7.1.6. Understands the special examination needs of patients with learning and other disabilities.

Question 1

Ability to Empathise:

Answer 1

• Put yourself into the patient’s shoes. That’s how you will start to empathise with them
• Listen carefully & attentively
• Summarise what they’ve said

Question 2

Flexibility in Examination & Communication Approach:

Physical Disability:

Answer 2

• 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, if they’re in a wheelchair & propped forwards
  • Make sure they can see letter chart e.g. by using cushion underneath
    
    • Tilt the mirror if needed
    • 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.
• Other 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
  • Use a trial frame as patient may not be able to press head against phoropter

Question 3

Deaf:

Answer 3

• 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

Question 4

Children:

Answer 4

• Different tests & different order of doing tests
• Speak to both parent & child
• Do not be afraid to rebook if you can’t do everything on the day
• Toys & relevant equipment
• Rely more on objective than subjective
• Give lots of praise, end on a high & have fun
• Remember child protective laws! —> Child under 16 must have parent accompanying them at all times either in the room or outside. If outside, must have an open door policy to protect against unfound allegations of inappropriate misconduct due to physical proximity and contact. This can be distressful for children & vulnerable adults (disability, mental illness, sickness & age)

Question 5

Autism:

Answer 5

• 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

Question 6

Other:

Answer 6

• Find out how the patient likes to communicate, including if sensitive to anything like sound, touch, smell
• Ask about patient’s health plan or communication passport
• Talk directly to patient, and speak slowly. Don’t repeat what you said unless you have to. You need to allow the patient to process what you have said then they will respond
• Warn patient before touching them
• Explain & show equipment before using
• Makaton may be helpful
• Patient may have a “telling the optometrist” form from SeeAbility with them beforehand. Carer will fill this out
• “Feedback from the optometrist about my eye test” from SeeAbility
• Use dynamic retinoscopy if needed for accommodation measurement
• Attempt visual fields even if only with confrontation
• Mydriasis may be worth using
• Record any reasons for limitations on the examination and results obtained

Question 7

When examining a px with learning disabilities you should:

Answer 7

• Make reasonable adjustments to the px’s eye care e.g. using a range of tests and procedures that are appropriate to the needs of the px
• Seek their consent to get a briefing from a relative or carer, if necessary
• Encourage the px to visit your premises before their eye exam to help them become familiar and comfortable with the environment
• May help to book the px in at a quieter time of day
• Make sure store and test room are wheelchair accessible
• Encourage the px and carer to complete See Ability ‘Telling the optometrist about me’ form and bring it to the appointment
• Website also lets you find an optometrist near you which can accommodate pxs with specials needs
• Find out how the px likes to communicate and how their disability affects them, including if they are particularly sensitive to touch, lights and sounds
• Communication passport
• Find out about any recent signs, symptoms or behavioural changes that might be relevant
• Ask to refer to the px’s health action plan or communication passport if they have one
• Be prepared to spend longer on the exam and to arrange repeat visits to obtain full and valid results
• Use an objective measure of accommodative function e.g. dynamic ret, to determine the accuracy of the px’s accommodation
• Attempt visual field assessment, even if only be using confrontation techniques
• Use cycloplegic exam, if necessary, to determine the full refractive error
• Use mydriasis, if necessary, to internally examine the eye
• Give clear info to the px or carer about the effects of eye drops
• Record any reasons for limitation on the exam and results obtained
• Consider whether you need to refer the px for further tests e.g. under anaesthetic, or electrophysiological tests
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