Paul Graveson started Hobart Optometry, Tasmania’s only optometry practice specialising in aged care, in 2007. He has practised for 24 years, including 14 years as a low vision consultant.
Graveson was inspired to specialise in aged care because he found that nursing home residents were not getting the regular eye examinations they needed to prevent loss of sight. He advises those interested in domiciliary care to remember that the tools and medicines of the visiting optometrist are linked, often in unpredictable ways.
Few might make the connection between mydriatic eye-drops and ergonomics, but Graveson makes a pretty good case for it. Because there are rarely any hydraulically-raised examination chairs for the patients at the facilities, direct ophthalmoscopy can be hard on the optometrist’s back.
‘Mydriatic drops are among the most essential things I bring with me to each facility,’ he said. ‘It means I can use a binocular indirect ophthalmoscope, which gives me a much better, wider field and stereoscopic view of the fundi, allows me to see through media opacities and is way better on my back.’
The use of mydriatic drops also makes it easier to use a retinoscope or hand-held autorefractor, when subjective refraction is difficult for patients with dementia or dysphasia.
Paul carries about $40,000 of equipment, which weighs close to 50 kilograms. Most of it is solely for use in the mobile practice and wouldn’t be used much or at all in a typical practice. ‘There are times when I wish I were a GP carrying a laptop, a blood pressure monitor and a stethoscope’, he said.
Optometry Australia is in discussions with the government to ensure fairer domiciliary loading rebates.
BOptom BA GradCert(Optom) PGCOT
Keeler All-Pupil II (wireless) Binocular indirect ophthalmoscope: Volk Pan Retinal and Volk Clear Mag
I have two BIO lenses: the Pan Retinal for general use and the Clear Mag for a better view of discs and maculae. This is important because it’s almost impossible to use a 90 D with the hand-held slitlamp; it’s very hard to get everything aligned and too much strain on my back. The second lens is crucial to get a higher magnification view of some structures.
Shin-Nippon XL-1 Slit Lamp
A good hand-held slitlamp is essential, especially to look at the anterior chamber angle before dilating, and get a good view of cataracts, corneal opacities, capsular opacification and so on.
Pachymeter – Pachmate handheld
A pachymeter is mandatory because many residents in nursing homes have undiagnosed glaucoma, and visual field analysis is not possible because units aren’t portable enough. Even if you refer patients, often they are too frail or cognitively limited to do a useful fields test. You need every little bit of information you can get to determine glaucoma risk.
A hand-held fundus camera is really important. It’s great to have a baseline photo of discs and maculae for later comparison. I use a Smartscope because it works well with dilated pupils. If I can’t dilate the pupils for whatever reason (narrow angles, patient with dementia who resists drops), sometimes an undilated fundus photo is the only view of the retina I can get.
A good trial frame
I take a set of full aperture trial lenses but not the entire set. I use 0.50 steps in both sphere and cylinder, which halves the weight carried.
I previously used a Tono-Pen but I find the iCare is better by far for nursing home work and much better tolerated by those patients.
Retinoscope—any good one, I use a Keeler
This might be your only way of measuring the refractive error. Again, dilate the pupil if possible.
Barraquer cilia forceps
The need to remove in-grown lashes is very common and you can make a big difference with surgical forceps. Epilation while looking through the hand-held slitlamp takes some getting used to and you need really good tools, not just the usual eyelash tweezers. I use Barraquer cilia forceps. They are expensive but I’ve never regretted buying them.
Many nursing homes residents just need better light rather than magnifiers or stronger spectacles. Demonstrating the improvement with a light positioned close to the page is great. Having the magnifier in the middle is good for demonstrating to patients who need a bit extra for reading, and as an alternative view when epilating lashes. I use a floor mount; it’s heavy and bulky but worth carrying.
Speaking of carrying, I use a folding Clax trolley, which fits in the back of my car. It’s expensive but very good quality. I’ve made customised modular boxes that clip on to the trolley, with the weight evenly distributed so they are not too heavy to lift out of the car.
The Births and Deaths page of the local newspaper
Bring something your patients actually read. There’s no point using a beautifully-printed near chart; test them with pages from the newspaper, which have relatively low-contrast print.
I have made my own logMAR chart, calibrated for two metres, five letters each line and going from 6/6 to 6/120 (equivalent at two metres). Often it’s impossible to get a three-metre chart distance in nursing homes but two metres is usually fine. I just need to remember to take +0.50 off my subjective refractions. I have the chart formatted in a flip-book format (3 lines per page) and position it on a folding music stand.
A carefully selected range of Frames and magnifiers
Don’t fall into the trap of assuming all residents of nursing homes want the most basic frames. Many of them are very keen to have something that makes them look nice or is more durable.