The College of Optometrists

Assessing and managing patients with low vision

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Sub-sections

Key points

  • 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.

Principles of assessing and managing patients with low vision

A147
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. 
A148
You should assess all patients according to their needs.
A149
You should follow local protocols for the assessment and management of patients with low vision. 
A150
You should ensure the patient has had a recent eye examination, which determines their refraction and ocular health, before performing a low vision assessment. 
A151
You should consider the patient’s needs for emotional support and social care.
A152
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. 
A153
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.
A154
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.   

Assessing patients with low vision

A155
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. 
A156
You may need to assess the patient's:  
  1. 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
  2. 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
  3. contrast sensitivity
  4. glare function
  5. central visual function using, for example, Amsler charts and appropriate colour vision tests
  6. 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
  7. pay particular attention to measurement of binocular and accommodative status, where appropriate, for example in phakic children with low vision.
A157
When you have completed the appropriate assessments you should: 
  1. 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
  2. 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.

References

46 Equality Act 2010 [accessed 4 Dec 2013]

Managing patients with low vision

A158
Following an assessment you should advise the patient, as appropriate, using suitable formats and terminology, on: 
  1. 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 
  2. illumination for visual tasks as well as the use of specific tints and glare shields and non-optical devices such as typoscopes
  3. the cause and effects of the condition affecting their vision, and
  4. the benefits and disadvantages of optical appliances and other low vision devices – see paras A170-A172.
A159
You may also consider providing a report or low vision passport that specifically outlines the patient’s visual function status.
A160
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.
A161
You should be aware of the impact sight loss may have on people who have other sensory, physical or intellectual impairment.

Referral

A162
You should refer patients, where possible, to: 
  1. named rehabilitation or other appropriate professionals with specific advice for the professional about the patient’s visual function and copied to the patient
  2. appropriate local professionals to advise on services, a Low Vision Services Committee or an Eye Clinic Liaison Officer who may operate in your area.
A163
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 
A164
You should follow local referral protocols. 
A165
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. 
A166
You should be aware of the risks of secondary eye disease, associated with ageing and some congenital eye conditions. 
A167
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: 
  1. older people
  2. children
  3. people whose first language is not English
  4. carers
  5. people who live alone
  6. people with learning difficulties, and
  7. people in, or seeking, employment.
A168
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. 

Dispensing low vision devices

A169
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 
A170
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. 
A171
Advice on visual ergonomics should include reading posture, reading stands, copy holders, clip boards and higher reading additions.
A172
Devices may also include: 
  1. typoscopes
  2. writing frames and signature guides
  3. glare shields, or
  4. specialist tinted lenses.
A173
You should be familiar with the optical characteristics of devices and whether a specific spectacle correction is required for optimum use of each device. 
A174
You should consider binocularity and accommodation when supplying a patient with any device. 
A175
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.
A176
After supplying any device you should provide the patient with full instructions on: 
  1. the tasks the device has been issued for
  2. 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
  3. the initial programme of low vision training, including:
    • reading or skill practice
    • aftercare
    • what post-supply support is available, and
  4. care, storage and cleaning of the device, including maintenance of batteries and integral lamps if appropriate. 
A177
You must give appropriate elements of these instructions in writing to comply with the Medical Devices Directive.49
A178
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. 
A179
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). 
A180
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. 
A181
Dispensing opticians are a valuable part of the low vision team. ABDO has advice and guidelines for their members on low vision practice.50
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