Building Your Low Vision Practice: Next Steps

Low vision work is something that divides the dispensing optician community. Practitioners who are involved in this specialism love it. Many DOs, however, just don’t see low vision patients in their practice. In this article we look at how to build your practice into a profitable income stream.

If your practice doesn’t offer much in the way of low vision services, you will be interested in the experiences of Jenny McKenna, a dispensing optician at Specsavers in Peterborough. She explains how she got a low vision clinic off the ground: “My interest in low vision started in my pre-reg year; I did an ad hoc repair on someone’s spec mounted telescope and found it really interesting, but my LV interests had to take a back seat to doing my exams. I renewed my interest when I went for this job: the director wanted someone to focus on low vision work. Now it is a big part of my work.

“Most of the time I sit down with people who come for a routine exam, diabetic or glaucoma screening. I’m aiming for a day a month when all I do is low vision work, but usually I see people post-sight test or post-screening. I find that many patients have been handed a leaflet and sent on their way. Our area isn’t good for cross referrals, people aren’t reaching low vision clinic at the hospital, they may not then be referred to social groups or support. I have a bundle of leaflets and talk about who can come to their home. I share tips such as using contrasting crockery to make it easier to see their food. When you give them something that isn’t a purchase option it makes them relax. I reassure them I don’t want their money.

“You can see patients’ acuities on paper, but that doesn’t always relate to what they struggle with. I advise on magnifiers and reading aids more than electronic equipment. We have a licence for bioptic telescopes, but they aren’t a great seller. I do get a lot of phone queries about them, but nine times out of ten they end up with something simpler. I’m looking into offering CCTV and portable electronic magnifiers. Space for low vision sample equipment is an issue, but magnifiers are an important part of everyday practice. In our area we have 80% of patients who qualify for NHS sight tests, 60% of our patients are over 60, and so we know more people developing eye problems. We need to give space in the shop to that. It is a trade-off. Practices don’t want to buy equipment that they won’t sell, but if you don’t have it, you can’t demonstrate it.

“I have bolstered links with local hospitals. Our work with kids, diabetic and glaucoma screening, and cataract referrals meant we had close links already. I went into talk to the hospital staff and discuss how we could help each other. As a result the hospital started referring people to me. In the beginning I made a lot of my fitting kit from scrap lenses. As I was putting orders in, I could upgrade my fitting kit.”

Jenny advises, “If you are bewildered about what you need, call your local suppliers, find out who is close by and will come in and do a demo. They may have items you can borrow and showcase to patients to generate orders before you buy your own.”

Dispensing optician and LV practitioner, Alison Williams, is another low vision enthusiast. Alison is now working at Jane Smellie Opticians. She says, “My low vision work is mainly in Wrexham as we are based in the area that is covered by the NHS Low Vision Service Wales scheme.” There are 187 low vision practitioners across Wales who have undergone training and been accredited by the School of Optometry and Vision Sciences, Cardiff University. Dispensing opticians who wish to provide the service are required to undergo further training with regards to pathology. This is in the form of two distance learning modules and assessment by MCQs.

Alison was working for a North Wales independent group of practices when she did her low vision training. She says, “Low vision assessments takes 60 minutes and most sight test appointments take 30 minutes with the potential of a high value dispense at the end, so potentially the Welsh system isn’t that profitable if you use the optometrist for chair time. My former employer saw training DOs as a better business decision. I had qualified as a DO in 2003, and I started the LV course in 2013. I’d done 10 years as a DO and wanted to revise and improve my skills.

“I did ABDO distance learning Low Vision course with a four-day block release during the course which I completed over 18 months. I really enjoyed it. I put a lot of effort in. There were eight of us on the course, most of whom had been qualified for a short while, whilst I’d been qualified for a long time. I went back through all my old notes to revise the things you don’t use in day-to-day practice. I probably worked 10 times harder on this than on the original DO course. I wanted to prove to my employer that they had made a good investment in me. I got the awards for the highest mark in every exam I sat. It was difficult and took work and effort, but it all made sense. When something interests you that makes all the difference.”

Many opticians find it hard to get the practical experience they need to feel confident in low vision. Alison explains how she did it: “I was fortunate that we already had the NHS Low Vision Service Wales scheme in place with several of our optometrists. I was assigned to one of them for training which made it easier to get case studies and practical experience. I know people who came from practices who didn’t do any low vision struggled: some tried to find hospital experience. I tried to see if I could get into hospital clinics so I could see more interesting pathology, but fortunately I could get my case studies in practice.”

For Alison, the emotional connection with patients has been one of the biggest differences when doing low vision work compared to dispensing spectacles. She explains, “It is a completely different aspect compared to dispensing. With low vision the difference you can make to someone is enormous. Someone who has had recent sight loss is going through difficult emotions. Giving them something as simple as a hand-held magnifier can change their world. They go out thrilled. I found that really overwhelming when I first started. I felt a real empathy for what people are going through and how it affects their lives.

“Sight loss affects the most basic of tasks. Isolation spirals into depression, and family members can’t comprehend what people are going through,” Alison continues. “You are not only trying to help the person with the sight loss but equally can be explaining to a family member the pathology, the effects and what might help around the house. It is in a different dimension to dispensing on the shop floor. People are going through a process of bereavement as they lose their sight, and you need to be able to cope and manage that situation. That takes time and experience. When I first started doing my own clinics that was the thing I was most nervous about. People are vulnerable and you have to be very sensitive and careful. You can’t always get to the end of the assessment in the planned form: people don’t work that way. You have to adapt as you go through the assessment depending on the person.”

Financing low vision work can be a thorny issue, but there are ways to work with the NHS funding a range of equipment through a local contract. Jenny McKenna says, “The public perception is of a Sherlock Holmes style magnifier. They want bigger, stronger ones and expect to pay £5-6. They can be taken aback when we show them something that costs £50-60, but I compare it to the cost of a varifocal. We have to combat cognitive dissonance. My initial conversation may take 45 minutes or an hour with someone who has been in the practice for an hour already. I may see five people a day, it’s not always monetarily rewarding.”

Alison Williams explains how the Welsh scheme works for her practice: “As a DO, we get £77 for a 60-minute assessment which has to cover 12 months of follow-up too, whether we see someone once or 15 times. I feel that providing low vision support is a journey with someone, and we have a duty of care to make sure people are on the right track. Sometimes someone needs picking up and encouraging along the way.

“I book a two-month follow-up appointment with everyone, asking them to bring in their aids which hopefully they will have been trying for at least six weeks. Some opticians simply follow up by phone or get the optical assistant to call and ask how they are getting on, but in a phone call you can’t see if someone is using an aid in the best way. Are they using the correct eye, the right working distance? The smallest tweaks can make the biggest difference. Expanding how many letters in the field can improve the fluency and speed with which they are reading. It can help their self-esteem and relieve depression.”

The NHS funds low vision work in practices in some areas. Samantha Scullion is a dispensing optician at Specsavers in Middlesbrough. She says, “We were awarded an NHS contract for low vision work in store, and they decided to make our work DO led. I had only been qualified eight months when we started and have been doing it four years now. I work with a colleague and we manage the low vision referrals from the hospital and optometrists, and we have a close relationship with the eye clinic liaison officer.

“Each week we see four to five people, maybe totalling 30 a month. We have a clinic on a Tuesday and Wednesday, and spend 40 minutes with each person. We have a pre-appointment chat when we get the referral, to establish the person’s lifestyle needs and what they are struggling with. I may then order in magnifiers for them to try. During the assessment we talk about lifestyle needs, contrast, lighting, we discuss organisations in the area and the support they might get from RNIB and other local societies. We often refer people on. We go through the magnifiers that we have available and explain how to use them.

“Due to the NHS funding the services is all free to the patient,” Samantha explains. “Our area is a low income area and we don’t often sell bigger electronic items things but can refer on if we need. We get a lot of people who have been to the optometrist and have been told nothing more can be done. We provide hope and alternatives, so it is great that out contract was renewed to continue this work.”

Another optician who is passionate about low vision work is Russell Ham, who works at Specsavers in Newport. Russell is the only optician in Wales to receive a recent ‘five-star award’ from the Wales Council for the Blind. Russell was nominated by his patients who praised the high level of care he has shown them during 13 years in practice. His practice also offers an Ophthalmic Diagnostic Treatment Centre (ODTC), with funding from the Welsh government in collaboration with the Aneurin Bevan University Health Board. The ODTC provides initial screening and referrals for people with symptoms of wet age-related macular degeneration (wet AMD). NHS staff deliver treatment for the condition from the same high street location.

Russell says, “The ECLO is very good at referring people from the ODTC. Many come to me. I currently have 468 low vision patients who travel from as far as West Wales to access the store’s services. I hope the Wales Council for the Blind award demonstrates the high quality of care and support we are able to provide to low-vision patients here in Newport. I get great satisfaction from enabling people to enjoy a better quality of life and independence and to be recognised for that work is wonderful.”

Russell has two tips for anyone who wants to expand their low vision practice. He says, “Speak to the local NHS and set up a scheme. Then, you need to keep actively speaking to all suitable patients.” All too often patients just don’t know what support is available to them, and every dispensing optician can transform people’s lives by just letting them know about the services available.

Resources: building your low vision practice

There is a complete list of ABDO recommendations for low vision demonstration equipment to keep in stock in Appendix C, www.abdo.org.uk/advice-guidelines

Have you thought about developing your low vision skills? This is a growing area of need due to the ageing population, and more LOCs/AOCs/ROCs are now recognising the need for a low vision pathway, with funded services. In order to meet the needs of people with sight loss, and at the same time build your own career, why not think about the Low Vision Honours course from ABDO College?

Commencing each January, the Low Vision Honours course is your chance to develop an in-depth knowledge that can be put to practical use every day. It is open to every qualified DO, and the majority of the course is studied by distance learning. Once you have registered, you are sent a timetable and coursework and assignment questions to answer for each part of the course. You are allocated a personal tutor to support you throughout. There are 23 units of coursework that you will work through, each taking one or two weeks. You then send your work to your personal tutor who will mark it for you and return it to you with feedback. As the course is at honours level, you also need to undertake additional research and read around the subject in order to gain a thorough understanding of the subject. In total, you can expect this coursework to take you approximately 20 hours per week and you will need to be disciplined to make sure you keep up.

Alongside the coursework, you also need to attend a four-day period of intensive study that will support you with your theory and practical studies and give you the chance to meet some of your fellow students. This is held at ABDO College in Godmersham, Kent, and it is a compulsory part of the course.

Applying for the ABDO College Low Vision Honours course is the ideal next step for anyone with the ABDO Level 6 Diploma in Ophthalmic Dispensing (FBDO) who wants to take their low vision practice to the next level. You can find more details, an example timetable and application forms at abdocollege.org.uk/course/low-vision-honours/, email info@abdocollege.org.uk, or call ABDO College on 01227 738 829 for more information.