Summary Pre registation notes: Stage 1, visit 3

VISIT 3 NOTES:
1.2.1 Understands the patient’s expectations and aspirations and manages situations where
these cannot be met.
RA
How did you adapt?
How did you put px’s mind at ease?
What advice did you give px?
What would you do or say differently?

2.2.1 Is able to manage all patients including those who have additional clinical or social
needs.
PR with visual impairment
 Patients who are SI/SSI have recall of 1 year
 Protected group under the equality act (2010): focuses on providing the same level
of care and not discriminating against anyone, and making reasonable adjustments
for people.
 Guidelines (SSI)
o 3/60 or worse in better eye
o 6/60 or worse with markedly restricted fields
o 6/60 or better with severly restricted fields
 Guidelines (SI)
o Better than 3/60
o 3/60 to 6/60 with full fields
o 6/24 with moderate field constriction or media opacity
o 6/18 or better with gross field defect
 Registration process:
o Low vision leaflet: self-referral, can let council know they need help
o CVI: if px has level of vision and wants to be referred, refer for CVI, registers
them for sight impairment. Needs to be done by consultant ophthalmologist.
This is called a BP1 in Scotland.
o RVI: if px presents but has not been seen by consultant yet, hospital can
notify council about px needing extra help.
Once px is registered with their local social services they can get: reduced council
tax, half price TV license, help with NHS costs and tax allowances.
What services can you recommend?
 RNIB
 Glaucoma society
 Macular society
Low vision aids:
1. Near magnifiers: hand held and stand
2. Distance aids: telescopes

Explain to px how to use the magnifiers

,Adaptation of routine for visually impaired px:
 LogMar: scored by letter (0.02 per letter), crowded uses bailey lovie letters
 Pelli-Robson: Triplets of letters decreasing in contrast, test at 1m- each letter is 0.05,
lowest contrast where 2/3 seen determines CS, normal score is 2.0 and 1.5 or less
suggests impairment.
 Lighting and glare advise
 If px disabled use direct over volk

2.2.4 Creates and keeps full, clear, accurate and contemporaneous records.
DO and PR (any sampled record)

2.2.6 Makes an appropriate judgement regarding referral and understands referral
pathways.
2x referral letters

Emergency Urgent routine
AACG CRVO Suspect glaucoma
CRAO Disc haemorrhage Cataract
Hypopyon Wet AMD Anterior eye
Uveitis Optic neuritis
Retinal detachment Rubeosis
Chemical injuries Scleritis
Penetrating injuries Suspect cancer
IOP >45mmHg
Orbital cellulitis
Sight threatening keratitis
Suspected AAION
Nerve palsies
Unexplained sudden loss of
vision


3.1.4 Identifies abnormal colour vision and appreciates its significance.
PR: px with CV defect

Reasons for assessing CV:
 Careers: police, armed forces and pilots
 Safety: wiring etc
 Pathology
Human eye can see 380-780nm using 3 cone photoreceptors, S (blue), M (Green), L (red),
cones function at high level luminance and rods and low level luminance

Congenital CVD:
 Monochromat- single functioning cone
 Dichromacy (absent cone): protanope 1% (L cone Missing), deuteranope 1% (M cone
missing), tritanope 0.001% (S cone missing)
 Anomalous trichromacy: protanomaly 1%, deuteranomaly 4.9%, tritanomaly.

,  Protanope- red green
 Deutranope- red green
 Tritan- blue yellow
Mostly affects males because it is an X-linked recessive trait. So in males only 1 X
chromosome needs to have the gene for deficiency , but for females both X chromosomes
have to have the gene for the condition.

Acquired CVD:
 Secondary due to pathology, drug linked.
 Usually fluctuate in severity, associated with loss of VA and VF, monocular and
asymmetrical.
 Type 1 (like protan)- found in macular dystrophy
 Type 2 (like deutran) – found in retrobulbar neuritis
 Type 3 (like tritan- blue found in many central and peripheral retinal lesions of the
visual pathway.
Colour vision tests:
 Screening: ishihara, city university
 Diagnostic: Anomaloscope, city university, HRR
 Hue discrimination: D15, 100 hue test.
Indications for checking colour vision:
 Children’s 1st test
 Career requirements
 Aids in diagnosis of optic nerve conditions, such as optic neuritis, rod-cone dystrophy
and orbital cellulitis.
 Medication induced CV defects
 Monitoring disease progression.
Ishihara:
 38/24 plate version: 14 screening plares, 2 classification plates
 Doesn’t grade severity, simply a screening test, pass or fail, indicates type of defect.
 4 seconds per plate at 75cm, daylight is best.
 Transformation plates: normal sees a number, abnormal sees another
 Vanishing plates: only seen by defective Px
 Hidden digit plate: only seen by defective Px
 Classification plates: only used if screening failed to identify defect
 No tritan plates
 If normal CV: shouldn’t be able to see 14-15
 24 plates edition: <9 is classified as CVD

The city university test:
 10 plates: 5 coloured targets per place
 Can be used to detect protan, deutran and tritan
 Grades severity
 Each page shown for 3 seconds at 35cm


Vision standards:

, Police:
 Mild anomalous trichromats are allowed
 Severe anomalous dichromats and trichromats can be accepted for some roles
 Monochromats not allowed
Pilot:
 Normal trichromat or have colour vision deemed safe to fly
 Must pass ishihara (able to identify 1st 15 plates)
Fire fighter:
 Must pass ishihara and D15
 Very strict on CV requirements

3.1.5 Investigates the visual fields of patients with all standards of acuity and analyses and
interprets the results.
2 x PR
Px with VF defect
Px with reduced VA ,6/18 requiring VF assessment

Superior: 60 degrees
Inferior: 70 degrees
Nasally: 60 degrees
Temporally: 100 degrees

Blind spot is 15 degrees temporal
Heteronymous: opposite half of VF homonymous :(same half of VF)


Defect respects the horizontal midline: retinal issue
Defects respects vertical midline: chiasmal/neurological
Homonymous: post chiasm
Compressive: more likely higher up in pathway
Vascular: further down pathway