BS(Anatomy) BOptom MA(Research) PhD Student UNDA
Honorary Fellow, Australian Health Research Institute, University of Wollongong
Visiting optometry services are important to the community. Many people are unable to easily visit a regular mainstream primary care optometric practice or access their usual specialist ophthalmology practice.
While essential in a multidisciplinary environment, the scope of eye care that can be effectively delivered by visiting general medical practitioners and nursing staff of a residential health-care facility can be limited. Visiting optometrists can be called on for routine comprehensive eye examinations or when there is a particular concern with vision or eye health.
Fortunately for visiting optometry services, in recent times most of the equipment useful for conducting eye examinations—autorefractors and retinal cameras—have become easily transportable and more affordable. To be able to successfully examine people in residential health-care facilities as a visiting optometrist primarily requires some familiarity with the essentials of infection control and personal protective equipment (PPE). Gloves, facemasks and aprons are the most commonly used PPE in standard precautions of infection control and a visiting optometrist should be ready and able to use this equipment when required.
People living in residential health-care settings often have chronic conditions that require the correct use of PPE. At certain times during an eye examination, such as when conducting tonometry or fundoscopy, there is considerable time spent in close proximity to a patient. To ensure the safety of the resident, the clinician and the community, the correct use of PPE is essential.
In this setting, visiting optometrists need to come prepared, to use good communication skills and to practise good hygiene habits. Above all, they need to be creative when conducting eye examinations.
Preparation is the first step when entering a clinical environment where an understanding of the use of PPE is required. Government and industry literature is readily available and should be understood by the visiting optometrist in the context of an eye examination. Again, the basics are important, such as knowing which size gloves you require and being prepared to supply your own, particularly if due to allergy or irritation you are not able to use a standard issue size or material.
Communication is the key and is essential for the rapport that the visiting clinician has with the residential aged-care facility staff. Be kind to everyone, introduce yourself to everyone and attempt to communicate as effectively as possible at all times. Exchanging names and roles with staff is important. Always ensure that the residents and staff understand that you are a Visiting Optometrist and not a GP, podiatrist, clergy, dentist or hairdresser. A handy visual acuity chart is usually a help with the hard of hearing and people who are easily confused.
It is also important to recognise the usual and special practices of communication with respect to the use of PPE in the company of the resident. For privacy concerns a code may be on display, such as a yellow flower for methicillin-resistant Staphylococcus aureus infection, a purple butterfly for cytotoxic treatment, or yellow biohazard disposal equipment for identified vancomycin-resistant enterococcus or other gastro infection.
The condition of a resident can change quickly and a trolley full of PPE supplies placed in a corridor could be an indication that a resident has recently become unwell.
Professional hygiene habits play a role with the use of PPE. For example, appropriate hand-washing, instrument care and record-keeping will mean that PPE use will be effective.
Creatively plan your visit and eye examination around the known and potential risks, and your ability to protect the resident and yourself from harm. This often needs to be done with a view to novel solutions for unforeseen challenges. For example, when conventional diagnostic equipment fails to meet infection control standards, there is often a way to gather relevant information about vision or eye health by a different means that may not compromise PPE integrity and pose unnecessary risk.
The most complex instrument that is deployed during an eye examination is the shared understanding and expectations of what constitutes the social and professional role of an optometrist. The scope of this understanding places wide and varied demands on the equipment that can be deployed in a visiting optometry service.
These include everything from vision examination resources (occluders, visual acuity charts for near and far, high and low contrast, and for illiterate and low vision), to portable optical dispensing type equipment (trial frames and lenses, spectacle repair and adjustment equipment, and low vision aids and so on), to ophthalmic diagnostic equipment (ophthalmoscopes), all of which must be supplied and maintained by the visiting optometrist.
This equipment comes at a considerable cost to acquire and maintain. In the context of a visiting service, reliability and portability are essential. Still, due to stringent hygiene requirements, and the demands of frequent use and transport over short and long distances, usually a spare at hand and a spare in the car are often required for all basic and essential types of PPE.
The understanding of what a visiting optometrist is expected to perform during an examination must be balanced with the frequency and severity of complex eye and vision disorders encountered when preparing required equipment.
For example high IOP (> 30 mmHg) is often encountered and having various instruments available to help verify an elevated eye pressure measurement and its cause can mean that clinical confidence in how to proceed with management can be greatly improved. I prefer to have a mix of options available, such as a digital tonometer and an optical applanation type device, for example, the Perkins tonometers. This type of consideration applies to the type of vision examination resources and optical aid related equipment used as well. That is, clinical presentations of vision disorders can be complex (for example, after a cerebrovascular accident with aphasia and visual field defect) and the aids encountered and required can be varied (for example, prismatic corrections or high astigmatism in spectacles post corneal graft due to corneal decompensation). The correct equipment professionally maintained and skilfully applied is essential.
Impact of technology
The final aspect of visiting optometry services to consider is the way that this type of practice is in direct contact with the social demographic and technological practices of people in their home environment. Along with traditional visual demands, such as printed text and hand craft, information technology and portable visual display devices are now part of everyday life. The resources available to the optometrist for diagnosis, intervention and communication must be recognised along with the expectation that this sort of resource will be deployed in clinical practice.
It is important to be aware that the technological resources and clinical presentations of people with vision problems are changing. Increasingly, avid readers are presenting later with visual acuity changes because, with the aid of electronic reading devices, there is the option of simply enlarging the letter size to a level that is comfortable and effective. This can mask the onset of low vision. Conversely, with increased screen resolution, there is the prospect of very small print being regularly displayed, for example, on a smartphone screen, which can infuriate and beguile even experienced IT users with relatively normal vision.
Remember the diagnostic impact of new technology does not apply only to electronics. My favourite area of novel practice is deploying advanced optical equipment such as the latest condensing lenses in conjunction with a hand-held direct ophthalmoscope. Research and advances in optics still hold many keys to solving the frequent hygiene and diagnostic challenges of visiting optometric practice.
Equipment resources required in visiting optometry practice are varied and evolving. The challenges of this type of practice are considerable, but by collaborating in a multidisciplinary environment to achieve required safety standards, by being creative in the meeting ophthalmic equipment requirements, and finally by being responsive to future prospects for research and economic opportunities, visiting optometry services will continue to meet the needs of the community.
There is a great need for primary care optometry in a visiting capacity in residential health-care facilities, not only because of the increasing numbers of frail elderly and chronically ill residents in care, but also because effective vision care helps prevent and explain vision loss, helps manage eye health and enables vision aids to be used to maximum benefit such that every person is important. Quite simply, as one resident noted: ‘Life is much better when you can see.’ With preparation, effective communication, professional hygiene habits and creativity, optometrists can gain access to people who have unique challenges that are professionally rewarding to serve.