday, or offering an urgent optician appointment as the safe option.
●Referring routinely, by a two week pathway, or arranging an outpatient scan.
●Treating the headache as migraine or tension type because it is mild.
●Missing the pupil history, or deciding it is safe because the pupil seems normal.
●Asking him to test his own pupils or eye movements by phone and relying on the answer.
●Letting him drive himself, or giving no driving or DVLA advice.
●Starting prednisolone at home in place of assessment, or never thinking of giant cell arteritis.
●Frightening him without a plan, or reassuring him falsely.
●Safety netting of "come back if it gets worse" with no 999 triggers, and no check that he reached hospital.

Mapped to the RCGP curriculum topic: Neurology.

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