Optical training for carers

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Code of Practice for Domiciliary Eyecare

Preparation

• NHS eye examinations will be provided on request to those who cannot access

community optical practices unaccompanied, as a result of mental or physical disability

• NHS contractors will satisfy themselves that an NHS eye examination is clinically

necessary and in the customer’s best interests

• Providers will respect the right of each customer to make their individual choice

of provider of both services and appliances

• Each customer will be treated as an individual and providers will not condone ‘group

testing’ of customers unless this is clinically feasible and by customer or carer choice

• NHS eligibility for a domiciliary examination will be established and the reason noted

on the record card, as will any eligibility for an optical voucher

• Providers will make clear the likely cost of glasses in advance and the specific cost

before placing an order

• Providers will ensure that venues are suitable for testing and meet the requirements

of NHS regulations

Eye examination

• Customers will receive an eye examination in accordance with their individual needs

and the duties of care and confidentiality of the optometrist* towards the customer

• All NHS eye examinations will be provided in accordance with NHS regulations

• Specialised portable equipment will be used to enable the optometrist* to deliver

the best possible care to the customer

• Where the environment or medical limitations of the customer make it impossible

to include the full range of procedures, the reasons will be noted on the customer’s record

• Providers recognise that, when providing domiciliary services, they are acting in a

privileged position of trust

• Where appropriate, providers will follow the College of Optometrists’ guidelines

on treating customers with dementia or acquired cognitive impairment and similar

ABDO guidelines on the challenges of dispensing to such customers

• Providers will monitor and support clinical staff with regular clinical

governance reviews

Promoting eye health and maximising independence for all

September 2009 The Domiciliary Eyecare Committee is grateful for the comments of the UK Departments of Health on this Code

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Continuing care

• Glasses dispensed will be fitted individually to

customers and any tolerance problems will be

addressed by fully trained staff

• Customers who are under 16 or blind or partially

sighted will only be supplied with optical appliances

by, or under the supervision of, GOC registered staff

• Customers have a right to expect a high standard of

continuing care which ensures that any follow-up

care required or requested is provided efficiently

and professionally

• Providers will advise the customer as to when their next

eye examination is due. They will not normally re-test

before this unless the customer is experiencing specific

difficulties, which will be noted in the customer’s record

• Providers have an obligation to ensure that, when a

customer opts to be cared for by another provider,

relevant information (e.g. lens prescription and date

of last eye examination) is made available to the

new provider with the consent of the customer or

customer’s carer

• Providers will make clear in advance whether follow-up

care will be provided free of charge (i.e. under the NHS

or at the provider’s expense) or a cost to the customers

*or Ophthalmic Mediacal Practitioner (OMP)

Communication

• Providers will ensure that personnel receive

appropriate training in the specialist communication

skills necessary for domiciliary customers

• Each customer will be treated as an individual and

communication will be with them throughout their

care unless this is inappropriate

• When the customer is able to do so, their agreement

will be sought before any aspect of their care is

discussed with relatives or carers. Where a customer is

unable to consent, carers and relatives will be involved

where appropriate

• In addition to issuing a lens prescription or a

statement that no correction or change is necessary,

providers will leave further information with the

customer (if relevant) or, with the customer’s

permission, with their carer or care home, to

summarise the outcomes of eye examination

Standards and probity

• Providers are committed to providing high

quality, personalised and professional eyecare and

optical services

• All practitioners will carry identification and show

it as appropriate and on request

• At the end of the appointment, customers will be given

the provider’s contact details which may be in the form

of a standard leaflet

• All eyecare will be provided in accordance with

regulations and, in the case of NHS care, additionally

in accordance with the provider’s NHS contract

• Providers will not offer or supply optical services

including eye examination services, optometric

products or other inducements (including any services

or products), to third parties including the owners

and staff of care homes, in order to gain or retain

domiciliary business

• This will not prevent legitimate advertising consistent

with regulations

• The competitive market is recognised as a positive

driver of quality and customer choice. Providers will not

therefore enter into ‘service level’, ‘preferred provider’

or similar agreements with care homes or care home

chains or compete in other ways that are inappropriate

• Providers will apply a non-discrimination policy

towards customers in the supply of domiciliary services

• Providers are committed to the highest standards of

integrity and to employing rigorous audit processes to

ensure eligibility for NHS funding

• In accordance with the national timetable, all

domiciliary practitioners will be ISA registered

• Providers will only claim higher rate domiciliary fees

for more than two NHS customers resident at the same

establishment where such visits were reasonably made,

e.g. by request of a customer or carer exercising their

choice of provider

Complaints

• Complaints about any aspect of provision should be

addressed to the provider in the first instance

• If the complaint relates to an NHS eye examination

or the offer of inducements, the local Primary Care

Organisation can be contacted

• If the complaint relates to glasses or contact lenses,

the OCCS can be contacted: Optical Consumer

Complaints Service (OCCS) P.O. Box 219, Petersfield

GU32 9BY Tel: 0844 800 5071

Email: postbox@opticalcomplaints.co.uk

• Complaints can also be raised in confidence with:

Domiciliary Eyecare Committee, 199 Gloucester Terrace

London W2 6LD Tel: 020 7298 5151

E-mail: optics@fodo.com

Programme Information

Welcome to Specsavers Healthcall’s eyecare training programme. We hope you find it useful and enjoyable and that together we can deliver quality eyecare for older people and those with disabilities.

This programme aims to provide you with supportive and

enjoyable learning that will develop your awareness of:

• How the eye works

• Common conditions that can affect our eyes and how those conditions

can be treated

• How eye and vision problems can affect the lives of the people in your care

• How, together with Specsavers Healthcall, care staff can provide support

to the people in their care.

Programme summaryThe programme comes in two parts:

1. Training DVD

Your session will include the following topics:

a About eyes: how they work and what can go wrong

b The eye test

c Trying on simulation glasses

d How eye problems can affect health and well-being

2. The candidate’s pack

This is a self-study pack that will let you learn in your own time

and at your own pace. The pack includes learning materials and

a self-assessment question and answer sheet to encourage you

to think about and record what you have learnt.

An introduction to eyecare

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Evidence of trainingAlthough this is not an accredited course, some parts of it can provide

useful supplementary evidence of knowledge that can count towards

mandatory training requirements. The information can also contribute

to a personal development plan. Skills for Care guidance states that:

‘all social care staff will need to maintain a record of their own training

and achievements’. We therefore suggest that you use and retain the

self-assessment question and answer sheets. If, or when, you are involved

in any of the below programmes you can show this evidence of learning

to your assessor who can advise you how to use it.

Depending on how the assessment question and answer sheets are

completed, they may provide evidence towards the following, as well as

the Scottish Credit and Qualifications Framework and other qualifications:

Skills for Care Common Induction Standards

Standard 2.4 Producing a personal development plan

Standard 2.5 Using learning opportunities and reflective practice to contribute to personal development

Standard 7.1 Promote person centred values in everyday work

Standard 7.2 Working in a person centred way

QCF Level 2 diploma in Health and Social Care (adults) for England

Group B, Unit SS MU 2.1 Introductory awareness of sensory loss

Group C, Unit HSC 2004 Contribute to monitoring the health of

individuals affected by health conditions

We hope that you will find this training of real value and that it will help

you identify the areas in which you can make a difference to the quality

of life of those in your care.

Details of the Eye ExplainedHow our eyes workThe eye can be likened to a camera. Light passes

through a lens at the front of the eye and is focused

on a light-sensitive area at the back. From there the

information travels to the brain, where it is turned

into pictures.

The eye is made up of six main parts:

1 The cornea

The cornea is the clear window at the front of

the eye, and it is this surface that bends or refracts

light to focus on the retina. The white of the eye is

called the sclera and is the semi-rigid shell of the

eye. It is covered by a transparent membrane

called the conjunctiva.

2 The anterior chamber

The anterior chamber contains a watery fluid

called the aqueous humour, the pressure of which

helps to maintain the shape of the cornea. This fluid

is constantly produced and drained away through

drainage channels, located near the junction of

the cornea and the sclera.

3 The iris

The iris is a coloured muscular diaphragm which

varies the size of the pupil according to the light

intensity. The pupil is simply a hole through which

light passes into the eye. The reaction of the iris

to light is used in many diagnostic tests.

4 The crystalline lens

The crystalline lens is made up of several concentric

layers, rather like an onion. It is surrounded by a

muscle, the ciliary muscle, which changes the lens

shape and therefore its focus. When looking into the

distance the muscle should be relaxed and when we

look at something close to us, the muscle contracts,

bending the lens into a steeper curve to bring closer

objects into focus on the retina. The main chamber

of the eye is filled with a transparent jelly-like body

called the vitreous humour. Unlike the aqueous

humour this is not a renewable substance and

tends to deteriorate with age.

5 The retina

The retina is a complex structure of light receptors.

The two types of receptors are rods and cones.

The rods are mainly located in the periphery of the

retina and are particularly sensitive to low levels of

light. The cones are packed more to the centre of

the retina and are responsible for our colour vision

and ability to resolve fine detail. When we look

directly at an object it is focused on the area of the

retina called the macula. This is the most sensitive

part of the retina and is most receptive to colour and

detail. We may feel that we see clearly and in full

colour to the extremities of our field of view, but in

fact at these extremes we are seeing in monochrome

and with poor resolution: the brain makes us believe

otherwise. It is only if there is damage to the macular

area that we become aware of this fact.

6 The optic nerve

The optic nerve carries the information gathered

by the retina to the area of the brain responsible

for sight, which is located at the base of the skull.

Damage to the retina, optic nerve or this part of the

brain will result in some loss of sight, depending on

the extent of the injury.

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Maximising Visual PotentialThe detection and treatment of eye conditionsMany people simply accept deteriorating vision as they grow older, but this does not have to be the case.

Cataracts

Cataracts are the most common problem experienced

by older people, although in some cases they can be

caused by injury in younger people. German measles

(Rubella) can cause babies to be born with cataracts.

Most people do not understand what a cataract is and

are fearful of the condition. It is often described as ‘a

film or skin that grows over the eye’, but this is not the

case. A cataract is simply a clouding of the crystalline

lens inside the eye – the variable focus

lens mentioned earlier.

Cataracts are treated with surgery. Many years ago

it used to be the case that cataracts had to be ‘ripe’

before they were operated on and, after the operation,

patients had to wear very thick lenses in their glasses.

Today, operations can be carried out as soon as the

patient experiences difficulties, and with the latest

intraocular lens implants (replacing the crystalline lens

with a clear plastic implant), patients may only require

reading glasses after the operation.

The operation is usually very straightforward and

can be carried out under local anaesthetic.

Retinal detachment

If the retina becomes detached from the back of the

eye, the sight will be permanently damaged in the

area of the detachment. When the detachment occurs

at the edge of the retina only, then the peripheral

vision will be affected and the individual will have very

little visual disability. If the detachment is near the

centre of the retina then the patient will be aware of a

severe reduction in visual acuity. It is essential that any

detachment is treated quickly to prevent the area of

detachment spreading – the whole of the retina could

come away, which could result in total blindness in

that eye. Retinal detachments are normally treated

with lasers.

Glaucoma

Glaucoma is a condition that rarely affects people

under the age of forty, and the chances of developing

it increase with age. A fluid (aqueous humour) is

produced inside the eye at a constant rate and

normally drains away at the same rate. If the drainage

slows down or the eye produces more aqueous

humour than normal, the pressure of the fluid builds

up and damages the optic nerve. Unless the pressure

is controlled that eye will eventually go blind. The

most common treatment is the use of eye drops, but

if these are not effective, laser surgery can help. If the

disease is detected early enough, treatment is very

effective and individuals may suffer no noticeable

visual impairment. Patients with a close relative

who has glaucoma are at greater risk of contracting

the condition.

Age-related macular degeneration (AMD)

AMD is a condition that mainly affects older people.

AMD causes reduced central vision that gradually

becomes worse, leaving the peripheral vision

unaffected. Eventually it becomes impossible to read or

recognise faces and many sufferers will be eligible to be

registered partially sighted. There are two types of AMD:

wet and dry. There is no effective treatment for the more

common dry type although some studies have shown

that certain dietary supplements may help to slow down

the progression of the degeneration. The wet type can

sometimes be helped if detected early enough.

Retinopathy

Certain medial conditions, in particular diabetes

and high blood pressure, can affect the retina,

causing haemorrhages and other complications.

Early detection of these conditions is essential and

requires diagnosis and treatment by the patient’s GP

so that blood pressure and blood sugar levels can

be controlled to prevent further damage. It must be

remembered that often patients are unaware that they

have a problem until the optometrist refers them to

their GP for further tests and diagnosis. Diabetes is

one of the major causes of blindness in the developed

world and the majority of blind diabetic patients are

middle-aged or older. Between 20 and 40% have

ocular involvement at the time of diagnosis.

Conjunctivitis

Conjunctivitis is a relatively minor infection of the

membrane that covers the white of the eye and

the inside of the lid. It is often associated with the

common cold or an allergy such as hay fever. The

eye becomes blood-shot and feels gritty, and there

is often a mucus discharge. It can usually be

successfully treated with antibiotic drops.

Blepharitis

Blepharitis is a chronic inflammation of the eyelid

margins, giving rise to sore, red, crusty eyelids and

burning, watering eyes. It can sometimes be managed

by cleaning the eyelid margins morning and night using

cotton buds and a 50:50 solution of baby shampoo and

water. Due to the chronic nature of the condition, this

treatment should continue for some time.

For older people good eyesight is essential for getting the most out of life. It can prevent

feelings of loneliness or of being isolated from events around them and, of course, it means

they can watch television, read newspapers or magazines and pursue their hobbies.

Even those who do not have the concentration levels necessary for prolonged occupational

activity will benefit from good near vision. It will allow them to see their meals clearly

or read their own letters and greetings cards. Stroke victims whose speech is impaired

can frequently feel isolated and frustrated, so their other senses – sight and hearing – are

extremely important.

Eye tests can be carried out without the need to ask the patient numerous questions

by using ‘objective’ methods. These methods can be employed when examining patients

who are confused or have cognitive impairment. For these individuals it is very important

to have regular eye tests, as they will become increasingly disabled if deprived of

visual stimulation.

Early detection of ocular conditionsMany age-related ocular conditions can be detected by the optician

before the person is aware of any problems. This is particularly the

case with glaucoma, which is discussed further on. Early detection

and treatment means that the condition can be controlled more

effectively and patients may never experience visual difficulties

related to the condition. Additionally, when the optician examines

a person’s eyes with an ophthalmoscope, he or she can see the

blood vessels at the back of the eye. It is the only part of the

body where blood vessels can be seen in this way without

surgery. This means that conditions that affect blood

vessels and circulation, such as raised blood pressure,

arteriosclerosis or diabetes, may be detected

during an eye test.

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Appropriate Eyecare Domiciliary eye testsMost of us visit the optician because we don’t think we can see too well and to find out

whether we need glasses or contact lenses to solve the problem. If a patient can’t visit

the optician unaccompanied, the examination can be conducted in his or her place of

residence, which may be their own home or a care home. The eye test, or ‘sight test’ as it

is described by the NHS, addresses visual problems as well as including other procedures

which provide the customer with a more extensive check up than just visual capability.

Eye tests are carried out by optometrists (persons who are qualified to test sight and

prescribe and dispense glasses) or ophthalmic medical practitioners (medically qualified

doctors who have undergone extra training in sight testing). The optometrist has a duty

to carry out necessary tests to determine the patient’s needs with regard to both

eyesight and health, enabling him or her to assess the:

• Standard and quality of all aspects of the patient’s sight

• Optical prescription and, where necessary, prescribe any corrective lenses

that are required

• State of the eye to detect any disease or abnormality which may be present and which

may require referral to the GP, hospital or ophthalmologist for further investigation.

The precise routine and content of the examination will be determined by the professional

judgement of the practitioner and minimum legal requirements. This requirement must

be fulfilled whether the patient is in the consulting room or in a domiciliary environment.

Disability is no bar whatsoever to receiving a comprehensive eye test. Practitioners may

have to adjust their routines to allow for patients who, for one reason or another, are not

able to fully co-operate with all the tests, for instance in the case of cognitive impairment

or difficulty with communication. Techniques are, however, available to deal with many

possible difficulties and, just because a patient suffers with cognitive impairment, it does

not follow that they should be denied eyecare as they may well benefit from improvement

in their vision.

Record keepingOne of the most important requirements of any examination is the necessity to keep

comprehensive records. As well as recording the standard information such as name,

address, date of birth etc., the optometrist will wish to know, where possible, some of

all of the following:

• Any previous history of eye problems and use of glasses

• Any symptoms which may be present in relation to vision or the eyes

• Any current medication in use, whether ocular or otherwise

• The visual needs of the patient, for instance the wish to watch television or read

• The reason for the domiciliary visit and why the patient is unable to visit a high

street practice unaccompanied

• The financial circumstance that may entitle the patient to help towards the

cost of glasses, along with evidence of this entitlement.

The domiciliary eye test

The role of the carerThe eye test consists of a number of procedures and can be a significant tool in the detection

of systemic conditions. Regular eye tests, particularly for the older person, are an essential

element in the maintenance of quality of life and must be offered to all patients, including

those who cannot co-operate or communicate.

In the residential home environment, obtaining information directly from the patient is

not always possible, particularly information about their medication. The presence of

nursing or care staff during the clinic is therefore vital.

Prior to the start of the clinic, the optical team, comprising an optometrist and an optical

adviser or a dispensing optician, will wish to talk to senior care staff to discuss the patients

they are seeing. The daily experience of carers in observing patient behaviour and problems

that may be vision-related is crucial to ensuring that any symptoms are understood and

investigated. Many residents, for instance, profess to read a lot but this is not always borne

out by carers. The fact that a patient does not read, however, does not necessarily preclude

the need for glasses as these are used for any close activity, such as eating. The optometrist

will of course not want to prescribe glasses that will never be used.

Knowledge of the financial circumstances of patients is also important since NHS funding for

all or part of the cost of glasses is only available to patients in receipt of certain benefits.

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The Eye TestHaving taken full notes of history and symptoms, the optometrist will carry out the eye test.

Some or all of the following procedures will be undertaken depending upon the needs and

ability of the patient:

Assessment of visual acuity (the standard of vision)

with and without any current glasses

This will normally be achieved by asking the patient to read letters on the optometrist’s

chart and will help to indicate any major visual problems. It allows the practitioner to assess

whether any change in the final optical prescription will actually improve the vision.

Objective assessment of the glasses correction

Rather than going through the many hundreds of lenses in the optometrist’s lens case,

asking the patient whether they see better with one lens or another, the practitioner can

make a very accurate assessment of the glasses correction which is required, without asking

any questions. There are two main techniques available for this test.

Retinoscopy is the method whereby the optician uses a hand held instrument to shine a

light into the eye, which is then reflected back from the retina. The optician will add lenses

to the trial frame until there is no movement of the light returning from the eye, indicating

that the prescription in place is a good approximation of the prescription required.

The autorefractor is a hand-held or stand instrument that electronically measures the

optical prescription, usually producing a printout of the results.

Each practitioner will wish to decide upon a suitable way of doing an objective assessment

and both methods can produce satisfactory results. The final accuracy may depend upon

customer co-operation and clarity of the internal media of the eye.

These techniques are invaluable in examining any patient, particularly if there is no

previous prescription. However, the great value of the objective procedures is that they

do not require any patient response and little co-operation, making it possible to provide

an optical assessment for patients who are unable to co-operate or communicate.

Subjective assessment of the glasses correction at distance and near

The subjective techniques involve asking the patient whether they can see better with one

lens or another. Following the objective test, this is usually a fine-tuning of the prescription

found and allows the practitioner to ensure that the final result achieves the best and most

comfortable prescription. Again, the technique involves reading letters on the Snellen chart

or a reading card. Where a patient is unable to recognise letters, picture charts are also

available. When assessing the prescription for reading glasses, the optometrist will wish

to ensure that the glasses are focused at the distance which most suits the patient (some

people like to read close and others further away).

Further variations may be needed for other activities, such as using a computer, playing a

musical instrument or painting. The subjective assessment does, of course, require some

co-operation from the patient but, even if this is limited, the procedures can be carried

out with useful results.

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Investigation of the mobility of the eyes and any muscular

imbalances at distance and near

Tests to evaluate the actions of the six extraocular muscles, which give the eyes their

movement, may be carried out. Often used for children to assess any possible squints,

they are also performed on adults to ensure that the eyes are working together and in

muscular balance. Any symptom of diplopia (double vision), particularly of recent origin,

needs to be investigated to assess whether any of the muscles are performing incorrectly

and to allow a full investigation of the cause and possible treatment.

Assessment of the quality and extent of peripheral vision

The measurement of visual fields is an important aspect of the eye test in ascertaining

any loss of peripheral vision. Glaucoma is characterised by a reduction in peripheral

vision, which, in its early stages, will be unnoticeable to the patient.

Other conditions, such as strokes and retinal conditions, can also affect visual

fields. In the older person in care, diagnosis and treatment are both important,

but the condition might not affect their daily lives much. In a patient who, for

instance, drives a vehicle, any reduction in visual field would be significant.

One of the problems in assessing visual field loss is that the tests are

extremely subjective and mostly require a high degree of patient

involvement. The patient has to indicate awareness of the lights

or targets. Recent advancements have made these instruments

more portable and suitable for domiciliary work but they are

not ideal for patients with limited concentration.

Measurement of intra-ocular pressure (IOP)

Measuring the pressure of the eye is important in identifying glaucoma. All eyes maintain

their shape because of the pressure of the fluids inside them. If the pressure rises too much it

can cause damage. Traditionally there have been two main methods used to measure the IOP:

contact and non-contact tonometry. The contact method requires the tip of the instrument

to touch the surface of the eye, and necessitates the use of a drop of topical anaesthetic.

The non-contact method blows a puff of air at the eye, and does not require drops.

Specsavers Healthcall uses the iCare tonometer, which has been shown in studies to be

more ‘patient friendly’ than the other two methods. It uses a very small probe to touch

the surface of the eye so quickly and gently that, in the majority of cases, the patient is

completely unaware that the measurement has been taken. There is no puff of air and

no drops are required, making it perfect for the domiciliary environment.

Examination of the external and internal structures of the eyes

The optometrist will want to examine the eye to check for disease or abnormality.

Externally, this will be achieved largely without instrumentation and includes a note of the

state of the lids and conjunctiva etc. Any redness, excessive lacrimation (tear secretion) or

dryness may need attention. Internally, the clinician will use an ophthalmoscope to examine

the eye from the cornea at the front, through the pupil, to the retina at the back, including

the lens and media. As well as the retina, the ophthalmoscope will present a view of the optic

nerve head (particularly important in recognising glaucoma and neurological problems) and

retinal blood vessels. This entire panorama of the back of the eye is known as the fundus.

The veins and arteries of the fundus are the only vessels in the body not covered by the skin

and so they present a unique opportunity to view these structures. Small haemorrhages

or blockages will be visible, indicating conditions such as diabetes, hypertension or other

systemic problems. These conditions are frequently first identified during an eye test and

should be referred to the patient’s GP. The optometrist will, of course, also wish to note

any changes to the retina itself.

Supplementary procedures

The practitioner may wish to, or need to, carry out other procedures, dependent upon

the needs of the patient. These may include colour vision tests or tests for stereopsis

(depth perception), although these will rarely be general practice in the care home

environment. More detailed examination of parts of the eye that are of particular concern

may also be carried out, including dilation of the patient’s pupils, or the use of the many

diagnostic instruments available to the domiciliary optometrist.

In conclusion

In the domiciliary situation, the optometrist may not carry out all the procedures

described, and the order of tests will vary between clinicians. The eye test is a thorough

and important examination, emphasising how optometry plays an important role in

primary and secondary health care.

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How To Support A Visit By The OptometristThe following guidelines are helpful in facilitating a visit from the optometrist.

Useful Information

1 Make an appropriate room available. It should be private, at least three metres in

length, equipped with electrical points and capable of being darkened.

2 Advise the patients’ relatives that the eye tests are taking place and invite them to

attend. If they’re not attending, make sure that the patients’ relatives have agreed

to the dispensing of glasses if required. Specsavers Healthcall provides information

letters for patients’ relatives.

3 Check the patients’ financial status and inform Specsavers Healthcall. This information

is very important if any of the patients require glasses.

4 Get HC1 (SC) forms for customers of unconfirmed status. Please ask Specsavers

Healthcall if you do not have these forms.

5 If any patients are new to the home, find out when they last had an eye test.

Was it over a year ago? Are they currently attending the eye hospital?

6 Advise Specsavers Healthcall of any patients suffering with conditions such as

glaucoma, diabetes, MRSA or hepatitis.

7 Nominate a member of staff to help liaise between patients and the optical team on

the day of the eye tests. It is important that the optometrist is aware of any medication

the patients are taking and their medial histories. Access to the patients’ care plans

would be very much appreciated.

8 Make sure the patients are aware that they will need to bring their current and

any old glasses along to the eye test.

1 The cornea

The cornea is the c

Lens strength is measured in dioptres. A prescription showing a + lens indicates the patient

is long-sighted and one showing a – lens indicates the patient is short-sighted.

Many people have astigmatism, which can be in one or both eyes. Astigmatism is when

the eye is not quite a perfect shape i.e. the eye is rather like a rugby ball instead of a football.

This causes images on the back of the eye to be distorted. This condition is more common

than people realise and, like short and long-sightedness, can be corrected by glasses and

contact lenses.

Remember that as people get older, more light is required for the eye to function properly.

Please make sure that all your patients have access to a desk lamp or direct reading light

when reading.

It is extremely important that glasses lenses are kept clean and free of smears to allow for

maximum vision and penetration of light. Current ophthalmological opinion is that over-

exposure to ultraviolet light can cause an earlier onset of cataracts. Sunglasses, which

absorb UV light, should always be worn in bright sunlight. It is also important that patients

are wearing the appropriate glasses for reading, eating, sewing or looking at photographs,

and distance glasses for walking about, watching television and general use.

If the patient has been prescribed bifocals or varifocals, they should be worn for all activities.

Macular Society

PO Box 1870

Andover SP10 9AD

Tel: 0300 3030 111

www.macularsociety.org

Royal National Institute of

Blind People (RNIB)

105 Judd Street

London

WC1H 9NE

Tel: 0303 123 9999

www.rnib.org.uk

Age UK – Head Office

Tavis House

1-6 Tavistock Square

London

WC1H 9NA

Tel: 0800 169 6565

www.ageuk.org.uk

For assistance in determining a patient’s eligibility for help towards the cost of glasses,

we recommend calling the Pension Credit Helpline on 0800 99 1234, 8am-8pm Mon-Fri,

9am-1pm Saturday.

Useful Organisations

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Ophthalmic Terms Optometric Case StudyMyopia* is the common term for short-sightedness

Hypermetropia* or more usually known as hyperopia is long-sightedness

Emmetropia means that there is no refractive error in the eye

Presbyopia* is the loss of near focusing ability due to age

*All these eye defects can be corrected and vision improved with glasses

Other conditions that can affect vision include:

• Dementia

• Strokes

• Head injury

Patients suffering from these neurological disorders could experience

visual problems and may require ophthalmic assessment.

1 The cornea

The cornea is the c

Using the example below, you may wish to write

your own case study based on your personal

experiences with someone for whom you have

responsibility of care.

Patient Mr A T, Born: 30 August 1919

Mr A T is over 90 years old. He lives alone following

the death of his wife in 1999 and suffered a mild

stroke in 2000, which left him partially paralysed

on the left side.

He has stopped taking the aspirin prescribed by

his GP. Mr A T had an exemplary war record, being

commended by the King and was awarded the MBE in

1978 for services to the Scout movement. He remains

mobile using a stick but moves slowly and cannot

walk far. He presents with some transient dysphasia.

Mr A T requested a domiciliary visit through his Social

Services visitor because he had not had an eye test

for six years.

The examination

On examination, Mr A T wears a pair of

non-prescription sunglasses for bright days

but has no prescription glasses.

Refraction reveals:

Unaided vision:

Right eye: Hand movements

Left eye: 6/24

Correction:

Right eye: -2.25 / -1.25 x 90

Visual acuity: 1 / 120

Left eye: -1.25 / -1.00 x 85

Visual acuity: 6 / 12 + Add + 3.00

Near visual acuity: N6

Mr A T had long been aware of the poor

vision in his right eye but was not particularly

concerned about his left eye. He was prescribed

a distance prescription for television but declined

help with reading. External examination revealed

right lower lid ectropion (lid turning out) and the

conjunctiva was infected on this side. He admitted

that he had some drops for this, but had stopped

using them.

The left conjunctiva and sclera were quiet. Internal

examination revealed what was believed to be old

choroidal lesions (scarring) spaced around both fundi.

There was some slight dry disturbance of the macula

on the left side and extensive age-related macular

degeneration on the right.

He presented with nuclear cataracts in both eyes,

which were only mild in development and not

considered an issue. He also presented with a

small flame-shaped haemorrhage on the left optic

disc, which was of concern as this can be a sign of

glaucoma. Intra ocular pressures were, however,

within acceptable norms of right eye: 16mm/Hg

and left eye: 17mm/Hg. Other ocular functions

appeared normal.

Mr A T was referred in relation to the disc

haemorrhage and the possibility of a condition

known as low-tension glaucoma, an even greater

concern in view of the lack of vision in the right eye.

Ophthalmic diagnosis

The ophthalmologist confirmed the choroidal

lesions as presumably being old choroido-retinal

scars (toxoplasmosis). He diagnosed glaucoma and

this he treated with Xalatan drops at night in both

eyes. Mr A T has now received his glasses and

enjoys watching the television.

Summary

Mr A T is a classical case of lack of optometric care

through not being able to get out, not experiencing

any particular symptoms and being unaware of

the availability of domiciliary care. His sight would

undoubtedly have deteriorated in time, maybe to

the point of partial sight or worse. Treatment for

the glaucoma will, hopefully, delay progress of

the condition, providing he continues to take his

medication. This will allow Mr A T to continue to lead

a life, which is satisfactory for his needs and wants.

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Self-AssessmentThe following questions and activities will help you think about and develop what you have learnt from the awareness session and the learning materials in the candidate pack.

You can obtain further training manuals, DVDs and simulation glasses by calling

0800 198 1135. Remember, this is not an exam, it is a record of what you have learnt.

If you want to use this section as evidence towards other training, remember that

your assessor is interested in your understanding and not in your presentation or

written skills. Your assessor can also ask you additional questions or discuss your

answers, so your written work does not have to be perfect.

1 List six parts of the eye.

2 Join the boxes. Match the parts of the eye with their correct descriptions.

3 Each row on the following table looks at a common

eye condition, its description and a common treatment.

Using the learning materials, can you fill the gaps?

4 For some people an eye condition is something they have accommodated in their lives. For others

it can have serious effects on their health and/or well-being. For each of the following headings list

three or four ways in which someone who has a visual impairment may be affected.

Physical effects

Emotional effects

Social effects

5 List three warning signs that might suggest that a patient or service user may be having problems

with their eyes (for example, changes in behaviour).

Name of eye condition Description and effect Common treatment

Cataracts

Presbyopia Difficulty seeing things close up.

Occurs from middle-age onwards.

Macular degeneration

Glaucoma

Perceptual problems There may be difficulty recognising

familiar objects or knowing how to

use them. Although vision may not be

affected directly, it may be difficult for

the brain to interpret what the eyes

see. Seen in patients who have suffered

stroke, head injury or dementia.

Macula Opening in the iris that

opens and closes to adjust

the amount of light entering

the eye.

Lens Provides the most detailed

level of vision.

Pupil Multi-layered, light sensitive

membrane. The innermost

layer of the eyeball where

light is converted into

nerve impulses.

Retina Elastic, colourless, transparent

body of cells behind the iris.

Shape modified to focus on

subjects at different distances.

Optic nerve Passes images from the inside

of the eye to the brain.

12082_Healthcall_Training Doc_MASTER.indd 21-22 09/10/2013 08:52

6 Case studies

Case study one

You have noticed that one of your patients is becoming quiet and withdrawn. When you have a

chat with him he complains of difficulty reading his favourite book. He wears glasses but they are

no longer working. Without being able to read he is getting very bored and is unable to distract

himself when his arthritis starts niggling him.

a What could you and your care team do to help?

b What other organisations could help in providing care?

Case study two

A patient who has recently suffered visual impairment is becoming tearful and has had several

accidents whilst trying to get to the toilet. When you talk to her she is very angry at her loss of vision

and is frightened of falling. This is causing her to delay going to the toilet until she is desperate.

a What can you and the care team do to help this lady?

b Which people or organisations could you get involved in this person’s care?

c Where could this person get information about her condition?

7 Describe two patients your care team has cared

for who have benefited from the services of an

optometrist. What were the problems they had

and how were they resolved?

8 List five key roles of the optometrist.

9 How can a patient who is living in a care home

or sheltered accommodation access the services

of an optometrist?

10 Using the Specsavers Healthcall eye test checklist, list two

ways you can support patients during a visit (for example

check that they have their normal glasses with them at

the time of the appointment).

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