The College of Optometrists

Examining patients with learning disabilities

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Key points

  • Patients with learning disabilities may have additional ocular conditions and other health problems.
  • You should use tests and procedures that are appropriate to the patient’s needs.
  • You must follow the guidance on consent when discussing the patient’s condition with a relative or carer.
  • When you communicate with the patient, you should talk directly to them rather than their carer.
  • If possible, in advance of the appointment, you should discuss with the patient and their relative or carer what adjustments may be needed to help them understand information and participate in the examination.
  • You should provide the patient and relative or carer with a written, as well as a verbal, report.
This guidance does not change what you must do under the law.
The Mental Capacity Act 2005 and the Equality Act 2010 are particularly relevant to examining adult patients with learning difficulties.

Definition of learning disability

A learning disability is a reduced intellectual ability and difficulty with everyday activities, for example household tasks, socialising or managing money, which affects someone for their whole life. People with a learning disability tend to take longer to learn and may need support to develop new skills, understand complex information and interact with other people. The level of support someone needs depends on individual factors, including the severity of their learning disability.26


26 Mencap Learning disability explained [Accessed 26 Oct 2017]

Some causes of learning disability

The major causes of learning disability in the UK are:27
  • unknown aetiology
  • prematurity
  • chromosomal disorders
  • Down’s syndrome
  • Fragile-X syndrome
  • cerebral palsy
  • genetic disorders
  • metabolic disorders
  • iatrogenic disorders.

Ocular and health conditions of patients with learning disabilities

Patients with learning disabilities can have the same range of visual problems as the general population. It has been estimated that people with learning disabilities are ten times more likely to have specific ocular conditions,28  including:
  1. amblyopia
  2. blepharitis – common in people with Down’s syndrome
  3. cataract
  4. concomitant strabismus
  5. cortical visual impairment
  6. entropion – common in people with Down’s syndrome
  7. field defects
  8. high refractive error – especially myopia and astigmatism
  9. impaired accommodation
  10. keratoconus
  11. nystagmus
  12. reduced vision.
Some people with learning disabilities may also have a wider range of health problems than the general population and may have other disabilities, including hearing impairment.

Principles of examining patients with learning disabilities

When examining a patient with learning disabilities you should:
  1. make reasonable adjustments to the patient’s eye care, for example by using a range of tests and procedures that are appropriate to the needs of the patient, and
  2. seek their consent to get a briefing from a relative or carer, if necessary.
If they are unable to consent, refer for advice to the section on Consent.
Encourage the patient to attend with a relative or carer if they are unlikely to be able to give full and accurate details, history and the reason for visit.
When examining a patient with learning disabilities you should:
  1. encourage the patient to visit your premises before their eye examination to help them become familiar and comfortable with the environment
  2. encourage the patient and carer to complete SeeAbility’s ‘Telling the optometrist about me’ form29  and bring it to the eye examination
  3. find out how the patient likes to communicate and how their disabilities affect them
  4. find out about any recent signs, symptoms or behavioural changes that might be relevant
  5. ask to refer to the patient’s health action plan or communication passport, if they have one
  6. be prepared to spend longer on the examination and to arrange repeat visits to obtain full and valid results
  7. attempt visual field assessment, even if only by using confrontation techniques
  8. use cycloplegic examination, if necessary, to determine the full refractive error
  9. use mydriasis, if necessary, to internally examine the eye
  10. give clear information to the patient or carer about the effects of eye drops
  11. record any reasons for limitations on the examination and results obtained, and
  12. consider if you need to refer the patient for further tests, for example examination under anaesthetic, or electrophysiological tests. If you decide that you do, you should involve learning disability health professionals for advice about access to health care and treatment for a person with learning disabilities.
When you communicate with a patient with learning disabilities you should:
  1. talk directly to the patient, rather than their carer
  2. take time to speak clearly
  3. explain what you are doing in plain English
  4. warn the patient before you touch them, and
  5. explain and show them the equipment you are using.
In England the Accessible Information Standard applies to NHS patients, including those using General Ophthalmic Services, who have information or communication support needs relating to a learning disability, sensory loss or other impairment. GOS contractors need to ensure that patients receive information in a suitable accessible format unless the provision of this would be at disproportionate or unreasonable cost. The Optical Confederation produces guidance on this,30 and SeeAbility provides information in ‘Easy Read’ factsheets.31 Practitioners in the other UK nations should also make the information they produce accessible.

Providing patients with a report of their eye examination

You should provide the patient and relative or carer with a written, as well as a verbal, report. This should be copied to the patient’s GP if the patient consents. You can use the suggested accessible feedback form ‘Feedback from the optometrist about my eye test’ from SeeAbility32 to help the patient and their relative or carer to understand their eye examination and what you have found. A report specifically suitable for children is also available from Seeability.33 Your report should also include:
  1. reasons why results of the examination may be limited
  2. details of referral to another practitioner
  3. information on agencies that may be able to provide further advice or support, and
  4. advice on spectacle wear, copied, with the patient’s consent, to other relevant professionals involved in their care and to staff at a college or day centre that the patient attends.

Supply of spectacles and aftercare

If you supply spectacles to a patient with a learning disability you should consider labelling them with the patient’s name, date of supply and whether they are for distance or near tasks. Labelling should be suitable in terms of the patient’s dignity, infection control and type of frame supplied. SeeAbility has factsheets on wearing spectacles for people with learning disabilities. 34

See section on Safeguarding children and vulnerable adults.



34 SeeAbility Wearing glasses [Accessed 26 Oct 2017]

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