- 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 need 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.
A104
This Guidance does not change what you must do under the law.
A105
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.33
A106
You should assess all patients according to their needs.
A107
You should follow local protocols for the assessment and management of patients with low vision.
A108
You should ensure the patient has had a recent eye examination, which determines their refraction and ocular health, before performing a low vision assessment.
A109
You should consider the patient’s need for emotional support and social care.
A110
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.
A111
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.
References
33 Clinical Council for Eye Health Commissioning (2017) Low vision, habilitation and rehabilitation framework for adults and children [Accessed 18 Nov 2020]A112
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.
A113
You may need to assess the patient's:
- needs. Some patients may have a personal care plan or low vision passport that would assist in this assessment
- 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
- contrast sensitivity
- glare function
- central visual function using, for example, Amsler charts and appropriate colour vision tests
- 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
- binocular and accommodative status, where appropriate, for example in phakic children with low vision.
A114
When you have completed the appropriate assessments you must advise the patient your findings in a way they can understand. 34, 35, 36 This may include using large print, sending as an audio file, Braille, or in an easy read format.
A115
You should pass on relevant information to the low vision team or other appropriate parties, with an explanation of the results.
References
34 Equality Act 2010. [Accessed 18 Nov2020]35 General Optical Council (2016) Standards of Practice for Optometrists and Dispensing Opticians para 2.1. [Accessed 18 Nov 2020]
36 General Optical Council (2019) ~Standards for Optical Businesses para 1.3.1. [Accessed 18 Nov 2020]
See section on Consent.
A116
Following an assessment you should advise the patient, on:
- 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
- may need to demonstrate how to make adaptations to every day practical tasks such as reading door signs, mobile phone screens, newspapers, timetables and packets
- illumination as well as the use of specific tints and glare shields and non-optical devices
- the effects of the condition affecting their vision
- the benefits and disadvantages of low vision devices.
A117
You should know where to direct people for information on support services. You may wish to provide information on:
- the most common eye conditions that cause low vision
- support services, such as talking books, holidays, safety at home, lighting and travel.
A118
You should be aware of the impact sight loss may have on people who have other sensory, physical or intellectual impairment.
A119
You should follow local referral protocols.
A120
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.37
A121
You should ensure that 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.
A122
You should be aware that some patients may need additional support to access services, particularly at the onset of visual impairment. These include:
- older people
- children
- people whose first language is not English
- carers
- people who live alone
- people with other sensory impairment or learning difficulties
- people in, or seeking, employment.
A123
You should advise patients to continue with their routine optometric or ophthalmological care.
References
37 Department of Health (2018) Registering vision impairment as a disability [Accessed 18 Nov 2020]A124
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.38
A125
You must supply the patient with the most appropriate low vision device. Factors to consider include magnification, care and ergonomics.
A126
Advice on visual ergonomics should include reading posture, reading stands, copyholders, clipboards and higher reading additions.
A127
You should consider binocularity and accommodation when supplying a patient with any device.
A128
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.
A129
After supplying any device you should provide the patient with full instructions on:
- the tasks the device has been issued for
- 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
- any specific advice on lighting
- the initial programme of low vision training, including:
- reading or skill practice
- aftercare
- what post-supply support is available
- care, storage and cleaning of the device, including maintenance of batteries and integral lamps if appropriate.
A130
You must give appropriate instructions in writing to comply with the Medical Devices Directive.39
A131
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).
A132
If you consider a low vision aid unnecessary or unsuitable, or the patient rejects it, you should explain to the patient that their situation or technology may change and encourage them to return for regular assessments.
A133
Dispensing opticians are a valuable part of the low vision team. ABDO has advice and guidelines for their members on low vision practice.40
References
38 Opticians Act 1989 s27(1)(b) [Accessed 18 Nov 2020]39 Council Directive 93/42/EEC concerning medical devices [1993] OJ L169/1. [Accessed 18 Nov 2020]
40 Association of British Dispensing Opticians. Advice and Guidelines for Dispensing Opticians: paras 2.19-2.23. [Accessed 18 Nov 2020]
Certification of people as visually impaired, including the benefits of certification, and links to guidance notes [Accessed 18 Nov 2020]
Research has shown that depression is common in people with visual impairment. See Nollett CL, Bray N, Bunce C, et al. Depression in visual impairment trial (DEPVIT): a randomised clinical trial of depression treatments in people with low vision. Invest Ophthalmol Vis Sci. 2016;57:4247-4254
Clinical Council for Eye Health Commissioning (2018) Low Vision, Habilitation and Rehabilitation Framework for Adults and Children [Accessed 18 Nov 2020]
The College of Optometrists higher qualifications in low vision [Accessed 18 Nov 2020]
The College of Optometrists and Royal College of Ophthalmologists (2013) Commissioning Better Eye Care: Adults with low vision [Accessed 18 Nov 2020]
Diabetes UK [Accessed 18 Nov 2020]
Guide Dog [Accessed 18 Nov 2020]
International Glaucoma Association [Accessed 18 Nov 2020]
Look [Accessed 18 Nov 2020]
Macular Society [Accessed 18 Nov 2020]
NHS England guides to help staff support people with access needs [Accessed 18 Nov 2020].
National Institute for Health and Care Excellence (2013) Falls in Older People: Assessing Risk and Prevention. Clinical guideline 161. London: NICE [Accessed 18 Nov 2020]
Partially Sighted Society [Accessed 18 Nov 2020]
RNIB [Accessed 25 Nov 2018]
Ryan B, Woodhouse M, Sinclair A (2009) Low Vision, the Essential Guide for Optometrists. Guide Dogs for the Blind Association and College of Optometrists [Accessed 18 Nov 2020]
Visionary [Accessed 25 Nov 2018]
Wales Eye Care Services. LVSW-Low Vision [Accessed 18 Nov 2020]
