Lecture 5 - Additional support needs (ASN)

Question 1

General Guidelines:

Answer 1

• Always ask carer’s name & relationship to Px
• Always ask doctor’s name and address
• Always ask if the patient has a diagnosis

*Pre-visit questionnaire – see GCU
Learn
*Be realistic: having to re-book to
complete exam is OK

*Give clear unambiguous instructions
*Explain what you are going to do
*Check if patient is happy with this
* Consent
Show each piece of equipment before
you use it
– Demos are always a good idea

Question 2

What is Capacity and consent?

Answer 2

A person lacks capacity if
- they cannot make decisions or communicate them
- they cannot understand or remember their decision

For consent to be valid a patient must be able to
- understand and remember the information given
- evaluate the information given
- communicate their decision

Question 3

Communication guidelines:

Answer 3

– Presume Competence
* Expressive < Receptive language
– Use key words
* Keep it simple
– “Face to face”
– “OWLing”
* Observe
* Wait
* Listen
– Avoid distraction

Question 4

Whats the risk of Visual impairment with Learning deficiency?

Answer 4

• People with LD 10 x more likely to have a visual impairment
  – 1 in 3 people with severe or profound LD
  Assume visual impairment until proven otherwise
• Carers often not aware of the sight problem
• 6 in 10 people with LD need refractive correction
  – Support often needed to get used to them.

Question 5

Cerebral Visual Impairment
(CVI)

Answer 5

• Visual impairment that cannot be explained by a refractive error or ocular condition
• Most common cause of visual impairment in children
• Associated with preterm birth/very low birth weight
• Also associated with neurodevelopmental disorders
• Prevalence increasing as survival rates for children with disabilities improves

Question 6

Visual Behaviour in CVI

Answer 6

Typical pattern of visual dysfunction
* impaired visual search in cluttered environments
* difficulty splitting attention between tasks (e.g. walking into obstacles while talking)
* impaired visual guidance of movement, particularly lower limbs

Question 7

Visually guided behaviour includes:

Answer 7

• Interaction with objects:
Visually guided reaction or reaching
Response to seeing food or drink

• Interaction with social content:
Visually guided reaction to people
Response to silent smile
Response to a face in the mirror

Question 8

How to do Fixation Preference: (preferential looking)

Answer 8

• Sit at the correct distance
• Don’t look at the test cards
• Hold at patient’s eye level
• Use all cues to make your decision
• looking/pointing/naming
• Use “bracketing” to find the
  threshold

Question 9

How to do Letter/picture matching:

Answer 9

• Use at correct test distance
• Test 2 letters per line until near
  threshold
• Use single letters/pictures only
  when the patient is unable to do
  crowded test

Question 10

Does Mohindra’s technique differ between ages?

Answer 10

Use hand-held lenses
For Working Distance = 50cm/2DS

Infants < 2 years
* Subtract 0.75D from result
* Allows for 1.25D accommodation

Patients > 2 years
* Subtract 1.00D from result
* Allows for 1.00D accommodation

Question 10

How is Mohindra’s technique undertaken?

Answer 10

• Relies on observation that in the dark
  
  1. eyes accommodate by predictable amount
  2. both eyes accommodate equally
• Undertaken in complete darkness
  
  • Explain to patient what is going to happen
  • Dim lights gradually
• Often undertaken monocularly
  
  • Theory: Avoids convergence clues to distance of retinoscope
  • Not necessary

Question 11

Advantages of Mohindra’s Technique

Answer 11

• No drops
  
  • No risk of side effects
  • Can be distressing for patient
• Binocularly balanced refraction
  
  • Depth of cycloplegia unpredictable
• Accommodation may be assessed at same visit
• Good where frequent follow ups are required

Question 12

Which Ocular structures are at risk with Learning Disability:

Answer 12

• All structures and components of visual pathway are at risk
• Visual risk increases with the severity of the disability

Question 13

Which devices can be used in an ocular health assessment:

Answer 13

• Observation
• Direct ophthalmoscope
• Binocular indirect
• Hand-held slit lamp

Question 14

How are pressures done with an ocular health assessment?

Answer 14

• Digital palpation
Both index fingers
Palpate above tarsal plate
* Raised IOP: firm and hard
* Normal IOP: Soft
Poor accuracy

• iCare Tonometer
Rapid
No drops
Compares well with Goldmann

Question 15

Field assessment:

Answer 15

• Modified confrontation
Gross test only
often binocular
Interesting target
Allow time for a response - apraxia

Question 16

Eye movements and ocular alignment:

Answer 16

Strabismus is common

Prevalence increases with severity of disability
- Exotropia > Esotropia

May be intermittent

Frequently incomitant (angle varies with direction of gaze)

Question 17

Common Anterior eye conditions with ASN Group:

Answer 17

• Blepharitis
• Conjunctivitis
• Dry eye
• Corneal scarring
• Keratoconus

Question 18

Ocular Health – common
conditions with ASN (non anterior)

Answer 18

Lens
- Cataract
- Aphakia/Pseudophakia
- Lens dislocation

Optic Nerve
- Hypoplasia
- Coloboma
- Atrophy

Question 19

Prescribing for patient:

Answer 19

• Adapt to patient’s needs
• Consider whether low Rx is really needed
• Children may not emmetropise – so give full Rx?
• Always try a high Rx “as often as tolerated”
• Consider single vision with +1.00 intermediate add for presbyopes

Question 20

Prescribing for ocular health:

Answer 20

Always provide a written report to carers/GP

Be practical and realistic about risks and benefits of surgery, contact lenses etc.

However, patients with learning disabilities have the same right to good sight

Question 21

Prescribing for low vision:

Answer 21

• Most care is supportive
• It is very helpful if carers have a good estimate of vision and understand the
  nature of any field loss
• Consider blind registration