7.1.6 Understands special examination needs of pxs with learning and other disabilities

Question 1

Describe the disability and equality act (2010) and how it applies to optoms?

Answer 1

Disability and Equality Act (2010):
Patients should be treated equally and prevented from discrimination (e.g. in education,
employment, good service, facilities, transport).
For Optometrists:
* Provide the same level of care.
* Adapt your routine to accommodate a patient.
* Allow them to access the facility.

Question 2

What are the types of disability?

Answer 2

• Physical – Amputation, Motor Neuron Disease, Advanced MS
• Sensory – Blind or Deaf
• Intellectual – Dyslexic, Dementia, Down Syndrome
• Emotional – Anxiety or Depression
• Developmental – Autism

Question 3

What adjustments can be made when testing pxs with disabilities?

Answer 3

• accessible test room
• trial frame
• cyclo an adult
• dilate if adult px can’t stay still
• ophthalmoscopy over Volk
• Provide space for carer
• iCare/Perkins
• Confrontation and amsler
• Rely on objective over subjective (mental disability)
• Communication with appropriate carer/family member to highlight any concerns
  or needs of Px
• Remove obstacles
• Face the patient and speak clearly and concisely
• Use Kay’s Pictures or Tumbling Es

Question 4

Describe testing pxs with intellectual impairement: causes, ocular problems, px behaviour?

Answer 4

o Causes: Chromosomal abnormalities, trauma, hypoxia, prenatal infection, prematurity, metabolic disease,
neurological disease, idiopathic
o Associated ocular abnormalities: Optic atrophy, High myopia, Cataract, Retinal Diseases, Anisometropia
o Px behaviour – Lack of eye contact, Lack of verbal communication, Loud speech, High emotions, easily
frightened (Improvement in vision can result in positive behaviour changes)

Question 5

Describe testing pxs with multiple impairements?

Answer 5

o These Px represent the greatest challenge to the optometrist. Impairment: intellectual, mobility problems,
communication deficiency, behaviour problems, low vision, additional health problems.

Question 6

Describe testing pxs with head injuries or strokes?

Answer 6

o Head trauma or stroke px may result in memory and attention deficits, as well as in intellectual and emotional
disturbances. Many px suffer from persistent language impairment.
o Visual Features: Conjugate ocular deviation towards the affected hemisphere in acute stroke, CN palsies,
Nystagmus, Squint, Diplopia, Reduced stereopsis, reduced convergence, accom insufficiency, loss of vision,
visual neglect, transitory VF defects, homonymous hemianopias, photophobia, headache, ptosis, cortical
blindness, abnormal hand eye co-ordination, difficulty reading, Severe communication difficulties
o Techniques: Use written information, formulate question in yes/no format, address the patient directly, be
patient and do not patronize the patient but praise and encourage the patient at the same time. Appropriate
correction of any Rx, BV issues and visual training to visually rehabilitate the px, co-ordinate with other health
professional involved in px management.

Question 7

Describe testing pxs with cerebral palsy?

Answer 7

Permanent, non-progressive condition affecting motility and co-ordination, Brain damage
o Risk: Infection, Prematurity, Trauma
o Systemic Findings: Seizure, Hydrocephalus, Respiratory problems, Hearing difficulties, Mental disability,
Motility problems.
o Visual Impairments: Common (40-75%) – Hyperopia, Amblyopia, Strabismus, Rx, Nystagmus, Accommodative
Insufficiency, ON atrophy/hypoplasia, defective function of Retrochiasmal visual system (inability to fixate, to
direct gaze towards stimulus, chaotic eye movement
o Scheduling Appointment: Assess the special need of the px, allow extra chair time, protect patient’s privacy,
prepare the practice to handle a medical emergency, prepare practice for wheelchair
o Initial Assessment: Observe px head position, behaviour, look for indication how to approach and
communicate, communicate directly with short simple sentences, obtain an accurate history, involve patient
and carer in as many steps as possible, use diagram to illustrate what to do, have number of test on hand to
switch if difficulty encountered, use breaks, praise the patient.
o Post Examination: Discuss the findings with the caregivers, provide carer with written report of findings and
management scheme, provide prescription, send a copy to GP and any referral for specialist support,
highlights patients strengths.

Question 8

Describe testing pxs with down syndrome?

Answer 8

1/600 children, Chromosomal abnormality, Systemic: Mental disability, seizures, heart defects,
leukaemia, skull deformities, ADD/autism
o Mental Impairment: Mild to severe cognitive impairment, Seizures, Delayed speech and motor abilities, ADD,
Autism, Obsessive-Compulsive and Depression
o Anterior Segment: Brushfield spots on the periphery of iris, Cataract, Keratoconus
o Posterior Segment: Glaucoma, Psuedopapilloedema
o Other: Rx, Accommodation Deficiency, Amblyopia, Strabismus, Nystagmus, Epicanthal folds, Recurrent
infections, Nasolacrimal duct obstruction, congenital ectropian
o Guidelines: 0-6 weeks – Assess visual behaviour and check for congenital cataract, 6-12 months assess visual
behaviour and check for strabismus, 18-24 months Orthoptic and ophthalmic examination and refraction, 4-
4.5yrs full Ophthalmic examination and refraction.
P a g e 101 |
o Extra Care – If possible examine the child in familiar surroundings, book early slots and allow extra times,
advise parents and teachers even with glasses vision may be below normal especially at near, parents may be
anxious provide accurate information and reassure them. Be patient and allow patient to answer questions,
reassure patient and be friendly they tend to blame themselves for small incidents, use test specifically
designed to test these type of children, Kay picture, Cardiff Acuity Cards

Question 9

Describe testing pxs with Autism?

Answer 9

Autism spectrum disorders (ASD) represent a common pathological neuro-developmental entity
characterised by lack of social interaction, abnormal communication and limited language as well as repetitive,
stereotyped activities/behaviours. The spectrum includes conditions such as autism, Aspergers syndrome, Rett’s
disorder, childhood disintegrative disorder (CDD) and pervasive developmental disorder (PDD).
o Ocular: Atypical gaze, difficult in maintaining visual attention and difficulties with face processing, MearesIrlen syndrome, Hypersensitivity to light, difficulty with high contrast, difficulty maintaining attention, tunnel
vision, Rx, strabismus, oculomotor dysfunction, eye pressing
o Examination: Try to get complete history from the patient or carer, observe the patient special postural
adaptations, use simple and specific words when explaining what you are doing, check if patient understood
instructions, warn patient before touching them, often these children are over stimulated by touch, ask carer
for help when needed, use agitation and unusual behaviour as a sign that px in uncomfortable, even low noise
may stress child
o Snellen or Logmar can be used in some patient, for other single letters are better, picture test can be useful
for children or for adult who use sign communication
o Test near vision: this is particularly important in autistic patients are most of their daily routine is controlled
through written schedules, close work etc.
o Preferential looking in px unable to communicate
o Test motility, binocularity, eye tracking, fixation, depth perception, colour vision and VF.
o Be careful with illumination even a pen torch is enough to trigger a seizure.
o Post-examination: explain in detail your finding, explain need for correction (why and what for glasses should
be worn) exactly.
o Management: Improves Rx, recommend vision training, colour vision assessment for Meares-Irlen, refer to
behavioural optometrist who can develop specific management plan

Question 10

Describe testing pxs with dementia?

Answer 10

– Degenerative brain disease resulting in impaired memory, thinking and behaviour
o Ocular: Abnormal nerve fibre layer and retinal ganglion, Macula cell loss, Glaucomatous ON cupping,
Supranuclear cataract, abnormal pupillary innervation
o Visual Effects: Decreased VA, VF loss (inferior), Rapid loss in px with glaucoma, reduced CS, abnormal colour
discrimination, delayed saccadic eye movement, abnormal VEPs, excessive pharmacological mydriasis/miosis,
visual hallucination.
o Examination: characteristics of AD such as defective memory, unreliability of answers, confusion, slow
response and low attention span, make exam challenging. Correct any deficit in Rx, caregivers encourage px to
wear correction, advise caregivers to have spare pair and label specs. Use yellow filter which is proven to
increase reading speed in CS patients. Cataract removal improve VA and stop visual hallucination, High colour
contrast in px environment could result in better behaviour. Annual examination