It’s 8.15am – I walk through the doors of RNIB in central London wondering what my clinic for the day will be like. My clinics usually include a combination of domiciliary and centre based low-vision appointments and some patients who have learning disabilities.
Preparation
I have an hour to review the notes for the day and decide what equipment I need to take with me on the domiciliary visits. The large suitcase of low-vision aids (Figure 1) is taken on all visits along with a portable LogMAR chart and lighthouse contrast chart. Reviewing the notes enables me to decide if any specialist charts are also required such as Lea Symbols, Hiding Heidi Low Contrast Cards, Kay Pictures and Cardiff Acuity Cards.
Deciding what equipment to take is only one part of the preparation for going on a domiciliary low-vision visit. The notes also enable us to consider other aspects which include:
- Is the patient known to have co-morbidity and therefore unable to get to the door easily?
- Is there a known cognitive impairment, perhaps due to a stroke or dementia?
- Do they have a hearing impairment?
- Will there be any family or carers present?
- Is the visit taking place at their home or a day centre?
- Is it sheltered housing? If so, who is the warden in charge and do they know that we are coming?
- Does our patient have a learning disability as well as low vision? If so, do they have any challenging behaviours and do we have a SeeAbility questionnaire on file?
9am – the rehabilitation worker on duty arrives. Today, it is Maggie McIntosh who is the deaf/blind specialist working in the sensory needs team for Islington Council. I brief her on today’s patients and she fills me in on any additional details that she is aware of. There are times when we have a clear idea of what a patient’s needs are before going to see them and then there are other times when we don’t have a lot of information. One of the great things about working in a multi-disciplinary team is that we have access to information from the social services which is extremely helpful in ensuring that our ‘at risk’ patients are accessing the services and support that they need in all aspects of their care.
9.30am – The cab arrives to take us to our first patient. As the cab stops outside the first patient’s home, I spot the three flights of stairs awaiting us! With the trial lens case, ruck sack, charts and suitcase, we make our way to the front door and the clinic begins.
During the low-vision assessment, Maggie and I work together on a detailed history and symptoms with Maggie focusing on how the patient manages with activities of daily living and me relating that to the optometric side of their visual impairment. The impact of sight loss is so individual and an extensive history and symptoms helps me to tailor the low-vision assessment accordingly.
Taking into account the nature of the vision loss, we discuss with the patient possible solutions to various everyday tasks that may be challenging. For example, making a hot drink, being able to see the television, being able to see the reading on a blood glucose monitor for a diabetic patient or being able to see a light switch. The options may include using a magnifier, moving closer, non-sighted strategies, tactile or audio aids. We apply the strategies of bigger, brighter, bolder, audio and tactile to address each problem that has been identified.
If the patient has had a recent eye examination by a domiciliary optometrist, we focus on the low-vision aids and rehabilitation input only. I measure the visual acuity, contrast sensitivity and make an assessment of the patient’s field of vision. Depending on the needs identified I will select suitable magnifiers and teach them how to use the devices to get the best results. When selecting the magnifier it is important to take the following into consideration:
- The weight of the magnifier especially in patients that have arthritis.
- Other general health problems that will make using the magnifier difficult such as Parkinson’s disease
- The patient’s cognitive function and any progressive condition such as dementia
- The magnification required
- The willingness of the patient to use a short working distance.
The low-vision assessment may also involve talking to carers and discussing how to make things easier for the patient, for example advising on where to place objects to avoid accidents and falls. In some cases, we cannot resolve the patient’s issues due to other factors such as learning disabilities, but explaining the nature and impact of their visual impairment to the carers can enable them to adapt their environment appropriately. An example of this would be in patients where a visual field defect is suspected and advising the carers so that they approach the patient where they can be seen. The importance of appropriate lighting is also always discussed.
10.30am – We usually spend just over an hour with our patient before heading on to the next appointment. As we are packing up our equipment, Maggie and I write a list of things that we need to put in place for this patient. It may be a referral via the GP to the Falls Clinic, it may be a referral to Occupational Therapy for a walking stick, it may be Maggie needing to put in place some more lighting, bump on markers on the microwave, a magnifier that needs to be posted to the patient, a note to the GP to double check that the patient is still under the HES and not been lost to follow up, or a note to the hospital requesting them to consider sight impaired registration at the next appointment. The ‘to do list’ may also include a referral to a befriending service or to the other services at Action for Blind People such as our emotional support team. With this list of things written down, we then leave with all our equipment and move to our next patent.
1pm – Back at the RNIB offices, after returning from a morning of home visits, it is now time to write reports for each of the patients seen. Each patient will receive a report (in an accessible format) outlining the points covered during the assessments, the magnifiers issued and the agreed rehabilitation input. A copy will also be sent to the GP, rehabilitation worker and where appropriate, the eye hospital.
Action for Blind People
Action for Blind People (Action) provides practical and emotional advice and support across England to people who are blind or partially sighted and their friends and family. Action works with RNIB and Cardiff Institute for the Blind (CIB) to make sure people who are blind and partially sighted can face the future with confidence and live independently.
The service that Action for Blind provides is a Clinical Commissioning Group and social services commissioned service available to low-vision patients in Camden and Islington. The referrals come through a number of routes including referrals from GPs, other hospitals and allied health professionals. Self-referrals are also accepted and referrals from other optometrists are always welcomed. There may be instances where a low-vision patient may be receiving regular eye tests from a domiciliary optometrist. In this situation, the patient may also be entitled to a low-vision assessment from Action for Blind People and this would not interfere with the care that they receive from their domiciliary optometrist. Often patients that are housebound do not get access to low-vision services because it is not offered by the acute trusts. As such, we are keen to work alongside domiciliary providers in order that these patients get the specialist support that they are entitled to. The referral process is simple and just involves a phone call to the low-vision clinic where the administration team will ask a few questions and book the appointment either for a domiciliary visit or a centre-based visit.
Rewarding role
On a personal note, being involved in a low-vision service like this which is so holistic has given me a deep understanding of the importance in working in a team with other allied health professionals. I am constantly faced with situations reminding me that low vision goes far beyond the dispensing of magnifiers and infiltrates in to every aspect of life. As such, the difference a team of people can make to one patient is far greater and more effective than the difference that I would be able to make on my own. To see the difference it makes to a person’s wellbeing and independence is the best reward for climbing three flights of stairs with three large cases!
Further information can be found at www.actionforblindpeople.org.uk
Dr Zahra Jessa is a low-vision optometrist and Louise Gow is clinical lead low vision services based at Action For Blind People (RNIB Group) in London