1. Who’s who? From Optometrist to Ophthalmologist… and everyone in between. A guide to everyone involved in eyecare Mary Bairstow VISION 2020 (UK)

2. Why do you need to know? Many older people are needlessly living with sight loss. Almost two thirds of sight loss in older people is caused by refractive error and cataract. Both conditions can be diagnosed by a simple eye test. In most cases the person's sight could be improved by prescribing correct glasses or cataract surgery. RNIB – Nov 2010

3. “Diagnosed and dumped” Only 8 per cent of registered blind and partially sighted people were offered formal counselling by the eye clinic, either at the time of diagnosis or later. In the year after registration, less than a quarter (23 per cent) of people who lost their sight say they were offered mobility training to help them get around independently. RNIB – Nov 2010

4. Mrs Rose 64 years old – African Carribean recently found she can’t see well for close work. Thinks she needs reading glasses. Ophthalmologist Optometrist OrthoptistSocial Worker Eye Clinic Liaison OfficerRehabilitation Worker Boots counter assistant GP (“ready readers”) Optician

5. The Optometrist Mainly work in ‘High Street’ practices – though some in hospital eye departments Previously known as ophthalmic opticians – the protected title – optometrist came into use in the 1980s.

6. The costs Eye examination mainly funded by private sale of spectacles Vouchers (for children and low income) give a certain amount of money towards whole

7. They do what? Refraction – using instruments to determine lenses to focus the eye Examine the eyes to detect defects in vision, signs of injury, ocular diseases or abnormality and problems with general health Tests may include – binocular vision, eye pressure, peripheral vision, external and internal eye health

8. Next steps..... Her optometrist discovers – raised intra-ocular pressure and signs of diabetic changes at the back of her eye and refers her to the local hospital with an Ophthalmology (Eye) Department.

9. But in between........ Mrs Rose is ‘desperate’ for new spectacles so she asks to see the dispensing optician - but agrees to postpone buying glasses ‘til she is seen at the hospital

10. The Dispensing Optician Trained to dispense and fit spectacles, contact lenses and other optical aids Don’t ‘test eyes’ or produce prescriptions for glasses – they work from the optometrists results Advise patients on types of lenses and spectacle frames, including advice on style, weight There are 3 routes to qualification. Only qualified opticians can register with the General Optical Council (GOC)

11. The Ophthalmic nurse Based in hospital eye departments Ophthalmic training and experience Specialist practitioner roles – glaucoma and additional roles Measure vision, explain treatment, assist in theatre

12. And next.....The Ophthalmologist Medically trained doctor – working in clinics ( as an ‘eye’ physician) and theatre (surgeon) Examine, diagnose and treat diseases and injuries in and around the eye. Use specialist equipment – slit lamps (microscopes designed to examine the eye under magnification) and ophthalmoscopes (lenses to look at the eye) After medical school they must do 7 years of special training with ‘rigorous’ exams set by the Royal College of Ophthalmologists

13. What they use Slit lamps Scans of the back of the eye Head mounted ophthalmoscope ©Brainerd Eyecare centre © Royal College of Ophthalmologist

14. Surgery http://www.nhs.uk/Conditions/Cataract- surgery/Pages/How-it-is-performed.aspx http://www.nhs.uk/Conditions/Cataract- surgery/Pages/How-it-is-performed.aspx Or http://www.thecoplow.co.uk/cataract/surgery. html http://www.thecoplow.co.uk/cataract/surgery. html

15. The Ophthalmic Technician Usually based in eye departments – they undertake specific investigations including testing of peripheral vision (visual field testing). http://www.goodhope.org.uk/departments/eyede pt/goldmanfield.htm http://www.goodhope.org.uk/departments/eyede pt/goldmanfield.htm They may take pictures of the eye using various techniques, such as digital fundus imaging, ultrasound and optical coherence tomography (OCT).

16. Nobody sees you..... Meanwhile Mrs Rose has developed double vision associated with her diabetes. Her eye is turning down and out due to a third nerve palsy. © Ophthobook.com

17. The Orthoptist Mostly working in the NHS as part of the ophthalmic team Specialise in visual development, binocular vision (how the eyes work together as a pair) and eye movements. They test, assess and offer non-surgical treatment (such as eye exercises) including: Children presenting with misalignment of the [turning] eyes(strabismus/squint) or problems with vision development Patients presenting with double vision (diplopia). Lazy eye (amblyopia) and other visual disturbances Low Vision Other technical roles such as visual fields © NHS North Lincolnshire and Goole Hospitals

18. And beyond the eyes? Breaking bad news Certification as Sight Impaired and Severely Sight Impaired – CVI (Certificate of Vision Impairment) 45% said they did not receive an explanation of the process There were many comments which highlighted that some people felt dissatisfied that the eye clinic did little beyond diagnosis. Network 1000 Access to information, services and support for people with visual impairment October 2008

19. All this talk of growing old (When the drugs don’t work) LASER treatment for diabetic retinopathy hasn’t prevented macular oedema and so Mrs Rose’s Ophthalmologist suggests certification as Sight Impaired, referral to the Eye Clinic Liaison Officer for advice and the hospital optometrist for a low vision assessment.

20. Integrated care -Eye clinic support Eye Clinic Liaison Officers (ECLO), Support at the Point of Diagnosis, help desk volunteers Information and sign posting for people in the Eye Clinic (occasionally elsewhere) Links between health and social care Counselling often offered RNIB accredited course – developed in 00’s Different funding ‘models’

21. Eyes in Social Care Often specialist Sensory or VI teams with social workers and rehabilitation workers or ROVI (Rehabilitation Officer for people who are Vision Impaired) Obliged to offer an assessment when in receipt of a certificate of vision impairment (CVI) or a referral of vision impairment (RVI - a form designed to refer from the hospital eye service [HES] – but rarely used) Assessment does not depend on certification

22. The ROVI or Rehab worker Mainly work for local authority though some based in local voluntary societies Currently 3 courses ( 2 Degree level and one BTEC) Initial assessment and registration as blind or partially sighted. Emotional support Specialist assessment – lighting, environment and equipment Teaching guiding skills – mobility and moving around safely Low vision techniques

23. Skills and equipment Daily living skills training - helping people learn / re-learn skills - cooking, cleaning, care of clothes Communication training - Braille, Moon, deafblind manual, keyboard skills, use of technology /digital equipment, phones Equipment - timepieces, liquid level indicators, raised markings for appliances, talking labels and other household gadgets © RNIB

24. Local Organisations Visionary (organisation supporting local Societies) Variety of services and professionals Resource centre staff Social group co-ordinators Home visitors and community workers Emotional support

25. And talking of ‘professionals’ Mrs Rose She’s started her own peer support group with help of her local voluntary society.............

26. m.bairstow@vision2020uk.org.uk M Mary Bairstow