The College of Optometrists Primary eye care COVID-19 pandemic guidance

This guidance is to help optometrists understand how to adapt their working practices when in the red (lockdown) and amber (recovery) phase of the coronavirus (COVID-19) pandemic.

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Contents

1. Introduction 

2. Infection control

3. Managing patients

4. Consultations

Appendix 1: Definitions 

  • Emergency care (used in Scotland) 
  • Urgent care (used in England, Wales and Northern Ireland) 
  • Essential care (throughout the UK) 
  • Essential contact lens practice (throughout the UK)  

Appendix 2: Social distancing in practice 

Appendix 3: Staff considerations in response to COVID-19 

  • Risk assessment
  • Pregnancy 

References

 

1. Introduction

1.1  This guidance is written to help primary care optometrists understand how to adapt their working practices during the various phases of the COVID-19 pandemic. It includes the existing College COVID-19 guidance on the ‘red’ phase. There are several phases of the pandemic. These are:

  • the ‘red phase’ (lockdown) when only urgent or emergency and essential eye care may be delivered face to face, subject to local protocols;
  • the ‘amber phase’ (not lockdown), when patients may be seen on a needs and symptoms led basis as determined by a clinician. Whether you can see asymptomatic patients, if you have capacity to do so, will depend upon local protocols; and
  • the ‘green phase’ when practices return to all eye care on an open access basis.

The definitions of urgent, emergency and essential care are in Appendix 1. The exact details of which patients may be seen during each phase may depend upon local and national protocols and more details are included here. As the situation is subject to change according to national guidance in the four countries of the UK you should check back regularly for the latest updates. As restrictions on retail and healthcare activities have been imposed for public health reasons, we advise that our guidance and recommendations apply equally to NHS funded and non-NHS funded care.

1.2  The aim of this guidance is to help primary care optometrists adapt their practice and working procedures to make their practices safe for patients and staff while there is still a risk of COVID-19 infection. This guidance builds on, and should be read alongside, the guidelines we published during the pandemic.  The Association of British Dispensing Opticians (ABDO) has developed guidance on dispensing.

1.3  Optometrists should not be seeing patients in primary care who have symptoms of COVID-19.  If you work in secondary care you should follow your Trust policies.

Practice modifications and staff considerations

1.4  Although this guidance is aimed at primary care optometrists, some of it – for example the requirements around the environment and staffing – will only apply to practice owners or managers. This information is included so that optometrists know what is expected in the workplace. Businesses that are registered with the GOC must comply with the GOC Business Standards. Relevant Standards are: 

  • 1.2.3 Maintains an appropriate standard of hygiene and repair of the premises from which care is provided
  • 1.2.9 Requires and enforces infection control protocols appropriate for your practice and ensures that all staff are in a position to follow them
  • 3.1.4 Allows staff sufficient time, so far as possible, to accommodate patients’ individual needs within the provision of care
  • 3.2.7 Supports GOC registrants to meet their professional requirements, including Standards of Practice for Optometrists and Dispensing Opticians.

1.5  Further information about practice modifications is included in Appendix 2 and around staff considerations in Appendix 3.

General Optical Council statements

1.6  During the pandemic, the GOC issued a joint regulatory statement: ‘We recognise that in highly challenging circumstances, professionals may need to depart from established procedures in order to care for patients and people using health and social care services’. They continue ‘Uncertain times mean that our registrants may be called upon to work at the limits of their scope of practice and vary their practice for protracted periods of time and in challenging circumstances.’ 

The GOC have issued a series of statements which they ‘hope to reassure our registrants and the education sector that when they act in good conscience, for the public benefit, exercising professional judgement in all of the circumstances that apply, the GOC will support them’. You should refer to the GOC website for up to date information on whether these statements still apply during the various phases of recovery.

Domiciliary visits

1.7  The provision of face to face domiciliary eyecare is different in the four nations of the UK. In England face to face domiciliary care is treated the same as practice-based eyecare, so patients should be seen on a needs and symptoms led basis, with routine patients being able to be seen if capacity permits. However, the situation is more complex and not the same in Wales, Scotland or Northern Ireland so you should check your local information regularly.

1.8  As for all optometric care, you may provide remote services to domiciliary patients throughout the pandemic in all of the UK. This would include repairing or replacing spectacles remotely and advising on home eye care where necessary.

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2. Infection control 

2.1  Have hand sanitiser (at least 60% alcohol) available at the front door, and ask patients to sanitise their hands on entering the practice. The UK governments have produced guidance for people who work in or run shops, branches, stores or similar environments in England, Scotland, Wales and Northern Ireland.

2.2  Disinfect everything the patient has come into contact with and frequently clean surfaces that are touched by staff if possible. This would include clinical equipment and other surfaces, such as a clipboard, that may have been contaminated with body fluids. Use a suitable disinfectant [see para 2.3].  All surfaces must be clean before they are disinfected. Open doors for patients, to avoid them touching the handle. If the patient touches the door handle, disinfect it. Ask patients to use their own pen to sign any forms, or sanitise any pen used.

2.3  Cleaning agents containing sodium hypochlorite 0.1% or 0.5% have been shown to be effective against SARS—CoV-2 when in contact with the surface for more than 1 minute. Ethanol of a concentration of 70% has also been shown to be effective. It is important to ensure the surface or equipment is cleaned before it is disinfected. The World Health Organisation (WHO) recommends 70% ethanol solutions to disinfect reusable equipment such as chin rests, handles, trial frames and other hard surfaces. For commonly touched surfaces, the WHO recommends 0.5% sodium hypochlorite. You should check the manufacturer’s advice to ensure these disinfectants are not likely to damage instrumentation or surfaces. Microbial wipes may be used provided they contain the correct concentration of ethanol. Wear an apron and disposable or washing up gloves when cleaning. These should be double bagged and stored securely for 72 hours, then thrown away in the regular rubbish after cleaning is finished.  

2.4  If you need to focimeter patients’ spectacles, ask the patient to take them off and provide the patient with a wipe to sanitise their frames before you touch them.

2.5  Support good practice for the use of tissues by patients and staff (‘catch it, kill it, bin it’) by having tissues and covered bins readily available. Empty the bins regularly throughout the day.

2.6  Tell patients and staff to practise regular hand hygiene and provide hand sanitiser in multiple locations. If you are using soap and water you should wet your hands, apply liquid soap and then rub the soap in your hands, covering all areas of your hands for at least 15 seconds before rinsing the soap off and drying your hands with a paper towel. If you are using hand sanitiser, you should apply the sanitiser to your hands, and rub all areas of your hands until the sanitiser is dry.  

2.7  Frequently clean work areas using your usual cleaning products, and frequently disinfect objects and surfaces that are touched regularly such as kettles. 

2.8  Practise hand hygiene which is extended to exposed forearms, after removing any element of personal protective equipment (PPE).

Personal protective equipment

2.9  All practice staff should wear appropriate PPE if they need to see patients at a distance of less than 2m, unless this is behind a screen.  

2.10  Technical specifications for PPE can be found here.

2.11  Instructions on how to put on and take off PPE can be found here or videos here and here.

2.12  You should dispose of PPE according to the advice of your waste provider. Unless advised otherwise you should double bag the PPE waste and store it in a safe area for 72 hours and then dispose of it in your normal trade waste stream.

Masks

2.13  All optometrists and other practice staff who work within 2m of a patient should wear a fluid resistant surgical mask (‘surgical mask’). The same surgical mask may be worn for examining multiple patients in one session, but you must be fastidious to avoid transmitting any potential virus on the front of the mask via your hands or your clothes. If you need to remove your mask do not touch the front of it and do not allow it to dangle on your chest.  

2.14  Fluid resistant surgical face masks are designed to protect others, but may also protect the wearer from respiratory droplets. They may also reduce the risk of contamination of oral and nasal mucosa by accidental touching of the wearer’s mouth or nose with a contaminated hand. They must be fitted properly around the nose, but do not require a ‘fit test’.

2.15  To reduce the chance of the mask misting up spectacles or eye pieces, ensure it is well fitting across your nose. You may also wish to tape the top edge of the mask to your face with medical tape to reduce the misting up further.

2.16  Wearing a FFP (filtering face piece) 2 or 3 mask is not recommended for primary care optometrists seeing non-COVID-19 symptomatic patients. However, if you do wish to wear a FFP3 mask this requires a fit test. If you wish to wear a FFP3 mask but this is not available the Health and Safety Executive advises that FFP2 may be an acceptable, pragmatic compromise.  HSE also advises that it is widely accepted by industry that N95 masks are comparable to FFP2 masks.

Gloves, aprons and face/eye protection

2.17  You should cover any cuts or abrasions with a waterproof dressing

2.18  You should risk assess whether to wear:

2.19  If you wear eye or face protection, you may wear this for the whole session (‘sessional use’) rather than changing it for each patient, unless the eye or face protection becomes soiled, damaged or uncomfortable.

2.20  If you wear gloves or an apron you should change them/it after conducting the procedure in which exposure to blood or body fluids is anticipated, or after each patient if this is sooner. You should not use alcohol based handrub whilst wearing gloves.

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3. Managing patients

3.1  When a patient makes an appointment, and on the day of the appointment, ask them to confirm that they are well and that no one in their household is exhibiting relevant COVID-19 symptoms (new, continuous cough, a high temperature and/or loss of or change in taste or smell). Patients with these symptoms, or where someone in their household has these symptoms, should not attend the practice, and should self isolate. We have posters you can display on your practice door.

3.2  If the patient has symptoms of COVID-19 as well as symptoms of a life- or sight-threatening condition, do not see them in your practice.  Follow local protocols or contact your local hospital eye service for advice, telling them that the patient has symptoms of COVID-19.

3.3  If a patient displays symptoms of COVID-19 whilst in the practice you should assess a suitable and safe point to bring the consultation to a close, withdraw from the room, close the door and wash your hands thoroughly with soap and water. Refer to the relevant national guidance for next steps: 

3.4  If a patient has to attend the practice, ask them to come alone where possible. If a companion is necessary, for example to support someone with sight loss, ask the companion to wait outside if possible, whilst the patient is seen. It is recommended that a child should only be accompanied by one parent if possible. If a patient needs a translator, consider whether this can be done by video or phone, to avoid too many people being in the consulting room.

3.5  Ask patients to sanitise or wash their hands on entering and leaving the practice.

Patient face coverings

3.6  Ask patients to wear a face covering.  If the patient does not bring a face covering with them you may choose to provide them with one, or ask the patient to come back at another time with a face covering to wear. 1, 2

The WHO has information about the dos and don’ts of wearing a fabric mask safely here and here.

3.7  If a patient refuses to wear a face covering you should consider whether there is a reasonable reason for this, such as the patient having a respiratory condition or a learning disability. In such circumstances you may wish to see the patient without them wearing a face covering, although if this is the case you should adapt the examination so you speak to the patient from a social distance, and do not use a handheld instrument.  

3.8  Young children do not have to wear a face covering, but you could ask them or their parent/guardian if they are able to do so. 

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4. Consultations

Symptoms and history

4.1  When the patient contacts the practice for an appointment ask them why they need to come in and ensure your booking process is responsive to the local protocols about which patients can be seen face to face. See our summary of practice during the pandemic. During the amber phase, see patients face to face on a needs and symptoms led basis, as determined by a clinician, and only see asymptomatic patients if your local protocol permits this and you have capacity to do so. To help with appointment planning and staffing, as part of your triage process you may ask whether the patient intends to purchase spectacles at their visit. 

4.2  If a patient reports a serious eye condition that requires urgent or emergency hospital treatment you should direct them to the HES without asking them to come to your practice. The Royal College of Ophthalmologists advise that patients who need to be seen and treated urgently include suspected:

  • Glaucoma: acute glaucoma, uncontrolled very high IOP >40mmHg or rapidly progressive glaucoma
  • Wet active age-related macular degeneration
  • Sight-threatening treatable retinovascular disease (proliferative diabetic retinopathy and CRVO)
  • Acute retinal detachments (macula on, macula off < 4 weeks)
  • Uveitis – severe active
  • Ocular oncology – active, aggressive, uncontrolled or untreated lesions
  • Retinopathy of prematurity (screening and treatment)
  • Endophthalmitis
  • Sight-threatening trauma
  • Sight-threatening orbital disease e.g. orbital cellulitis, severe thyroid eye disease
  • Giant cell arteritis affecting vision

4.3  If you cannot make an appointment for a patient - for example if you are experiencing a local lockdown or if you do not have capacity to see asymptomatic patients – tell the patient to contact you again if things change, or in a set period of time so that you can review them again and decide if their needs have changed. 

Remote consultations

4.4  We have written guidelines for video consultations, including a home visual acuity test chart for remote consultations, a clinical telephone review form and forms to help you with supplying replacement spectacles or contact lenses by phone. You should use your professional judgement to decide whether it is in the patient’s best interests to be supplied with spectacles or contact lenses remotely during the pandemic, and record your reasoning on the patient record card.

4.5  We have a course on how to provide telephone consultations during the COVID-19 pandemic here.

Reduce physical contact

4.6  If possible, contact the patient before they attend the practice and take as much of their symptoms and history as you can remotely, by phone or video. Be mindful of people who cannot talk confidentially at home and of those with other communication needs, such as those who have hearing loss or who are deaf and might prefer to do this at the practice. If this is done before the day of the appointment, confirm with the patient on the day of the appointment that nothing has changed since you spoke. It should be clear from the record which conversations were had when. If you need to discuss things with the patient when they are in the practice (before or after the consultation), do so at a safe distance.

4.7  If it is not possible to take symptoms and history before the appointment, do this at a social distance for example by speaking to the patient from the other end of the consulting room.

Adapt your routine

4.8  Adapt your routine to reduce the risk of infection and close contact with patients. See Appendix A3.11.

4.9  Avoid using direct ophthalmoscopy where possible. If the patient cannot reach the slit lamp, use another form of indirect ophthalmoscopy. If this is not possible you should risk assess whether to postpone the sight test to when the social distancing measures have been relaxed. If this is not possible you should consider your personal risk from COVID-19.

4.10  Do not talk when at the slit lamp, other than to tell a patient where to look.

4.11  If you need to refract the patient:

  • consider using a refractor head instead of a trial frame because it may be easier to disinfect. Some refractor heads can be operated without you needing to be as close to the patient, thereby reducing close contact.
  • If you use a trial frame, increase the back vertex distance (BVD) to stop trial lenses steaming up and to reduce the likelihood of trial lenses touching the patient. Remember to adjust the spectacle prescription for the increased BVD where necessary. Disinfect trial lenses that touch the patient or those that mist up with the patient’s breath and may be placed in the back cell of the trial frame.

4.12  If you use non-contact (air puff) tonometry, after each use.

  • wipe the instrument head with an appropriate disinfectant wipe, and 
  • perform three puffs between each patient to clear the tip.

4.13  Because of the potential to generate aerosols:

  • do not use Alger brushes. If you need to remove a rust ring, use a needle instead
  • do not use microblepharoexfoliation – use alternative blepharitis management, such as lid spuds, tweezers etc.

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Table 1: Covid pandemic modified sight test

Technique

Modification during red phase (lockdown)

Modification during amber phase (out of lockdown)

S&H

Remote or at a social distance

OMB

Consider if needed if asymptomatic

Motility

As clinically necessary.  Consider if needed if asymptomatic.

Pupil reactions

Ext/ant segment examination

Slit lamp

Media

Slit lamp.  Alternatively: retinoscopy to gauge if fundal reflex clear.  If opacities detected, slit lamp to identify location of opacities

Fundal examination

Fundal imaging where available.  Consider whether additional method needed based on patient’s clinical circumstances.

Use SL or headset-BIO where possible.   Fundal imaging where available.  Fundal imaging alone3 may be sufficient if the patient is asymptomatic, the image is clear and the field of view is sufficient considering the patient’s clinical circumstances.

Direct ophthalmoscopy

Risk assess, and only use when alternative methods unavailable.

Dilation

As clinically necessary

Retinoscopy/

Autorefractor

If clinically necessary.

Retinoscopy reflex helpful to determine clarity of ocular media.

Subjective refraction

Only if clinically necessary.  Streamlined.

Streamlined if no symptoms and VA good with current specs.

Amsler

As clinically necessary

Colour vision

Tonometry

As clinically necessary – use stand mounted tonometer if possible.  If not possible, risk assess whether to use hand held device.

Visual fields

As clinically necessary.  Consider omitting if discs and IOPs unchanged since previous visits, and no other relevant signs/symptoms.

Advice given

Give at a social distance

Contact lens fitting

Do as much as possible at a social distance – e.g. clear plastic screens and/or video instruction remotely (with optom/CLO on site) for application and removal training.

Download this table as a PDF (397KB)

4.14  If you need to conduct a visual field test, consider using an enclosed visual field screener rather than a bowl type, because an enclosed visual field screener is easier to disinfect. If you need to use a bowl type perimeter refer to the joint guidance from The College of Optometrists and the Royal College of Ophthalmologists.

4.15  To reduce physical contact between the patient and equipment, as well as the time the patient spends in the practice, only conduct examinations that are clinically necessary or required by law, rather than doing blanket tests on everyone (for example as part of pre-screening).  

4.16  To reduce the time the patient spends in the consulting room use your professional judgement to consider how accurately you need to refract them if you are performing a sight test.

4.17  If you have adapted your routine to alter or remove tests that the patient would normally have done, explain to the patient why you have done this and what the implications will be – for example if they will need to return earlier than usual for a follow-up.

Contact lenses

4.18  Where possible, ask the patient to insert and remove their lenses themselves.  

4.19  You may see patients for essential contact lens care during the red phase of the pandemic (see Appendix 1).  

4.20  You may see patients for non-essential contact lens care during the amber phase.  If you need to teach a patient how to handle their lenses, put social distancing measures in place. For example:

  • Put a clear plastic screen between practitioner and patient, and
  • Show the patient a video of how to apply and remove their lenses, and let them to practise this alone in an area of the practice, with you or the contact lens optician on hand to help in case of difficulties

4.21  We have information for patients about contact lens wear during the pandemic here and a paper on the important considerations for contact lens practitioners during the COVID-19 pandemic has been published here.

Referrals

4.22  Follow local protocols about referring patients.  If your local hospital has postponed routine appointments, you should continue to refer as usual, but warn the patient that they may not be seen in the usual timescale. Tell the patient to contact you should their condition worsen in the meantime.  

4.23  If patients are worried about delays to their hospital appointment, give them contact details of organisations that may help them in the meantime, for example Glaucoma UK, the Macular Society or the Royal National Institute of Blind People.

Record keeping

4.24  Make it clear on your record the adjustments you have made to your routine or clinical decision making, and that these were because we are in the COVID-19 pandemic. Examples would include omitting certain tests that would normally be conducted, or delaying a referral or a domiciliary visit because the patient is at greater risk of COVID-19.

Patient information

4.25  Our patient information on a range of conditions, including AMD, blepharitis and flashes and floaters is available on an open access basis on our public facing website lookafteryoureyes.org. During lockdown we have made our patient information leaflets available as pdf versions for members so that you can email them to your patients. If you wish to access these please fill in the form on our website.

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Appendix

Appendix 1: Definitions

Emergency care (used in Scotland)
This is for patients where, in the professional judgement of an optometrist or OMP, the circumstances in which a patient presents constitutes an emergency.  See our Guidance for Professional Practice on Examining Patients who Present as an Emergency

Urgent care (used in England, Wales and Northern Ireland)
This is not part of General Ophthalmic Services, and as such would need to be separately commissioned.  In England this may be via the Covid Urgent Eyecare Service (CUES), in Wales by the Eye Health Examination Wales and in Northern Ireland by the Urgent Care Service or NI Primary Eyecare Acute Referral Service (NIPEARS).  Practitioners should follow local protocols as to which conditions or presentations should be seen via these services.

Essential care (throughout the UK)
NHS England defined this as ‘this includes but is not limited to appointments for patients who would not normally be considered to be emergencies, but where, in the practitioner’s professional judgement, a delay in an examination may be detrimental to a patient’s sight or well being.  This may include where patients have broken or lost their glasses or contact lenses and need a replacement pair to function’.

Essential contact lens practice (throughout the UK)
Essential contact lens practice would be contact lens check-ups where the patient is symptomatic, or contact lens fittings for patients needing contact lenses for medical or other ‘essential’ reasons, such as needing to comfortably wear PPE.

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Appendix 2: Social distancing in practice

A2.1  Maintain social distancing, as recommended by national governments (England, Northern Ireland, Scotland, Wales), as much as possible during the pandemic, unless it is necessary to get closer to an individual for clinical reasons. Signs and markings should be clearly visible to help people with sight loss.

A2.2  To ensure that people only attend the practice when necessary, provide services remotely where possible – for example by posting spectacles or contact lenses to patients, and taking credit and debit card payments over the phone.

A2.3  Have a pre-booked appointment system (do not encourage drop-ins), including for repairs or dispensing, or operate a ‘one in, one out’ entry policy when the practice is at capacity to ensure people have space to maintain social distancing. Ask people to wait outside the practice (at a suitable distance) if the practice is at capacity. Alternatively if there is parking nearby, a patient may choose to wait in their car and you can phone them when their slot is available.

A2.4  Use acrylic (or similar) shields where necessary, for example around reception or contact lens teaching areas if a social distance cannot be observed.

A2.5  Assign workstations to an individual as much as possible. If they need to be shared they should be shared by the smallest possible number of people and disinfected between users.

A2.6  Use a cough guard on your slit lamp. The Royal College of Ophthalmologists has published advice on how you can make a temporary cough guard here.

A2.7  Remove all unnecessary items, such as magazines and toys, from the waiting/reception area.

A2.8  Encourage contactless card payment. If handling cash, follow infection control/PPE guidance. If a signature is required, ask patients to use their own pen to sign any forms, or follow infection control procedures if the patient uses a practice pen.

A2.9  You should consider the practice layout and ventilation of enclosed spaces, such as the consulting room, opening windows and doors where possible to help air flow, and considering having breaks throughout the day when the room can be thoroughly aired.

A2.10  Avoid consulting rooms being shared where possible, so that each practitioner works from their own consulting room rather than swapping between them on different days. Where a consulting room is shared between practitioners, disinfect this thoroughly at the end or beginning of the day and air the room overnight.

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Appendix 3: Staff considerations in response to COVID-19

A3.1  As key (critical) workers, optometrists are allowed to go to work, even in the red phase of the pandemic, and their children should be allowed to attend school and childcare settings where no home-based childcare options are possible.

A3.2  Staff should be appropriately trained in infection control policy and keep up to date with changes in national public health guidance and government policy.

A3.3.  Staff should be aware of the symptoms of possible COVID-19 and should not attend the practice if they, or any of their household, display these symptoms, as per government advice.

A3.4.  Consider how you can best use the space in your practice to ensure you can meet social distancing requirements of staff and patients, for example by using a spare consulting room to conduct non-clinical tasks that cannot be done from home.  

A3.5  To minimise the number of staff in the practice, follow national government advice and implement home working where possible (England, Northern Ireland, Scotland and Wales). Administrative tasks should be done from home if at all possible.

A3.6  NHS Employers has advice on enabling and supporting staff to work from home.

A3.7  Keep the same teams of people working together where possible, so each person only works with a few other people, to minimise mixing of colleagues. This may involve altering staff rotas.

A3.8  Reduce the number of people a patient has contact with during their patient journey, so – for example – have the same person doing the pre-screening as doing the dispensing for that patient, or have the optometrist do all clinical tests, including those that would normally be done by an assistant. 

Risk assessment

A3.11  Some people are more at risk from COVID-19 than others.  Employers should therefore consider each individual member of staff’s risk when assessing the most appropriate working environment for them.  People at particular risk, or those who live with people who are ‘extremely clinically vulnerable’ may go to work as long as the workplace is COVID-secure, but should work from home, or away from others, where possible.  The College, FODO, AOP and ABDO have produced interim guidance on a workforce risk assessment in primary care. This includes a risk assessment form for new and expectant mothers.

Pregnancy

A3.12  The Royal College of Obstetricians and Gynaecologists has information on COVID-19 and pregnancy here.

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References

1. Staying safe outside your home. Gov.UK.

2. In Wales a three layer face covering is recommended indoors where social distancing is difficult.

3. If a fundus image is used as the only form of internal ocular examination, this must be conducted by the optometrist conducting the sight test (Sight Testing (Examination and Prescription)(No 2) Regulations 1989 para 3(1)(a)(ii)).

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