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Knowledge, skills and performance

Examining patients with learning disabilities

  • 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 their relative or carer with a written, as well as a verbal, report.
A161
This guidance does not change what you must do under the law.
A162
The Mental Capacity Act 2005 and the Equality Act 2010 are particularly relevant to examining adult patients with learning disabilities.
A163
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.52

References

52 Mencap Learning disability explained [Accessed 1 Nov 2023]
A164
People with learning disabilities often have more than one diagnosis and have a set of conditions unique to them.53

Some of the conditions associated with learning disability are:
  • Down’s Syndrome
  • Williams Syndrome
  • Autism
  • Fragile X Syndrome
  • Global Developmental Delay
  • Cerebral Palsy
  • SYNGAP1.

References

53 Royal College of Ophthalmologists (2015) Eye care services for adults with learning disabilities [Accessed 1 Nov 2023]
A165
It has been estimated that people with learning disabilities are ten times more likely to have specific ocular conditions,54  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 
  9. impaired accommodation
  10. keratoconus
  11. nystagmus
  12. reduced vision.
A166
Some people with learning disabilities have a wider range of health problems than the general population and may have other disabilities, including hearing impairment.

References

54 Emerson E, Robertson J (2011) The estimated prevalence of visual impairment among people with learning difficulties in the UK. London: RNIB [Accessed 1 Nov 2023]
A167
When examining a patient with learning disabilities you must:
  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
  2. seek their consent to get a briefing from a relative or carer, if necessary.
A168
If the patient is unable to consent, refer for advice to the section on Consent.
A169
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.
A170
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’ form55  and bring it to the eye examination
  3. find out how the patient likes to communicate and how their disabilities affect them, including if they are particularly sensitive to touch, lights and sounds
  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. use an objective measure of accommodative function (e.g. dynamic retinoscopy) to determine the accuracy of the patient’s accommodation
  8. attempt visual field assessment, even if only by using confrontation techniques
  9. use cycloplegic examination, if necessary, to determine the full refractive error
  10. use mydriasis, if necessary, to internally examine the eye
  11. give clear information to the patient or their carer about the effects of eye drops
  12. record any reasons for limitations on the examination and results obtained
  13. consider whether 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.
A171
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
  5. explain and show them the equipment you are using.
A172
You must provide information to patients in a way that they understand. 56,57 In England, the Accessible Information Standard applies to NHS patients, including those using General Ophthalmic Services (GOS), 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,58 and SeeAbility provides information in ‘Easy Read’ factsheets.59  Practitioners in the other UK nations should also make the information they produce accessible.

References

55 SeeAbility (2016) About Me and My Eyes [Accessed 1 Nov 2023]
56 General Optical Council (2019) Standards of Practice for Optometrists and Dispensing Opticians para 2.1 [Accessed 1 Nov 2023]
57 General Optical Council (2019) Standards for Optical Businesses para 1.3 [Accessed 1 Nov 2023]
58 FODO NHS Accessible Information Standard [Accessed 1 Nov 2023]
59 SeeAbility (2016) Having an eye test [Accessed 1 Nov 2023]
A173
You should provide the patient and their 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 SeeAbility60 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.61 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
  4. advice on wearing spectacles, 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.

References

60 SeeAbility. Eye Test Results [Accessed 1 Nov 2023]
61 SeeAbility. The results of your child’s eye test form [Accessed 1 Nov 2023]
A174
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. 62

References

62 SeeAbility Wearing glasses [Accessed 1 Nov 2023]
See section on Safeguarding children and adults at risk.

British Institute of Learning Disabilities [Accessed 1 Nov 2023]

Department of Health (2013) Learning disabilities good practice project [Accessed 1 Nov 2023]

General Medical Council. Learning disabilities [Accessed 1 Nov 2023]

NHS England guides to help staff support people with access needs [Accessed 1 Nov 2023].

Public Health England: Eyecare and people with learning disabilities: making reasonable adjustments [Accessed 1 Nov 2023]

Royal College of Ophthalmologists (2011) The management of visual problems in people with learning disabilities [Accessed 1 Nov 2023]

Royal College of Ophthalmologists (2015) Eye care for adults with learning disabilities  [Accessed 1 Nov 2023] 

SeeAbility has various resources on eye health, sight tests, wearing glasses, eye conditions and eye operations that are useful to the optometrist, the patient and their carers [Accessed 1 Nov 2023]

SeeAbility has information on eye tests for children and young people with learning disabilities. This includes downloadable forms [Accessed 1 Nov 2023]

The Scottish Accessible Information Forum provides information and training on how to produce accessible information [Accessed 1 Nov 2023]

Turner S, Kill S, Emerson E (2013) Making reasonable adjustments to eye care services for people with learning disabilities. Learning Disabilities Observatory [Accessed 1 Nov 2023]

Ulster Vision Resources [Accessed 1 Nov 2023]

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