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Should optometrists be able to certify patients for visual impairment?

Clinical Practice
Cirta Tooth considers the results of a new study of ophthalmologist attitudes to optometrists being able to certify patients as being sight impaired or severely sight impaired

There are several reasons why suitably experienced optometrists might be allowed to certify patients as being sight impaired or severely sight impaired. This article takes a look at the arguments and then shows the results of a recent pilot study of what Scottish ophthalmologists think about such a proposed change. 

  

Background

Certification and subsequent registration for sight impairment or severe sight impairment (SI/SSI) is an important turning point for patients in terms of accepting their visual loss and receiving support.  

Ophthalmologists and patients recognise the importance of early intervention and timely certification.1, 2 However, in practice, this may not always be possible due to a number of challenges.  

Firstly, some patients may not attend their primary care optometrist for eye examinations.3 Secondly, there may be a delay in referral from primary care to the hospital eye service (HES) for certification.  

Thirdly, a long out-patient waiting list may mean there is further delay from the initial referral to actually being seen in the HES. Fourthly, patients attending ophthalmology clinics for management of their eye condition may not be offered certification, despite meeting the criteria for this. This may be for a number of reasons including; unfamiliarity with the process of certification and registration and a lack of understanding the benefits of registration for their patients.1, 4  

Finally, many hospital eye units are often under time pressure and prioritise diagnosis and management of the eye condition.4, 5 

Currently, in most parts of the UK, only consultant ophthalmologists have the authority to sign the Certificate of Vision Impairment, known as the ‘CVI’ in England and Wales and the ‘CVI (Scotland)’ in Scotland (figure 1). 

 

Figure 1: In most parts of the UK, only consultant ophthalmologists have the authority to sign the Certificate of Vision Impairment

 

In Wales, certification by optometrists is being piloted with a view to change the pathway for certification and registration for sight impairment or severe sight impairment (SI/SSI). Authority to certify is restricted to optometrists who hold a College of Optometrists professional certificate in low vision and are part of the Low Vision Service Wales (LVSW).  

This change appears to be appreciated by patients as it could remove barriers for certification such as long waiting times and poor accessibility.6 With greater pressures being placed on the HES, there is an increasing interest among specialist low vision optometrists across the whole of the UK to expand their scope of practice to include certification of vision impairment.7, 8

The College of Optometrists is in the process of forming a ‘Certificate of Vision Impairment Committee’ to develop the role of optometrists in this field of practice. Undergraduate training in low vision is limited and, therefore, optometrists are not expected to assess low vision patients if they feel they have insufficient expertise.9  

While the LVSW in Wales provides a solid platform for community optometrists to widen their scope of practice to include certification for SI/SSI, low vision services in Scotland and England are patchier and require improved uniformity and accessibility.10, 11 The question is; under what circumstances should optometrists be given the authority to certify patients for SI/SSI? 

  

Pilot study   

In order to explore this issue, the author sought opinions from 26 Scottish ophthalmologists on the topic of vision impairment certification and the potential role of the optometrist in certification and registration. 

  

Perceived challenges   

The survey showed that opinions are divided in terms of whether optometrists should be able to certify patients as SI/SSI. Half of the ophthalmologists supported this idea, while one third rejected this idea with the remaining 15% being unsure.  

The commonest identified challenges included a perceived lack of optometrists’ knowledge about eye conditions (62%) and that optometrists did not have sufficiently strong links with support services (42%), such as the Eye Clinic Liaison Officers and sight loss charities.  

Other challenges included the notion that optometrists may not have sufficient knowledge about certification guidelines and registration benefits, lack of experience in managing low vision patients and that community optometry was not an appropriate setting for registration.  

One respondent mentioned that there may be insufficient oversight of the optometrists and insufficient accountability. Figure 2 shows the results of the responses.  

 

Figure 2: Survey responses, when asked the question: ‘What are some of the challenges if optometrists were able to certify patients as SI/SSI?’  

 

Perceived benefits  

While there were some reservations, ophthalmologists also appreciated some of the potential benefits if optometrists were able to certify patients. More than half of the ophthalmologists felt that it could reduce the pressure on their clinics and almost half of the respondents assumed that this could lead to less unnecessary referrals into the HES.  

For patients, the most important benefits were thought to be improved accessibility/closer to home and timelier certification (see figure 3). 

 

Figure 3: Survey responses, when asked the questions: ‘What are some of the benefits if optometrists were able to certify patients as SI/SSI?’

  

Proposed conditions under which optometrists could certify patients 

On further questioning, respondents recommended that certification by optometrists should be limited to optometrists working in the HES (40%) or as part of a low vision service (44%). None of the respondents recommended limiting certification powers to community optometrists only.  

Twelve percent recommended that it should be limited to pre-defined eye conditions, although one respondent would leave it up to the optometrist’s judgement based on their own competence and to seek advice from the HES if they felt that they reached their limit. 

  

Training and experience 

More than two-thirds of the respondents recommended optometrists should receive specific training in certification and registration in order for them to be able to certify patients. A third recommended optometrists should have a professional certificate in low vision, a quarter recommended a higher certificate in low vision and one third of the respondents were of the opinion that optometrists should have prior experience in low vision.  

  

Discussion 

The decision to certify is not purely based on quantitative measures, but involves clinical judgement and subjective assessment to establish to what extent their vision impacts on their daily life (figure 4).12-14 The explanatory notes for eye care professionals are in place to guide this decision-making process, but these are not without ambiguity.15  

 

Figure 4: Certification takes into account the impact of sight loss on everyday life

 

It is, therefore, not surprising that optometrists and ophthalmologists are not always sure about the criteria for certification5 and that there is considerable variation in decision-making for certification among ophthalmologists.16  

Scottish optometrists who regularly encounter patients with low vision in the HES are more confident in their understanding of criteria for certification, compared to community optometrists without this experience.2  

In Wales, Bartlett et al compared clinical decision-making for certification in dry macular patients between LVSW optometrists, consultant ophthalmologists and a consensus group of consultant ophthalmologists and optometrists holding a College of Optometrists higher certificate in low vision.1

They concluded that there was reasonable agreement between ophthalmologists and LVSW optometrists. Scotland and England do not yet have a national low vision service with a substantial workforce of optometrists with specialist low vision qualifications and experience.  

A large proportion of ophthalmologists felt that optometrists do not have sufficient knowledge about eye conditions. However, one has to bear in mind that the main cause of SI/SSI is dry AMD,17 which is a condition that is usually managed within community optometry. Certification by optometrists could be limited to conditions such as these, as some of the ophthalmologists recommended.  

Good links with support services and charities are essential in terms of supporting patients with low vision, whether they are registered or not. It is reasonable to expect from optometrists, who take the role of SI/SSI certification, that they are familiar with these services. 

  

LVSW leading the way 

Specialist training and experience in low vision, along with the evidence about agreement between ophthalmologists and optometrists in terms of clinical decision-making for SI/SSI certification formed the basis for the proposed pathway changes in Wales.1, 6

The LVSW was established in 2004,18 which improved service access for this patient group.19 Optometrists participating in this service are required to complete a professional certificate in low vision. The piloted pathway for SI/SSI certification in Wales allows optometrists within the low vision service, who have undertaken additional training in the process of certification and registration, to certify patients with stable dry AMD. 

  

National Low Vision Service Scotland (NLVSS) 

NHS Education for Scotland has recently become an accredited provider of the College of Optometrists ‘Professional Certificate in Low Vision’ with a view to provide the NLVSS in the near future.20 Optometrists wanting to take part in the service will be required to complete this post-graduate training.

This service could form a basis for expanding the role of NLVSS optometrists to include SI/SSI certification in the future. In the meantime, it may be worth considering expanding the role of certification to optometrists who hold appropriate qualifications and who have appropriate experience in low vision. 

  

Conclusion

In conclusion, there appears to be scope for developing the role of optometrists in certifying patients as SI/SSI in Scotland, although not all ophthalmologists support this idea and this pilot study was too small to represent the entire ophthalmology workforce, and therefore the results need to be interpreted with caution.

While the optometry workforce currently counts very few low vision specialists who hold professional or higher certificates, this is likely to change in Scotland once the NLVSS is introduced, creating a better platform for optometrists to take on the role of certification. 

  • Cirta Tooth is a specialist low vision optometrist, working in both private practice and the hospital eye service. 

  

References

  1. Bartlett, R, Jones, H, Williams, G, Farewell, D and Acton, J H.  (2021). Agreement between ophthalmologists and optometrists in the certification of vision impairment. Eye, 35(2), 433-440 
  2. Tooth, C. (2022). Sight impairment: To refer or not to refer? That is the question. Optician. 6239, 19-25 
  3. Leamon, S, Hayden, C, Lee, H, Trudinger, D, Appelbee, E, Hurrell, D-L. And Richardson, I. (2014). Improving access to optometry services for people at risk of preventable sight loss: a qualitative study in five UK locations. Journal of Public Health 36(4), 667-673  
  4. Boyce, T, Leamon, S, Slade, J, Simkiss, P, Rughani, S and Ghanchi, F. (2014).  Certification for vision impairment: researching perceptions, processes and practicalities in health and so-cial care professionals and patients. BMJ Open. https://doi.org:10.1136/bmjopen-2013- 004319    
  5. Tooth, C and Cackett, P. (2022). Vision impairment: To register or not to register? That is the question. British Journal of Visual Impairment, 0(0). https://doi.org/10.1177/02646196221102833  
  6. Bartlett, R and Davies, H. (2022). People with dry age-related macular degeneration; views on certification of vision impairment in a primary care setting: An explorative qualitative study. Ophthalmic and Physiological Optics. https://doi.org:10.1111/opo.13137  
  7. Bartlett, R. (2021). To achieve such a seismic change is no small feat. Optometry Today. https://www.aop.org.uk/ot/in-practice/practitioner-stories/2021/03/09/to-achieve-such-a-seismic-change-in-practice-is-no-small-feat 
  8. O’Dowd, A. (2022). Can optometrists step up with sight impairment certification? Acuity. https://www.college-optometrists.org/professional-development/college-journals/acuity/all-issues/autumn-2022/can-optometrists-step-up-with-sight-impairment-cer  
  9. The College of Optometrists. (2023). Knowledge, skills and performance: assessing and man-aging patients with low vision. https://www.college-optometrists.org/clinical-guidance/guidance/knowledge,-skills-and-performance/assessing-and-managing-patients-with-low-vision#Keypoints 
  10. Court, H and Mitchell, G. (2017). A review of low vision service provision in Scotland: An in-dependent review commissioned by the Scottish Government. https://www.gov.scot/binaries/content/documents/govscot/publications/independent-report/2017/04/review-low-vision-service-provision-scotland/documents/00516692-pdf/00516692-pdf/govscot%3Adocument/00516692.pdf 
  11. The College of Optometrists. (2021). CCEHC survey highlights need for low vision services re-view. https://www.college-optometrists.org/news/2021/july/ccehc-survey-highlights-need-for-low-vision-servic 
  12. Department of Health. (2017). Certificate of vision impairment: Explanatory notes for con-sultant ophthalmologists and hospital eye clinic staff in England. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/637590/CVI_guidance.pdf 
  13. Scottish Government. [No date]. Certificate of vision impairment (CVI) (Scotland) Form: Ex-planatory notes for ophthalmologists and hospital eye clinic staff. [Currently not available online]. Carbon copy available on request from central enquiry unit: ceu@gov.scot 
  14. The Royal College of Ophthalmologists. (2016). The certification of vision impairment Wales (CNIW): A new process. https://www.gov.wales/sites/default/files/publications/2019-07/certification-of-vision-impairment-wales.pdf 
  15. Jawaid, I, Rotchford, AR, Stead, RE & King, RA. (2020). Comment on: Agreement between op-tometrists and ophthalmologists for sight impairment registration. Eye 35, 2331. https://doi.org:10.1038/s41433-020-01141-1 
  16. Guerin E, Bouliotis G & King A. (2014). Visual impairment registration: evaluation of agree-ment among ophthalmologists. Eye 28, 808-813.  https://doi.org:10.1038/eye.2014.66 
  17. Boswell, K and Kail, A. (2016). Visual impairment in Scotland: a guide for funders. https://www.thinknpc.org/wp-content/uploads/2018/07/Visual-Impairment-in-Scotland-a-guide-for-funders1.pdf 
  18. Charlton, MN, Jenkins, DR, Rhodes, C, Martin-Smith, T and Ryan, B. (2011). The Welsh Low Vision Service: a summary. Optometry in Practice, 12(1), 29-38. https://www.researchgate.net/publication/279366383_The_Welsh_Low_Vision_Service_-_A_summary 
  19. Ryan, B, Khadka, J, Bunce, C and Court, H. (2013). Effectiveness of the community-based Low Vision Service Wales: a long-term outcome study. British Journal of Ophthalmology, 97(4), 487-491. https://doi.org/:10.1136/bjophthalmol-2012-302416 
  20. The College of Optometrists. (2022). The College accredits NES Optometry as provider of Pro-fessional Certificate in Low Vision. https://www.college-optometrists.org/news/2022/december/college-accredits-nes-optometry-low-vision