2.2.1 Is able to manage all patients including those who have additional clinical or social needs.

Question 1

Rehab workers

Answer 1

Essentially like occupational therapists or essentially are, & provide help to the px within their home such as:
- Mobility training
- Advise on cane use
- Instructions on safe cooking methods & equipment use
- Advice on magnifiers & low vision aids
- Mark cookers & other appliances’
- Help decide if guide dog is suitable
- Advice about design of house environment
- Referral to other social workers like counsellors

Question 2

ECLOs

Answer 2

Eye care liason officers
- ECLOs —> at the point of sight loss diagnosis, they act to signpost px to emotional & practical support, talking about lessening impact of the eye condition on your life
- Talk about treatment for avoidable sight loss & general eye condition advice
- Discuss benefits of registration
- They are essentially the bridge between health & social services, supporting pxs in eye clinics

Question 3

Why do Reasonable adjustments need to be made?

Answer 3

• Disability & Equality act 2010
• Equality Act 2010 protects people against discrimination, harassment or victimisation in respect of protected characteristics. Duties apply to staff and patients
• Must make ‘reasonable adjustments’. E.g. allowing more time for examination, having correct instruments to assess patient like direct ophthalmoscope.
• Protected characteristics:
  age;
  disability;
  gender reassignment;
  marriage and civil partnership;
  pregnancy and maternity;
  race;
  religion or belief;
  sex;
  sexual orientation.
• If you have been certified as severely sight impaired (blind) or sight impaired (partially sighted) by a consultant ophthalmologist, then you are automatically protected under the Equality Act.
• Access to work - if reasonable adjustments not met then this scheme will help
  
  • Based upon individual needs. Grants given for travel to & from work, special equipment, support worker services
  • Done via gov.uk website via phone or website

Question 4

Awareness of different types of disabilities & patients with additional needs. Ensuring patient environment is safe, inviting and user-friendly as far as access & facilities are concerned.

Answer 4

• Physical (more information further down page)
  
  • Testing room not upstairs
  • Armed chairs in waiting room & consulting room (makes it easier for them to lift themselves up)
  • Enough space in consulting room & hallway to manoeuvre wheelchair
  • Ensure doors are wide open
  • Carpet floor better than laminate (slippery)
• Hearing
  
  • Make eye contact
• Lip reading
• Body posture towards them
• Stay positive & be patient!
• Do not do excessive mouth movements
• If they didn’t understand what you first said, repeat it in a different way
• Pause between sentences
• Less background noise
• Put refractor head infront & away when needed so they can see you
• Give written advise rather than verbal
• Visual
  
  • Differing floor e.g. one side of shop floor laminate & next is carpet
    
    • A little separation may be between these differing floor appearances & this might confuse a visually impaired px; they may think it’s a step
    • • Tripping hazards - Obstacles like chairs will make it more difficult for them to navigate
• Ensuring bright lighting across the store. May need a lamp during the eye examination
• Autism
• • Asking if they have any particular triggers or coping strategies
    
    • E.g. ask if trial frame can be put onto face beforehand & keep it on as short as possible, ask if bright light is ok before you shine it
• Break complex instructions into simple ones
• Use ‘again’ to indicate that you want to repeat what we just did - if child
• Patient may have echolalia so they repeat back last thing you said. If showing option 1 or 2, and they keep 2, then change it to showing option 2 then 1 and see if response is still 2 (keep the power for No. in this case the same as the power of No. 2 when you were showing either 1 or 2) . If it is, then they actually prefer option 2.
• Use a timer/countdown when doing ophthalmoscopy as they have bad perception of time
• If they do certain rocking & coping behaviours, do not stop this! Reassure patient regularly
• Intellectual
  
  • Same link as above
• Mental Health

Question 5

Certification & Registration:

Criteria for RVI/CVI registration. Guidance from Certificate of Visual Impairment (CVI):

Answer 5

• Sight Impaired:
  
  • Visual acuity between 3/60 and 6/60 with full visual field
    Visual acuity 6/24 or worse with moderate contraction of visual field, media opacities or aphakia or with a central part of vision that is cloudy or blurry
    Visual acuity 6/18 or better with gross field defects or marked constriction of the visual field - e.g. whole half of vision missing or significant portion of periphery
• Severely Sight Impaired:
  
  • Visual acuity worse than 3/60 with full visual fields.
    Visual acuity between 3/60 and 6/60 with a very contracted visual field unless long standing
    Visual acuity better than 6/60 with a very constricted visual field especially if in lower part of field

Question 6

Process for RVI/CVI registration: https://www.rnib.org.uk/eye-health/registering-your-sight-loss

Answer 6

1. Certification Stage 1: Deciding it’s right to certify (done after being referred by Optometrist or using LVL)
2. Certification Stage 2: Completing the CVI by ophthalmologist (official certificate)
3. Certification Stage 3: Sending CVI to SSDs, Eye Hospital, Patient and GP
4. Registration Stage 1: Initial SSD assessment (after social services asks if you want to be registered visually impaired - otherwise if no, then support still available to help from social services)
5. Registration Stage 2: Second (full) SSD assessment

Question 7

Low Vision Leaflet: https://www.glosloc.co.uk/ophthalmology/low-vision/

Answer 7

• If they are already certified but not registered, you can give them a LVL for them to access social services themselves without the need for registration if that is what they choose
  
  • A LVL contains contact details for sources of information, advice and help.
  • It has a tear off form with questions for the patient to answer about their home situation,
    difficulties and additional disabilities and then send to their local social services to ask for an assessment.
  • Px can also phone social services directly if there is no LVL & they don’t want certification. Your local council’s social services telephone number should be in the phone book, or directory enquiries. There is also a sightline directory on the RNIB website.

Question 8

RVI (referral of vision impaired px)

Answer 8

This form can be sent from eye clinic staff to social services in advance or instead of registration. Done if px declines certification or is not legible for it but still needs social services’ help

Question 9

Difference between Certification & Registration

Answer 9

• The Certificate of Vision Impairment (CVI) formally certifies a person as either sight impaired (partially sighted) or severely sight impaired (blind). The purpose of the CVI is to provide a reliable route for someone with sight loss to formally be brought to the attention of social care. In addition epidemiological analysis of CVI data provides information on the prevalence of sight loss.
• Registration as blind or partially sighted is provided by Social Service Departments (SSDs) and the purpose of these registers is to help local authorities plan and provide services for people who have sight problems. Registration is a voluntary choice.

Question 10

Benefits of Registration:

Answer 10

SIGHT IMPAIRED
Disabled person’s railcard
Free telephone directory enquiries
Protection under Equality Act
Universal credit, pension cried, tax credits

SEVERELY SIGHT IMPAIRED
As with SI, but also…
Blue badge
50% off TV license
Free postal service
Council tax exemptions (up to £2,290)

Question 11

Mobility support

Answer 11

• Sensory services from local councils can offer a mobility assessment and subsequent training to give a person with sight loss the skills and confidence to go out independently
  
  • Working out the safest routes to travel to specific locations
  • Tips about the safest places to cross roads
  • Cane training
    
    • Symbol - for busy places so people know you are SI
    • Guide - for finding obstacles ahead like kerbs or steps
    • Long - rolls or taps side to side to avoid obstacles whilst walking
    • Red & white banded - SI & hearing loss

Question 12

Changed their routine to adapt

Changed their Visually Impaired: to adapt

Answer 12

• Large fixation target - for cross cyl, preferably big round target (larger than best corrected acuity)
• Larger steps, from 2D to 4D to 6D to 8D until response & large cross cyl steps
• Spin the cyl & see if patient prefers an axis or use Stenopaic slit
• Should only prescribe if actually seeing better i.e. line improvement
• DO NOT attempt +1.00 blur or binocular balance (unless applicable)
• Use pinhole - checking if reading same line as before rather than looking for improvement

Question 13

Changed their routine to adapt

Physical Disability: (on College website under Management guidelines)

Answer 13

• Ask the patient if they are able to transfer to the consulting room chair.
  
  • Explain that you will be able to examine the patient in their wheelchair, but that they will be able to have more tests done if they can transfer to the consulting room chair. Say that it’s their own risk?
  • Ask the patient if they would like you to lift the armrests and/or footrest on the consulting room chair out of the way
  • Ask if need any help (only if really struggling)
• If patient in wheelchair in front of consulting room chair:
  
  • Make sure you look at patient in their eyes rather than looking at their back
  • Make sure they can see letter chart e.g. by using cushion underneath
    
    • Record distance at which test conducted e.g. 5/6 rather than 6/6
      
      • Adjust Rx accordingly i.e. 5m = 1/5 = 0.20D which is approx 0.25D so subtract 0.25 from final result
• Make clear notes of the adjustments that you made to your examination technique. This will help any follow-on optometrist understand what worked for this particular patient.
• Adaptations:
  
  • Using Direct ophthalmoscopy instead of Volk
    
    • Using the shadow test for example for Van Hericks
  • Using Pulsair instead of Tonoref 3
  • Using confrontation instead of visual fields

Question 14

Other definitions if sight impaired

Answer 14

 Functionally blind: can’t see to read/write with LVA, cannot move in unfamiliar surroundings without dog/cane
 Functionally sighted: VI but can read with LVAs and can move in unfamiliar surroundings without dog/cane
 Functionally sighted with aided mobility: VI and can read with LVA or visually identify objects but can’t move in unfamiliar surroundings without dog/can (e.g., RP)
 Functionally sighted without sighted literacy: VI, can move in unfamiliar surroundings but cannot read with LVAs (e.g., AMD)