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.
  • 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

A160
Patients need not be registered as sight impaired or severely sight impaired to benefit from low vision services. You should encourage patients to access low vision services as soon as they feel they need them, rather than waiting for significant visual loss, as this can lead to better outcomes.67
A161
You should assess all patients according to their needs.
A162
You should follow local protocols for the assessment and management of patients with low vision. 
A163
You should ensure the patient has had a recent eye examination, which determines their refraction and ocular health, before performing a low vision assessment. 
A164
You should consider the patient’s needs for emotional support and social care.
A165
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. 
A166
Low vision assessment is rarely a one-off process and you should encourage patients to return for follow-up assessments at appropriate intervals. This is in addition to any other regular optometric or ophthalmological care.   

Assessing patients with low vision

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If you do not have sufficient expertise to assess a patient with low vision you should refer the patient to someone who has. This may be an optometrist or a dispensing optician based in a low vision service, or the local social services department.
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You may need to assess the patient's:  
  1. needs. Some patients may have a personal care plan or low vision passport that would assist in this assessment
  2. visual acuity, including use of distance and near logMAR charts. If these are not available you may be able to use 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:
    • repeat field assessments, where necessary and possible, to obtain a meaningful result, and 
    • be aware of the limitations of static screening equipment particularly in cases of severe sight loss. If you do not have access to a conventional kinetic test, such as Goldmann, you should use confrontation type tests and Amsler charts for central vision to give practical advice to the patient
  7. binocular and accommodative status, where appropriate, for example in phakic children with low vision.
A169
When you have completed the appropriate assessments you should: 
  1. advise the patient of your findings and provide these in an accessible format.68 This may include large print, MP3, braille, or an easy read format
  2. pass on relevant information to the low vision team or other appropriate parties, with an explanation of the results.

See section on Consent.

References

68 Equality Act 2010 [accessed 9 Nov 2017]

Managing patients with low vision

A170
Following an assessment you should advise the patient, on: 
  1. their 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  differentiate between clinical measurements and practical ability, and
    • may need to demonstrate using practical tasks such as reading door signs, mobile phone screens, newspapers, timetables and packets 
  2. illumination as well as the use of specific tints and glare shields and non-optical devices
  3. the effects of the condition affecting their vision, and
  4. the benefits and disadvantages of low vision devices.
A171
You may wish to have 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.
A172
You should be aware of the impact sight loss may have on people who have other sensory, physical or intellectual impairment.

Referral

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You should follow local referral protocols. 
A174
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), which is 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.69
A175
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. 
A176
You should be aware that some patients 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 other sensory impairment or learning difficulties, and
  7. people in, or seeking, employment.
A177
You should advise patients to continue with their routine optometric or ophthalmological care.

Dispensing low vision devices

A178
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.70 
A179
You must supply the patient with the most appropriate low vision device. Factors to consider include magnification, care and ergonomics. 
A180
Advice on visual ergonomics should include reading posture, reading stands, copyholders, clipboards and higher reading additions.
A181
You should consider binocularity and accommodation when supplying a patient with any device. 
A182
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.
A183
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. 
A184

You must give appropriate instructions in writing to comply with the Medical Devices Directive.71

A185
You should be aware of the limitations of optical devices and direct patients to agencies that can advise on non-optical devices and electronic aids, such as electronic vision enhancement systems (EVES). 
A186
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. 
A187
Dispensing opticians are a valuable part of the low vision team. ABDO has advice and guidelines for their members on low vision practice.72
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