Continuing Education

In this article, Barbara Ryan and Tom Margrain look at the process of registration for adults and children in the UK and outline the health care professionals that practitioners may need to link with when providing eyecare to people with a visual impairment
(Module C4060)

The PDF for this module is not currently available.

Registration and certification.

In the UK, the registers of people with a visual impairment are known to underestimate the number of people with untreatable sight loss by a factor of 2 to 3 fold1 2  . Practitioners need to be able to discuss registration with their patients and, when appropriate, refer them to a consultant ophthalmologist to initiate the process or change their registration status.

Registration can be an important gateway to other services and benefits. Although people can usually access social services without being registered, registration automatically triggers a referral. Depending on the person's circumstances, registration may also entitle them to a benefit or higher amount of money. A list of entitlements is given in Table 1.

The authorities that fund services for visually impaired people use the epidemiological information gathered during the registration process to help determine the need for services. Therefore, ensuring the statistics are as accurate as possible is an important way of ensuring adequate provision of health and social services for people with a visual impairment.

People may be unwilling to be registered because of the stigma attached to it. If not explained carefully many people reject the process at the first instance. The low vision practitioner may be the first person to identify the possibility of registration or the first professional a person comes into contact with after registration is offered by an ophthalmologist. It is vital that discussions are handled in a sensitive manner encouraging the person by outlining the advantages but allowing them to make the decision themselves.

The process
The process of registration is currently different in different parts of the UK.

In Scotland and Wales

For a person to be entered onto the register it must first be certified by a consultant ophthalmologist that the person has a visual impairment. This is done using a five part form. In Wales the form is called the BD8 and in Scotland the BP1.
Onto the form the consultant ophthalmologist records the person's details, a diagnosis of the condition, information about the person's level of vision and the person's consent to be registered. Once a form has been completed the person is certified as partially sighted or blind. A copy of the information is passed to:

the General Practitioner
the patient
the hospital record
the authority that collect the epidemiological data

Copies of the form, omitting the diagnosis are also passed to the Local Authority which places the person's name on the register and passes the information to the specialist social services. At this point the person has been registered.

In Scotland this system is currently under review and in Wales the conclusion of a review was to adopt the system currently operating in England and Northern Ireland and implementation is likely in the next year.


In Northern Ireland and England

In Northern Ireland and England a new process for registration is in place.

For a person to be entered onto the register they must first be certified as eligible by a consultant ophthalmologist using a CVI. The CVI has replaced the BD8 in England and the AP655 in Northern Ireland.
There are three parts to the form and a consent form. The first part contains details of the person and requires their signed consent to be registered. In Part 2 the consultant ophthalmologist records a diagnosis of the condition and information about the person's level of vision. The third part can be filled in by another member of staff in the hospital department and includes details of the person's living conditions and any other disabilities.
Once a form has been completed the person is certified as having a visual impairment. A copy of all the information is passed to:
the patient;
the hospital notes
the General Practitioner;
the authority that collect the epidemiological data; and
the Local Authority
The Local Authority places the person's name on the register and passes the information to the specialist social services who arrange to carry out an assessment of the person's needs. At this point the person has been registered.
Copies of the new form can be viewed on the Department of Health's website
(http://www.dh.gov.uk/assetRoot/04/11/76/79/04117679.pdf) and
guidance notes are also available. (http://www.dh.gov.uk/assetRoot/04/11/86/66/04118666.pdf)


Along with the CVI, two additional processes with associated forms were introduced to speed up the provision of services to people with a visual impairment:

Optometrist Identification of a Person with Sight Problems- Low Vision Leaflet (LVL)
The Low Vision Leaflet (LVL) is to be given by an optometrist to anyone with a sight impairment that would benefit from advice and support from social services. It replaces the LVI which was introduced in England in 2003. The leaflet contains contact details for sources of information, advice and help locally and nationally. It also has a short tear- off form with questions for the person to answer about their home situation, difficulties and additional disabilities. If the person completes the form they can post it to their nearest social services department to ask for an assessment. Once received their local authority has a legal duty to advise the person of the range of services available to people with sight problems and carry out an assessment of their needs.


Referral of Visual Impairment (RVI)
Hospital eye clinic staff, with the consent of the person, can fill in a Referral of Visual Impairment (RVI). The form tells social services about the person's situation, requests an assessment of need and states how urgently they think the person requires help.

Categories of Certification

1) Blind- Defined in the Blind Persons Act 19203 and subsequently incorporated into the 1948 National Assistance Act4:
 'so blind as to be unable to perform any work for which eyesight is essential"

With the implementation of the CVI the terminology in England and Northern Ireland has also been updated and Blind has been replaced by the term Severely Sight Impaired.
Guidelines for measures of visual function for Blind/ Severely Sight Impaired:
Visual Acuity < 3/60
Visual Acuity  > 3/60 but < 6/60 with a very contracted field of vision ( unless this has been long standing)
Visual  Acuity of better than 6/60 with a very constricted visual field especially in the lower part of the field (excluding people who suffer from homonymous hemianopia or bi-temporal hemianopia with VA better than 6/18)

2) Partially Sighted - no definition is given but subsequent guidelines on the National Assistance Act 1948 define Partially Sighted as:
"substantially and permanently handicapped by defective vision caused by congenital, illness or injury" 
With the implementation of the CVI the terminology in England and Northern Ireland has also been updated and Partially Sighted has been replaced by the term Sight Impaired.


Guidelines for measures of visual function for Sight Impaired (Partially Sighted):

Visual Acuity of 3/60 to 6/60 with a full visual field
Visual Acuity of up to 6/24 with moderate restriction of visual field, media opacities or aphakia
6/18 or better with gross field defect (e.g. hemianopia) or a marked constriction of the field (e.g. retinitis pigmentosa)
It should be noted that the levels of visual function listed above are only guidelines. Decisions about who can be certified are made by a Consultant Ophthalmologist who is advised to take other circumstances (such as whether the person lives alone or if they also have a hearing impairment) into account.


Registration of Children

A child with a visual impairment may be registered on one or more of three different registers.

The Register of visual impairment
As outlined above. For children however it is not usually used as the main trigger for services.

Register of children with a disability
Social services keep a register of children with a disability. Inclusion on this acts as the main trigger for social services provision for children.

Register of children with special educational needs
Registers are kept by each school and each education authority. The register details the help to be provided to the child.


Liaison with other professionals and services

Optometrists and Dispensing Opticians are often not used to relating to professionals outside the 'eye' and 'medical' worlds. People with low vision may benefit from input from a large number of services and professionals. A practitioner who is providing low vision support will be part of a multi-disciplinary team which develops to assist the person with low vision to stay as autonomous and confident as possible. Each team is unique because each person and their needs are unique. It may be unlike the traditional view of a team in that you may never meet the other members and there may not be anyone co-ordinating it. To provide good low vision care you must communicate effectively with the other members of the team. At times this can be time consuming, humbling and frustrating but it can also be interesting and very rewarding.


Health Care Services

We are used to corresponding with GPs and ophthalmologists. In low vision work you will need to continue to refer people when new or changing ocular pathology is detected. However, the body of healthcare professionals you may need to be in contact with will probably be greater. Table 2. outlines some of those you may come across for different types of patients. You may need to request information from them or report your findings to them to ensure care is co-ordinated. In the case of people having problems taking medication a phone call with the practice nurse may be useful or if someone has additional disabilities liaison with an occupational or physiotherapist may assist with posture or grip when using LVAs.

There may be occasions when you feel the needs of a low vision patient would be better met by another practitioner. Some will have more expertise with certain groups of people with low vision e.g. children, people of working age or people with multiple- disabilities. Others may have more experience and facilities to prescribe devices such as near telescopes or head mounted CCTVs. Other low vision practitioners should be viewed in a similar way to other healthcare professionals and so you should refer to them if you think it would be of benefit to the patient.



1. Reidy A, Minassin, D.C. Vafidis, G. et al. Prevalence of serious eye disease and visaul impairment in a north London population: population based, cross- sectional study. BMJ 1998;316:1643-6.
2. Bruce I, McKennell A, Walker. Blind and partially sighted adults in Britain: The RNIB survey. London: Royal National Institute for the Blind, 1991.
3. The Blind Person's Act (1920)
4. National Assisstance Act (1948)

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