Assessing and managing patients with low vision
- Patients need not be registered as sight impaired or severely sight impaired to benefit from low vision services.
- You should assess all patients according to their needs.
- You should follow local protocols for the assessment, referral and management of patients with low vision.
- You should consider the patient’s needs for emotional support and social care.
- Low vision assessment and management is multidisciplinary.
- Low vision assessment is rarely a one-off process.
- You should refer the patient if you do not have sufficient expertise to assess a patient with low vision.
- You should give written information about your findings to patients in appropriate formats and comply with the Medical Devices Directive.
- You should provide patients with full and relevant advice following an assessment.
- You should be aware of the risks of secondary eye disease in low vision patients.
- The supply of spectacles or contact lenses to patients who are registered as sight impaired or severely sight impaired must be carried out by, or under the supervision of, an optometrist, dispensing optician or doctor.
- Patients need not be registered as sight impaired or severely sight impaired to benefit from low vision services; however, patients must have a diagnosis of vision impairment, or a working diagnosis, before they access low vision services.
- You should follow local protocols for the assessment and management of patients with low vision.
- You should ensure the patient has had a recent eye examination, which determines their refraction and ocular health, before performing a low vision assessment.
- You should understand the multidisciplinary nature of low vision assessment and management and give patients the contact details of other members of the low vision multidisciplinary team or other relevant parties, as appropriate.
- You may supply low vision devices, but you should be aware of your responsibility to ensure patients have access to wider rehabilitative and social care, as required. In the case of children and young people this includes their education and developmental needs. For adults, this might include awareness of access to employment schemes.
- Low vision assessment is rarely a one-off process and you should encourage patients to return for follow-up assessments at appropriate intervals. This will help them to get the best from their sight and any low vision devices. This is in addition to any other regular optometric or ophthalmological care.
- If you consider you do not have sufficient expertise to assess a patient with low vision you should refer the patient to someone who has, for example an optometrist or a dispensing optician based in a low vision service, or to the local social services department.
- You may need to assess the patient's:
- needs in the context of their educational, work or social care situation and get a briefing from a rehabilitation, education or other relevant professional, or take an extended history, concentrating on the patient’s practical needs resulting from their low vision. Some patients may have a personal care plan or low vision passport that would assist in this assessment
- visual acuity in relation to low vision, including use of distance and near logMAR charts. If these are not available you may be able to utilise conventional charts to achieve meaningful results
- contrast sensitivity
- glare function
- central visual function using, for example, Amsler charts and appropriate colour vision tests
- visual field. You should:
- if possible, repeat field assessments, where necessary, to obtain a meaningful result
- be aware of the limitations of static screening equipment particularly in cases of severe sight loss, for example if you do not have access to a conventional kinetic test, such as Goldmann, use confrontation type tests and Amsler charts for central vision to give practical advice to the patient
- give results from visual field assessments, where the patient consents, to rehabilitation, educational and any other relevant professionals. You should note that not all these professionals would be conversant with field analysis so, where possible, give additional explanation, and
- be aware that as well as giving an assessment of functional vision, for example residual peripheral vision in conditions such as glaucoma, visual field tests may also be used in screening for new, and monitoring progression of, existing disease, and
- pay particular attention to measurement of binocular and accommodative status, where appropriate, for example in phakic children with low vision.
- When you have completed the appropriate assessments you should:
- advise the patient of your findings and provide them in a format that is appropriate to the patient’s needs.46 This may include large print, MP3, braille, or an easy read format which is important for patients who have memory or comprehension difficulties
- ask for the patient’s consent to pass on relevant information to the low vision team or other appropriate parties and, if they consent, pass information on in a meaningful form to people in charge of the patient’s educational or social care.
See section on Consent.
46 Equality Act 2010 [accessed 4 Dec 2013]
- Following an assessment you should advise the patient, as appropriate, using suitable formats and terminology, on:
- visual function relating to visual acuity and contrast sensitivity levels; you:
- should explain this to the patient in relation to both threshold and sustained visual function
- should be aware of the need to differentiate between clinical measurements and practical ability, and
- may need to use practical tasks such as reading door signs, mobile phone screens, newspapers, timetables and packets for demonstration purposes
- illumination for visual tasks as well as the use of specific tints and glare shields and non-optical devices such as typoscopes
- the cause and effects of the condition affecting their vision, and
- the benefits and disadvantages of optical appliances and other low vision devices – see paras A170-A172.
- visual function relating to visual acuity and contrast sensitivity levels; you:
- You may also consider providing a report or low vision passport that specifically outlines the patient’s visual function status.
- You may wish to have low vision packs available which provide information on the most common eye conditions that cause low vision and on support services, such as talking books, holidays, safety at home, lighting and travel.
- You should refer patients, where possible, to:
- named rehabilitation or other appropriate professionals with specific advice for the professional about the patient’s visual function and copied to the patient
- appropriate local professionals to advise on services, a Low Vision Services Committee or an Eye Clinic Liaison Officer who may operate in your area.
- In England additional information for social care agencies can be provided by both the low vision leaflet (LVL), which is completed by the patient, and the referral of vision impairment (RVI), completed by the practitioner. You should advise patients about the process for certification of vision impairment (CVI) which is completed by a consultant ophthalmologist and registered by local social services departments.47
- You should ensure all patients have access to ophthalmological opinion, where appropriate, irrespective of their registration status and the severity or length of term of their sight loss.
- You should be aware of the risks of secondary eye disease, associated with ageing and some congenital eye conditions.
- You should be aware of the groups of patients that may need additional support to access services particularly at the onset of visual impairment. These include:
- older people
- people whose first language is not English
- people who live alone
- people with learning difficulties, and
- people in, or seeking, employment.
- You should advise patients to continue with their routine optometric or ophthalmological care since the impact of additional disease on their existing problem may be significant.
47 Department of Health (2013) Registering vision impairment as a disability [accessed 4 Dec 2013]
- The supply of spectacles or contact lenses to patients who are registered as sight impaired or severely sight impaired must be carried out by or under the supervision of an optometrist, dispensing optician or doctor.48
- You must supply the patient with the most appropriate low vision device so the patient can make best possible use of it and the optimum use of their vision. This includes magnification, care and ergonomics.
- Advice on visual ergonomics should include reading posture, reading stands, copy holders, clip boards and higher reading additions.
- Devices may also include:
- writing frames and signature guides
- glare shields, or
- specialist tinted lenses.
- You should be familiar with the optical characteristics of devices and whether a specific spectacle correction is required for optimum use of each device.
- Before you supply any device you should assess patients carrying out relevant practical tasks with the device to identify any limitations, such as using a switch or left or right hand use.
- After supplying any device you should provide the patient with full instructions on:
- the tasks the device has been issued for
- how to use the device, including:
- how far the device should be held from the eye and the object
- which spectacles, if any, to use with it, and
- any specific advice on lighting
- the initial programme of low vision training, including:
- reading or skill practice
- what post-supply support is available, and
- care, storage and cleaning of the device, including maintenance of batteries and integral lamps if appropriate.
- You must give appropriate elements of these instructions in writing to comply with the Medical Devices Directive.49
- You should advise patients in writing of any required changes in the type of device, its use and realistic goals. You should record this advice on the patient record.
- You should be aware of the limitations of optical devices and direct patients to agencies that can advise on non-optical devices, including electronic aids such as electronic vision enhancement systems (EVES).
- If you consider a low vision aid is unnecessary or unsuitable, or the patient rejects it, you should explain to the patient that their situation or technology may change and encourage the patient to return for regular assessments.
- Dispensing opticians are a valuable part of the low vision team. ABDO has advice and guidelines for their members on low vision practice.50
48 Opticians Act 1989 s27(1)(b)
49 Council Directive 93/42/EEC concerning medical devices  OJ L169/1 [accessed 4 Dec 2013]
50 Association of British Dispensing Opticians. Advice and guidelines on professional conduct for dispensing opticians: 2.19-2.23 [accessed 4 Dec 2013]
College of Optometrists. Professional Certificate in Low Vision. [accessed 23 Aug 2014]
International Glaucoma Association
Low Vision Service Wales
Blind Children UK
NHS Eyecare Services Programme (2007) Recommended standards for low vision services. [accessed 4 Dec 2013]
NHS Education for Scotland. The Knowledge Network
National Institute for Health and Care Excellence (2013) Falls: assessment and prevention of falls in older people. Clinical guideline 161. London: NICE [accessed 26 Jul 2016]
Partially Sighted Society
Ryan B, Woodhouse M, Sinclair A (2009) Low vision, the essential guide for optometrists. Reading: Guide Dogs for the Blind Association and London: College of Optometrists
Vision 2020 UK