The College of Optometrists

The routine eye examination

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Sub-sections

Key points

  • You must carry out such examinations as appear to be necessary to detect signs of injury, disease or abnormality in the eye or elsewhere.
  • In addition to the minimum legal requirements, you should use your professional judgement to decide the format and content of the eye examination.
  • You should record all clinical findings.
  • You should tell the patient your findings and recommendations.
  • The frequency of eye examinations depends on the patient’s clinical needs but there are recommended minimum intervals.

Principles of the routine eye examination

A37
When conducting a sight test, which is defined in law,18  you must perform an internal and external examination and carry out such additional examinations as appear to be necessary to detect signs of injury, disease or abnormality in the eye or elsewhere.19 20
A38
You should use your professional judgement and the minimum legal requirements to decide the format and content of the tests.
A39
You should allow sufficient time to perform the examination.
A40
There is a suggested equipment list at Annex 1.
A41
You must record all clinical findings. You must do this legibly and at the time of the examination, or as soon as possible afterwards.

References

18 Opticians Act 1989 s36(2) [Accessed 22 Oct 2017]
19 Opticians Act 1989 s26(1)(a) [Accessed 22 Oct 2017]
20 Sight Testing (Examination and Prescription) (No 2) Regulations 1989 s3(1)(a) [Accessed 26 Oct 2017]

Conducting the routine eye examination

A42
When conducting a routine eye examination, you should:
  1. make it clear to the patient whether you will carry out the examination under the NHS or privately
  2. agree payment for any private services in advance, and
  3. use your professional judgement to decide how to serve a patient who is unable or unwilling to pay a private fee and is not eligible for NHS services. The lowest level of service that is acceptable is to direct them to emergency medical care. Record your actions and reasons for them.
A43
You must not charge for any procedure you undertake as part of a General Ophthalmic Services (GOS) sight test in England, Northern Ireland, Scotland and Wales, if the sight test is funded by the NHS.
A44
You must conduct an adequate assessment for the purposes of the optical consultation.21 This should normally include:
  1. asking for and accurately recording:
    • full name
    • address
    • other contact details
    • date of birth
    • reason for visit
    • history including description of onset, character and duration of signs and symptoms
    • if relevant, history of ocular and general health
    • current general health
    • medication
    • family history of ocular and general health
    • visual needs in terms of occupation, recreation or general activities
    • whether the patient drives, with or without prescription, and
    • details of previous optical prescription and date of last eye examination. Ask for the patient’s best estimate if the date is unknown
  2. determining and recording the unaided and/or aided vision of each eye with the patient’s existing correction for each eye, together with the specific prescription used for the aided vision
  3. assessing and recording habitual ocular muscle balance and the method used, at least cover test, for distance and near. This should be done with the habitual prescription and/or without the prescription, if appropriate

  4. examining the eye internally and externally. As a minimum for internal examination you should use direct ophthalmoscopy on the undilated eye, although alternative methods may be used. If you cannot obtain an adequate view of the fundus you should dilate the patient’s pupils and/or use indirect methods of fundal examination. You should use slit-lamp biomicroscopy particularly where a detailed view of the anterior eye and adnexa is required, and
  5. establishing the prescription required and the visual acuity of each eye individually.
A45
If you feel it is clinically appropriate, you may:
  1. measure convergence
  2. assess ocular motility
  3. assess pupil reflexes
  4. determine objective refractive findings, using autorefractor and/or retinoscopy
  5. use fundal or other imaging
  6. measure intraocular pressure for patients at risk of glaucoma, see paras A148  and A157 in the section on Examining patients at risk from glaucoma
  7. assess visual fields, especially for those patients who are at risk of glaucoma. See section on Examining patients at risk from glaucoma
  8. repeat certain tests to eliminate spurious results
  9. perform binocular balancing and measure binocular visual acuity
  10. assess fixation disparity, for example if the patient has symptoms or shows a deviation on cover test
  11. assess accommodation, for example to determine any reading additions for intermediate and/or near tasks.

After completing the routine eye examination

A46
When you have completed the tests you should tell the patient what you have found and what you would recommend. You should tell the patient when you would recommend they have their next eye examination.
A47
You should provide patients with leaflets about the most common eye conditions, as appropriate.22
A48
You must only issue a prescription for the correction of visual defects when it is clinically justified and in the best interests of the patient.23 In all other cases give the patient a written statement, confirming a correction is not required or that there is no change in the current prescription.
A49
If you examine a patient who might have an eye condition or eye surgery that may change the prescription in the short- to medium-term, you should consider carefully whether it is in the patient’s best interests to have new spectacles. You should explain the benefits and disadvantages of prescribing spectacles that will be appropriate only for a short time.
A50
If you are referring the patient, see section on Working with colleagues for further guidance.
A51
You should record any information you have given to the patient.
A52
You may need to justify your actions at a later date, so if you decide not to conduct particular tests that would normally be expected, you should record the reasons for not carrying out those tests. You should remember that when conducting a sight test, certain tests are required by law, see para A37.

Frequency of eye examinations

A53
You should examine patients at the most appropriate intervals, depending on their clinical needs.
A54
Contact lens patients may need more frequent appointments for aftercare but are not entitled to more frequent NHS sight tests simply because they wear contact lenses.
A55
In the absence of clinical indications, you should not recall patients more frequently than the following intervals.
Patient age and/or conditionRecommended minimum re-examination interval
The intervals given below should not be taken as applying automatically to all patients in a category.
Up to 16, no binocular vision anomaly or refractive error 1 year
under 7 years, with binocular vision anomaly or corrected refractive error 6 months
7-15 years, with binocular vision anomaly or rapidly progressing myopia 6 months
16 years and over 2 years
with diabetes who are part of diabetic retinopathy monitoring scheme 2 years
with diabetes who are not part of diabetic retinopathy monitoring scheme 1 year
A56
In the absence of clinical indications you should not examine patients who are being monitored by the hospital eye service more frequently than every two years.

 

Clinical reasons for earlier recall

A57
Clinical circumstances may justify recalling a patient earlier than the intervals set out above, including patients:
  1. of any age with refractive error that is changing rapidly, or who are at risk of such changes, for example patients:
    1. newly diagnosed with diabetes whose condition you have decided to manage, rather than refer
    2. with a suspect visual field on one visit that is not confirmed on repeat; or
    3. with abnormal IOP with no other significant signs of glaucoma

  2. who are identified in protocols as needing to be seen more frequently because of risk factors, for example of developing glaucoma. See section on Examining patients at risk from glaucoma, and
  3. with pathology likely to worsen.
A58
You should record reasons for early recall of any patient.

Patients requesting re-examination

A59
You may have patients requesting early re-examination because they:
  1. have been referred by a GP, or
  2. present with symptoms or concerns that you can resolve only with an eye examination.
A60
You should note reasons for early re-examination of any patient.
A61
There will be cases when patients have symptoms, for example headaches, where no ocular cause can be found after examination.
A62
You do not need to re-examine a patient who has broken their spectacles and has no clinical need for examination.

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