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«Commissioning better eye care Clinical commissioning guidance from The College of Optometrists and The Royal College of Ophthalmologists Adults with ...»

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Commissioning better eye care

Clinical commissioning guidance from

The College of Optometrists and The Royal College of Ophthalmologists

Adults with low vision

Version: 1

Published: 25 Nov 2013

Commissioning better eye care: clinical commissioning guide

from The College of Optometrists and The Royal College of


This resource is to help those designing and commissioning eye care improve the

value of their services.

It was produced by the Colleges using a template provided by the Department of Health’s Right Care team led by Professor Sir Muir Gray. In addition to the Right Care team, The Royal College of General Practitioners, the National Association of Primary Care, the UK Vision Strategy and partners in the eye health sector have supported the Colleges to produce this guidance.

It is arranged in to the following sections:

 Summary and recommendations  Introduction  What is low vision?

 What are the causes of and scope of prevention for low vision?

 How many people have low vision?

 What are the best value diagnostic tests?

 What are the best value treatments?

 How can individuals and carers be best supported long term?

 Successful systems of care: pathways and service models  How to compare services based on activity, quality and outcome Children and people with learning or cognitive difficulties have specific low vision needs that go beyond the scope of this guidance. Commissioners should work closely with patients, patient groups and clinicians in their area to design specific low vision services for these people.

Summary: low vision  Low vision affects every aspect of someone’s life, from the ability to prepare food to recognising friends’ faces. Older people with low vision are more likely to be depressed and to fall.

 The primary aim of low vision services is to enable people with loss of vision to regain or maintain as much independence and autonomy as possible.

 Low vision services achieve this through a wide range of tools depending on individuals needs including: rehabilitation, visual aids, emotional support and advice.

Recommendations  Every part of the country should have access to a low vision service.

 Low vision services should not only be open to people who meet visual acuity thresholds or who register as sight impaired. Low vision services can mitigate the practical, emotional and occupational or educational impacts of sight loss for people who do not meet the criteria to register as sight impaired.

 Access to low vision services should be prompt and flexible. Early intervention is key to getting the best outcomes. Flexibility means service users can access the service from multiple routes and should be entitled to reassessments as their vision changes.

 Integration is particularly important for low vision services. Effective low vision services adapt to individual needs and work as seamlessly as possible with other services, including hospital eye units, education, social care, voluntary organisations and stroke, rehabilitation and fall teams. Serious consideration should be given to the provision of an eye care liaison officer (ECLO) in every eye clinic in order to facilitate this.

 Commissioners should ensure low vision services have dedicated funding in their programme budget for eye health and explore the possibility to jointly fund and provide the service with health, local authority and voluntary sector resources.

What is low vision?

Low vision is an impairment of visual function that cannot be remedied by conventional spectacles, contact lenses or medical intervention and which causes restriction in everyday life1. Low vision includes, but is not limited to, those who are registered as sight impaired.

Types of vision loss that can result in low vision include peripheral loss, central loss, distorted vision, blurred vision and hazy vision. The impact of low vision varies from person to person and will affect people in different ways.

Low vision can affect people’s ability to perform everyday tasks, such as reading, writing, shopping, watching television, driving, crossing roads or recognising faces.

There is a link between sight loss and reduced wellbeing. People living with sight loss report having lower feelings of wellbeing2. Older people with sight loss are almost three times more likely to experience depression than people with good vision3 and more likely to fall4.

People with low vision in education can find it difficult to engage with the curriculum and in incidental learning.

What are the causes of low vision and what is the scope for prevention?

Low vision can be caused by a wide variety of congenital, hereditary or age-related eye conditions or may be a consequence of trauma. Visual problems can also be a result of other health conditions, such as stroke, or be associated with a learning disability. The most common causes of low vision amongst adults are age-related macular degeneration, diabetic retinopathy and glaucoma.

Low vision can best be prevented by:

 improving general ophthalmic public health to ensure people look after their eyes, for example by not smoking and having regular sight tests to detect eye disease early  improving the quality of diabetic retinopathy screening services  effective eye care to prevent avoidable sight loss.

How many people have this?

It is estimated that 1 in 5 people aged 75 and 1 in 2 aged 90 and over are living with sight loss5. There is no definitive data on how many people have low vision. In 2011, 299,000 people in England were registered as sight impaired (blind or partially sighted)6. Of those, two thirds were over 75 and more than a fifth were of working age. Around a third had an additional disability, with physical disabilities and then hearing impairment being the most common. One in ten adults with a learning difficulty are thought to have a sight impairment7. In 2010, there were 34,492 people registered as sight impaired in Scotland, three quarters of who were over 65 and 32% had additional disabilities8.

The number of people with low vision will be higher than the number of people who are registered as sight impaired. Some people who are eligible to register do not do so for a variety of reasons, for example some are not offered the opportunity to register and some decline. Furthermore, as stated above, someone can have visual loss that affects their daily living without reaching the thresholds required to register as sight impaired.

The number of people with low vision is projected to increase as the population ages because most causes of low vision become increasingly common with advancing age.

What are the best value diagnostic tests?

The impact of low vision is assessed through a combination of discussions with the service user (and in some cases their family and carers) and clinical examination.

The discussion with the service user should examine how sight loss affects their everyday life, for example their ability to carry out everyday tasks (like cooking), their mobility and communication. Other issues such as whether the patient lives alone, how mobile they are, if they have had a fall and what medication they are taking should also be noted. Assessment should pick up any problems with glare, adapting to changes in light or having hallucinations as a result of Charles Bonnet Syndrome9. The assessment should also note any visual aids, support or treatment the service user already has and a discussion with the service user about what they want to achieve from low vision support10.

Clinical assessment should include11:

 An eye examination or evidence of recent examination or referral for an eye examination according to local protocols to confirm that the condition that has led to reduced vision has been treated optimally.

 A functional vision assessment which should include: a discussion of symptoms and issues, a refraction, assessment of best corrected distance and near visual acuity, reading ability, contrast sensitivity12 and the effect of light on these parameters.

 If appropriate, an assessment should also be made of central visual field, peripheral visual field, and/or colour vision.

Clinical assessment should be done sensitively and adapted to fit the service users’ ability so that tests are not upsetting or inaccurate13. LogMAR charts are more appropriate for measuring visual acuity than Snellen charts. Specific low vision charts, such as the Bailey-Lovie, exist to test near visual acuity. Sensitivity to contrast can be measured using a Pelli-Robson chart or low contrast electronic test.

To assess visual fields, fixation monitoring should be turned off and the fixation target adapted to improve its visibility. In many cases, it may be enough to plot binocular fields or confrontation fields.

Given a large minority of those with low vision will have a physical disability or hearing impairment, services need to give careful consideration to how to ensure their diagnostic services are accessible and how to adapt communication.

What are the best value treatments?

There is no good evidence on the cost effectiveness of low vision treatments but interventions have been shown to improve useful vision and people’s ability to carry out daily living activities14.

Low vision services commonly provide information on15:

 any eye conditions that are affecting the person’s vision  assistance with certification and registration  welfare benefits and other financial support  social care enablement services  specialist education services  relevant voluntary sector organisations.

They also frequently provide:

 emotional support  best correction with spectacles  low vision aids, including electronic aids, with advice on how to use them  changes to the service user’s environment  follow up appointments as necessary  an introduction to rehabilitative techniques There is good evidence that providing low vision aids improves reading ability and strong evidence that patients value and use aids16. Broadly, a low vision aid is any piece of equipment used by people with low vision to enhance their vision,


 magnifiers –including hand and stand magnifiers, illuminated magnifiers, telescopic lenses for both distance and near, and spectacle mounted magnifiers  electronic aids - such as closed circuit television systems (CCTVs) or specialised computer adaptations as well as mobile electronic aids, including some mobile phones, computer devices and e-readers.

 non-optical aids - such as typoscopes and large felt tip pens  appropriate lighting.

There is mixed evidence on whether or not service users benefit if they receive training in how to use aids properly, for example through home visits or follow up appointments17,18,19,20.

There is good evidence that rehabilitative techniques (such as steady eye strategy and eccentric viewing) improve the near visual acuity of people with visual loss, their reading speeds and their ability to carry out daily living tasks21,22,23.

There is also a link between sight loss and reduced psychological wellbeing, particularly for older people. Over one-third of older people with sight loss are living with depression24 and low vision services should have access to emotional support and counselling.

Low vision services commonly offer advice on how to adapt living and working environments, such as finding the best lighting or using colour contrast to help navigation.

Advice on welfare and financial support also form an important part of low vision services.

How can individuals and carers be best supported long term?

Flexible access, early intervention and well integrated, patient-centred services are key to supporting people with low vision in the long term.

A person with low vision should be able to use the service at any stage after low vision is identified. Access to services should not be exclusively determined by clinical parameters such as visual acuity or certification but should take account of social, emotional, psychological, educational and occupational effects. Patients should be able to access low vision assessment and services, regardless of whether or not they have been certified as being visually impaired or whether they have reached the end of the pathway for their underlying eye condition.

Early intervention is seen as an important factor in getting the best outcomes for people using a low vision service25. Without support early on people can lose their skills, confidence and motivation rapidly after they suffer sight loss and vision can decline further while users are waiting to access the service. People of working age who develop low vision are at considerable risk of becoming unemployed, but early intervention may allow them to remain in employment with suitable adaptations and improve the prospects for employment for those who are not working.

Support should be ongoing to help the patient respond to changes in their condition, their overall health and their circumstances and should not be rationed to a single low vision assessment or visit from a support worker.

Low vision services need to integrate very well with other eye care services. The majority of low vision patients are referred in to the service as part of their treatment for an underlying eye condition, such as AMD, glaucoma or diabetic retinopathy.

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