This Guidance does not change what you must do under the law.

When examining a patient who has a disability you must make reasonable adjustments to enable you to perform the relevant tests.³³ These would include:

1. allowing additional time where necessary
2. having instruments that are suitable to use on patients who are unable to move their head or put their chin on the chin rest of table mounted instruments. Examples of what would be suitable include a direct ophthalmoscope, handheld tonometer, and trial frame and lenses rather than a refractor head.

Do not assume that just because a patient has a disability, they are unable to understand you or interact with you normally. You should always speak directly to the patient, rather than to their companion.

Do not be embarrassed to ask the patient what has caused their disability or how long they have had it for.

Be flexible in your examination techniques, and be prepared to adapt your routine to accommodate the patient’s individual needs.

Patients may be confined to a wheelchair for many different reasons. It may be permanent or temporary, recent or longstanding. You should ask the patient why he or she is in the wheelchair and for how long.

Practices should ensure that wheelchair users have access to the instruments that are needed for their examination, such as a slit lamp, tonometer and visual field screener. Where this is not possible a comparable alternative must be made available.

You should ask the patient if they are able to transfer to the consulting room chair. The level of disability is not necessarily a guide as to whether a patient will be willing or able to do this. You should explain that you will be able to examine the patient in their wheelchair, but that they will be able to have more tests done if they can transfer to the consulting room chair. If the patient agrees to transfer you should:

1. ask the patient what the best position is for their wheelchair to help the patient to transfer out of it
2. lock the consulting room chair in position
3. ask the patient if they would like you to lift the armrests and/or footrest on the consulting room chair out of the way
4. ask the patient what help, if any, they would like
5. tell the patient that they transfer to the consulting room chair at their own risk.

If the patient remains in their wheelchair, positioned in front of the consulting room chair you should:

1. make sure that when you are talking to the patient you are able to look them in the eyes, rather than speaking to the patient from behind
2. make the necessary adjustments to ensure the patient can see the letter chart in the mirror. This may be by:
   • asking the patient, still in their wheelchair, to sit on a thick cushion to raise them up
   • tilting the mirror downwards, or
   • having a separate mirror on a stand that you bring into the consulting room
3. record the distance at which the test was conducted, for example 5/6 rather than 6/6
4. adjust the prescription that you find to take into account the reduced distance of the patient from the test chart. 

You should make clear notes of the adjustments that you made to your examination technique. This will help any follow-on optometrist understand what worked for this particular patient.

When you examine a patient who has hearing loss you should ask them how they would prefer you to communicate with them.

You should allow an appropriate amount of extra time for the consultation.

To help with communication, you should:

• face the patient and maintain eye contact to enable the patient to lip read
• keep your hands away from your face when talking. Be aware that beards and moustaches can also make it more difficult for people to lip read
• speak slowly, clearly and distinctly, but do not exaggerate mouth movements. Use short sentences where possible, and pause between sentences
• not shout
• minimise background noise if possible
• watch for the facial expressions that may indicate that the patient has not understood you, and rephrase what you have said rather than repeating it
• only turn the consulting room lights off when needed, and tell the patient before turning the lights off. Do not put the refractor head in front of the patient’s face until necessary. Where possible, move the refractor head away from the patient when speaking to them
• be patient, and repeat what you have said where necessary
• provide clear and accessible written advice if you are not confident that the patient has understood your verbal advice.  

(Also see sections on Examining patients with learning disabilities, Examining autistic patients and Examining patients with specific learning difficulties). 

If the patient has age-related hearing loss, they may find it more difficult to hear higher pitched voices, such as women’s and children’s voices. You can help these patients to hear you by lowering your voice.

You should explain what you are going to do before you do it, for example before asking the patient to put their head on the slit lamp, or bringing the refractor head in front of their face. 

If the patient prefers to communicate using an interpreter,³⁴ you should use a relevant accredited interpreter to protect both you and the patient. If the patient is an NHS patient you may contact your local NHS organisation to see what arrangements they have for providing this service. You may choose to use a video-interpreting service, using a video phone or other device.³⁵ You should talk directly to the patient rather than the interpreter. 

If you use pen and paper to help communicate, remember that patients who use British Sign Language (BSL) do not have English as their first language. You should therefore use shorter, simpler words and sentences where possible.

The BSL fingerspelling alphabet is useful to help communicate with deaf patients.