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Optometry

Read the following information.

Free OET Writing Sample Test with Answer Subtest Optometry #19

Write a referral letter to a neuro-ophthalmologist.

Case Notes

  • Patient: Mrs. Helen Roberts, 52 yrs

  • Medical history: Migraine, mild obesity

  • Presenting complaint: Sudden onset diplopia, drooping eyelid (RE), headache

  • Symptoms: Double vision, worse on looking sideways, blurred reading vision

  • Examination findings:

    • VA: RE 6/9, LE 6/9

    • Pupils: Equal, reactive

    • RE: Ptosis present, limited ocular motility (suggestive of CN III palsy)

    • Fundus: Normal OU

  • Concerns: Possible cranial nerve involvement, aneurysm not excluded

  • Request: Urgent neuro-ophthalmology referral for imaging and diagnosis

Neuro-Ophthalmology Department
City University Hospital

Dear Doctor,

I am referring Mrs. Helen Roberts, a 52-year-old woman, with an acute presentation of diplopia and ptosis, for urgent assessment.

Mrs. Roberts reported sudden double vision with a drooping right eyelid and associated headache. Symptoms worsen with lateral gaze, and reading has become difficult.

Examination showed visual acuity of 6/9 bilaterally. The right eye displayed ptosis and restricted ocular motility consistent with cranial nerve III palsy. Pupils were equal and reactive. Funduscopy was normal in both eyes.

Given the acute presentation and risk of an underlying aneurysm, I strongly recommend urgent neuro-ophthalmological evaluation and imaging to establish the cause and initiate management.

Thank you for your immediate attention.

Yours sincerely,
Optometrist

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