15/1

1/13

CET

52

My AcademyA unique online resource, offering personalised education to meet individual needs and interests.

CET CONTINUING EDUCATION & TRAINING

1 CET POINT

Sponsored by

Domiciliary eye care is a challenging yet fulfilling mode of optometric practice. Flexibility is an essential attribute to help practitioners deal with multiple testing environments each day and modify their routines substantially depending on a patient’s individual characteristics and abilities. With demand for domiciliary eye care set to increase over the coming years, more eye care professionals may become involved in the field. This article will explore the need for, and provision of domiciliary eye care, along with a practical consideration for delivery of mobile services.

Domiciliary eye care – the practitioner’s perspectiveKhaled Rashid BSc (Hons), MCOptom and Amy Sheppard BSc (Hons), PhD, MCOptom, FHEA

About the authorsMr Khaled Rashid is a full-time optometrist providing domiciliary services in north-west England, and is currently undertaking a practice-based

research project relating to the provision of mobile eye care.

Dr Amy Sheppard is an optometrist and lecturer in optometry at Aston University, where she is director of continuing professional development

courses, including the Ophthalmic Doctorate programme. Her research interests include domiciliary eye care in the UK, and she has received funding

from the Central Local Optometric Committee to study this field.

Course code C-34235 | Deadline: December 13, 2013

Learning objectives To be able to manage the care of domiciliary patients appropriately (Group 2.2.1) To understand the need to modify clinical methods when examining domiciliary patients (Group 7.1.1)

Learning objectivesTo be able to manage the care of domiciliary patients appropriately (Group 2.2.1) To understand the need to modify clinical methods when examining domiciliary patients (Group 7.1.1)

Average life expectancy at birth

Males

1986-88

1988-90

1990-92

1992-94

1994-96

1996-98

1998-00

2000-02

2002-04

2004-06

2006-08

2008-1066.0

68.0

70.0

72.0

74.0

76.0

78.0

80.0

82.0

Females

For the latest CET visit www.optometry.co.uk/cet

15/1

1/13

CET

53

Sponsored by

Introduction With life expectancy in the UK continuing to rise,1 it is inevitable that demand for domiciliary eye care services will increase as more older people are cared for at home, or in residential accommodation services.2 According to Office for National Statistics (ONS) data, life expectancy at birth increased from 72.2 years for males and 77.9 years for females in 1986–88, to 78.1 and 82.1 years, respectively, in 2008–10 (see Figure 1). Data from 2009–11 indicate that life expectancy at age 65 is 19.0 years for males, and 21.6 years for females in the south-west, although these statistics do show a north-south divide, with equivalent expectancies in the north-east being approximately 1.5 years shorter. Notably, the 2011 census revealed that 52% of the household population aged 65 years and over in England and Wales live with an activity-limiting illness or disability, and these people are increasingly remaining in households, rather than moving to communal accommodation.3

A fundamental NHS principle is that housebound and disabled patients have the same right to eye care provision as able-bodied people. A 2007 report from the Domiciliary Eye Care Committee (DEC) revealed an apparent under-provision of service, with just 349,172 domiciliary NHS

tests conducted in the year ending March 31, 2006, despite approximately 1.4 million people in Great Britain being housebound or unable to leave home unaccompanied.2 Many individuals are, therefore, missing regular eye examinations and it has been calculated that 20–50% of older adults in the UK have undetected reduced vision, with a substantial proportion of this vision loss resulting from correctable conditions including refractive error and cataract.4

Entitlement to an NHS domiciliary eye

examination covers all eligible individuals

who are unable to leave their home

unaccompanied, due to physical or mental

disability. In the same manner as conventional

ophthalmic services, patients have free choice

regarding the practitioner they wish to consult

for testing and provision of optical appliances.

Given that the optimum environment for eye

examination is a well-equipped consulting

room,5 domiciliary services are intended only

for patients unable to access community

practices. Charities such as Age UK, or local

council/NHS organisations may be able to

organise transport and assistance to enable

patients to attend a practice with which they are familiar. It should be noted that vulnerable patients or those with challenging behaviour might become distressed or feel intimidated outside of their home environment; in such

cases, domiciliary eyecare may be most appropriate. If an optometrist does not provide domiciliary care, they should offer information on how patients or carers may access such services from local providers.

The domiciliary eye examinationContractors are required to notify the relevant Health Board or NHS local area team (LAT) of their intent to provide domiciliary services prior to examining any patient. Details including the date and approximate time of visit; full name and address at which domiciliary services are to be provided; date of birth and National Insurance number (if known), along with date of last General Ophthalmic Services (GOS) test, are required for all patients. In England and Wales, the notice of intent must be submitted at least 48 hours ahead of examining one or two patients at the same address, while a minimum of three weeks’ notice (one month in Scotland) is required when three or more patients are to be examined at a single address (eg a care home).6

Equipment and set-upAppropriate portable equipment is required to allow optometrists to provide the highest possible level of eye care under the

Figure 1 Life expectancy at birth in the United Kingdom, 1986–88 to 2008–10 (three-year rolling averages). Data source: Office for National Statistics

15/1

1/13

CET

54

CET CONTINUING EDUCATION & TRAINING

1 CET POINT

chart units, and offer greater flexibility to adjust working distance if necessary. To reduce troublesome reflections during retinoscopy, it is helpful if the patient has their back to the room window. Curtains or blinds should be closed for retinoscopy and ophthalmoscopy, although ambient lighting levels are likely to remain significantly higher than in a darkened consulting room.

Examining the patientThe eye examination should ideally take place in the presence of a family member or carer, who may be able to provide valuable information relating to patient history and symptoms. The reason for a domiciliary sight test should be noted on the patient record, and it is good practice to record the name of any relative or carer present. A significant proportion of patients receiving domiciliary services will have dementia or other acquired cognitive impairment (ACI) such as stroke The exact content of the eye examination will therefore depend upon the individual’s responsiveness on the day, along with the practitioner’s

professional judgement and statutory responsibilities.

In patients with ACI or learning disabilities who may struggle with reading letters on conventional test charts, a Sheridan-Gardiner test is a useful method for checking visual acuity.9 Patient responses may be slow, meaning that more time is required to perform the sight test, or if the patient has a limited attention span, a greater emphasis on objective techniques such as retinoscopy may be required. When certain tests are not performed due to cognitive impairment, the reason for this should be documented.10

Testing in the home environment provides the practitioner with direct evidence of the patient’s habitual working distance, posture and lighting levels. Such information is valuable when assessing near vision requirements and determining the required add power. As domestic lighting is frequently poor and may be provided by a single ceiling bulb, a portable lamp is a valuable additional piece of kit for domiciliary practitioners and allows the benefit of good lighting for near tasks to be demonstrated.9

Assessment of the anterior eye and adnexa may be facilitated by use of a hand loupe, although portable slit lamps are available and newer models may even be combined with smartphones to capture video or still images. Direct ophthalmoscopy is widely used for fundus examination, with pupil dilation frequently required due to the high prevalence of media opacities encountered. Fundus photography may be performed using one of several commercially available retinal cameras, although the new Welch Allyn iExaminer system combines the PanOptic ophthalmoscope with an Apple

circumstances. Table 1 details examples of equipment that can be used to conduct the various elements of the eye examination, and is based on joint guidance from ABDO; the AOP; FODO and the College of Optometrists.7 The examples are not mandatory and it is also recognised that some optometrists may provide additional services and equipment, eg provision of low vision aids.A flexible approach is required when setting up the domiciliary kit, and to avoid unnecessary anxiety, providers may wish to warn patients or relatives prior to the appointment that some rearrangement of room layout may be necessary.8 Examinations are typically conducted in the patient’s living room or bedroom; the portable test chart (preferably remote-controlled and internally illuminated (see Figure 2) should be situated a known distance from the patient, generally 3 metres if room size allows. A tape measure is recommended for checking this, along with the patient’s near working distance. Laptops and tablet computers running test chart software are an alternative to

My AcademyA unique online resource, offering personalised education to meet individual needs and interests.

Figure 2 Remote-controlled domiciliary test chart unit with distance (3m) and near vision (35cm) tests. Image reproduced courtesy of Sussex Vision International

15/1

1/13

CET

For the latest CET visit www.optometry.co.uk/cet

Sponsored by

55

iPhone to obtain retinal photographs with or without pupil dilation.11

Tonometry and visual fields assessmentSeveral portable instruments are available for performing tonometry in domiciliary settings. Perkins tonometers are essentially hand-held versions of the gold-standard Goldmann applanation devices, but require topical anaesthetic and fluorescein

Task Examples of Equipment Notes

External examination of the eye

Small light source and magnification

In some instances, stains may be required, eg fluorescein and saline

Internal examination of the eye

Direct ophthalmoscope or Indirect ophthalmoscope or Portable digital imaging system

In some instances, dilation may be required, eg tropicamide drops

Refraction Distance test chart and near vision tests (eg Figure 2), and tape measure plus Retinoscope or Portable autorefractor plus Trial lenses, trial frame and accessories

Oculomotor balance/motility

Distance and near oculomotor balance tests plus Suitable targets and occluder

Intraocular pressure

Tonometer Some tonometers require anaesthesia and stains, eg benoxinate and fluorescein. Those that come into contact with the eye require either disposable heads or suitable sterilising

Visual fields Means of checking peripheral and central visual fields

Identification and measurement of current spectacles

Focimeter or Equipment for hand neutralisation

The power of the patient’s current spectacles should be read to see whether they need to be updated, or further investigations required

Table 1 Equipment for use in mobile (domiciliary) ophthalmic services7

instillation, along with appropriate disposal or sterilisation of probes. The Pulsair (Keeler) and iCare rebound tonometer do not require any drops for use, so may be preferred.

Visual field screening can prove more of a challenge in a domiciliary setting, moreover, there has been some debate regarding appropriate equipment for domiciliary use after some former Primary Care Trusts made possession of a portable

electronic visual fields analyser (EVFA) a requirement for contractors. Results of an online survey commissioned by the AOP to gather evidence relating to peer practice in this area were published in 2011.12 Of 667 respondents providing domiciliary sight tests, 86% indicated that confrontation was their primary method of domiciliary visual fields assessment, with 34% of these practitioners indicating that they also had access to

01/1

1/13

CET

56

CET CONTINUING EDUCATION & TRAINING

1 CET POINT

My AcademyA unique online resource, offering personalised education to meet individual needs and interests.

near vision may help patients maintain independent eating habits and adequate nutrition.2

A regular sight test may be required as part of the care plan for patients in residential homes. Practitioners providing domiciliary services in care home environments should bear in mind that residents may already be under the care of another practitioner, and be prepared to examine individual patients where necessary.5 On a practical note, patients are frequently found to be wearing inappropriate spectacles, eg belonging to another resident. Eye care practitioners can assist by clearly labeling spectacles provided and writing a brief report for carers relating to visual problems, the need for spectacles and date for next recommended eye examination.

Post-examination and continuing carePractitioners have the same duty to provide domiciliary patients with their prescription or a signed statement after the examination. Further information should be left with the patient or a carer, summarising the outcome of the test, and include the provider’s contact details. The code of practice for domiciliary eye care states that any spectacles dispensed must be fitted to individual patients and cases of non-tolerance should be addressed by appropriately trained staff.15

Many domiciliary patients will have

another technique, most commonly the red dot test or the Damato Campimeter, which is particularly useful as a glaucoma screening tool. Only five of the 667 respondents reported always or frequently taking and using an EVFA on home visits; the majority of practitioners indicated that they felt only a small proportion of domiciliary patients would be physically and mentally capable of undertaking a meaningful visual fields test. Guidance from the DEC recommends that all mobile providers ensure they have either a manual or portable means of visual fields assessment, in addition to confrontation testing.13

The care home patientAs of April 2012, there were 431,500 elderly and disabled people in residential care in the UK; 95% of these were aged over 65 years.14 Care home residents are likely to have greater support requirements and demand particular attention from domiciliary eye care providers. The emphasis of residential care is maintaining dignity and quality of life and vision can play an important part in several areas: the optimum spectacle prescription may enable a patient to participate in a range of activities that would otherwise be problematic, and can also improve their ability to navigate around their surroundings. Furthermore, good

ocular conditions which are referable; it should not be assumed that patients will not benefit from referral simply because they have significant physical or cognitive impairment.10 A 2007 study based in the US found that care home residents suffering with cataract, causing appreciable visual effects, experienced a significant increase in their health-related quality of life following cataract surgery, compared to residents with cataract who were not referred.16 If providers are uncertain regarding the patient’s wider circumstances and the potential benefits of referral, they may report their findings for potential further discussion, to the patient’s general medical practitioner.10

ConclusionDomiciliary patients have a right to the same standard of care as patients attending community optometric practices. A flexible approach is essential for mobile providers to manage patients with a wide range of physical and/or cognitive impairments. Recent technological advances in portable equipment assist optometrists in delivering the highest possible levels of care. The changing UK population demographic is likely to significantly increase the need for high quality domiciliary eye care in coming years, providing more practitioners with the chance to become involved with this fulfilling mode of practice.

MORE INFORMATION References Visit www.optometry.co.uk/clinical, click on the article title and then on ‘references’ to download.

Exam questions Under the new enhanced CET rules of the GOC, MCQs for this exam appear online at www.optometry.co.uk/cet/exams.

Please complete online by midnight on December 13, 2013. You will be unable to submit exams after this date. Answers will be published on

www.optometry.co.uk/cet/exam-archive and CET points will be uploaded to the GOC every two weeks. You will then need to log into your CET

portfolio by clicking on “MyGOC” on the GOC website (www.optical.org) to confirm your points.

Reflective learning Having completed this CET exam, consider whether you feel more confident in your clinical skills – how will you change the way you

practice? How will you use this information to improve your work for patient benefit?