Linklater & Warren
Chislehurst -
020 8295 5131
Linklaters Optometrists
Bexleyheath -
020 8303 4014
Leslie Warren Opticians
Sevenoaks -
01732 452 135

Eye examinations for people with learning disabilities



Accessible eye care

person with learning difficulties reading
Image courtesy of SeeAbility

Since the early 1990s Gordon Ilett has developed a particular interest in examining people with learning disabilities. This interest started when he was asked by Kent Association for the Blind, London Borough of Bexley and South East Thames Regional Health Authority to become involved in a study into the prevalence of visual impairment in people with learning disability in Bexley.

The knowledge gained from this work has allowed Gordon to work with RNIB, the College of Optometrists, DOCET and Special Olympics to publish a number of papers and other articles on the subject, as well as producing educational videos and DVDs for optometrists, carers, and people with learning disabilities both in the UK and USA. Gordon has lectured both nationally and internationally on this subject and worked with Special Olympics as far away as Japan with this patient group. Gordon is now a Trustee of SeeAbility and works with a number of organisations developing eyecare services for people with learning disabilities.

Can people with learning disabilities have a sight test?

More than 90% of people with learning disabilities can be examined in a normal high street optometrist’s practice with some adaptations to the routine tests and a sympathetic practitioner; the rest can be examined using more specialised tests, multiple visits to build confidence, and in a few cases multidisciplinary working with optometrists, ophthalmologists, orthoptists, and the rest of the health care, educational and social care teams.

Why is it important for people with learning disabilities to have an eye examination?

90% of our sensory input comes from vision, so in order to learn, communicate, and get around, it is important to see clearly. If there are any restrictions to an individual’s vision then it is important to correct these (where possible) to allow normal visual development and learning to take place. Sometimes a defect in vision cannot be corrected, for example damage to the visual pathway caused by brain injury, which is quite common in people with moderate to severe learning disabilities. In these cases it is important that parents, teachers, and other carers know the nature of the visual problem so that the necessary adaptations can be made to the living and learning environment. On more than one occasion we have encountered people who were thought not to be making progress due to their learning disability (e.g. changing from a speech synthesiser with 8 buttons to one with 32) only to find when they were examined that their vision was hindering progress.

Is an eye examination more important if an individual has a learning disability?

Studies both in the UK and around the world have shown that up to 66% of people with learning disabilities have some visual problem. 14-20% may be classified as blind or partially sighted, 15-30% may have defects in their vision which cannot be corrected with spectacles. For example, people with Down’s syndrome have a far higher need for spectacles than the general population and the proportion of this group who need strong spectacles (both for short-sightedness – myopia, and long-sightedness – hyperopia) are far higher. People with Down's syndrome and cerebral palsy are more likely to have reduced accommodation (the ability of the eye to focus on near objects), and everyone with learning disabilities is more likely to have a squint (turning eye) or lazy eye than the rest of the population. The presence of structural defects in the eye due to developmental abnormalities and developmental disorders associated with various syndromes are also more common in people with learning disabilities.

Will people with learning disability wear glasses?

Studies have shown that only 2% of people with learning disabilities who have a significant need for glasses fail to wear them. Sometimes an adaptation programme is needed to desensitise individuals to the sensation of spectacles on the nose, and the change on visual perception caused by the lenses, but in the majority of cases if the person can see better, then the spectacles are worn. It tends to be in cases where glasses make no perceptible difference to the quality of vision that spectacles are not worn.

How can an eye test be done if someone can’t read the chart?

If someone is unable to read letters they are often able to match them against a ‘clue card’ with 5 or 6 letters on it. Sometimes lines of letters are used, sometimes single letters (e.g. Sheridan Gardiner test). If letters are not recognised then we use pictures either asking the patient to name or match the pictures (Kay Pictures). If the person cannot name or match symbols or letters then a technique called preferential looking is employed. This relies on the fact that if an individual is given the choice between looking at a blank sheet of card or one with a pattern on it they preferentially look at the one with the pattern as this is more interesting. The examiner presents cards to the patient, with a pattern or picture at one end and plain grey at the other, then observes which way the patient looks when presented with this choice. The size of detail in the pattern is then reduced until no preference is detected. The appropriate acuity level is then recorded. Of course in a number of people no responses to any of these tests can be obtained and observation of responses to different stimuli, behaviour in various environments (Functional Visual Assessment), and an assessment of the structure and likely function of the eye and visual pathways is needed to estimate likely visual potential. These cases can prove the most challenging and may require multidisciplinary assessment to confirm findings.

How do you test for glasses in people with no verbal responses?

A technique called retinoscopy is employed. This allows the optometrist to work out the strength of lens needed, and whether someone is longsighted, shortsighted, or has astigmatism just by shining a light in their eyes and inserting various lenses to ‘neutralise’ the apparent movement of the reflected light from the retina. In some patients to increase the accuracy of this test drops are instilled in the eye to prevent unwanted focussing of the eye during the examination (Cycloplegic examination). Using a variation of this test the focussing power of the eye (accommodation) can also be assessed (dynamic retinoscopy). In some cases an instrument called an autorefractor can be used instead of a retinoscope. This is a computerised version of a retinoscope and can sometimes be helpful, but a degree of cooperation is needed from the patient which may sometimes either prevent its use or cause inconsistent results. From the results of these tests, spectacles of the correct strength can be prescribed.

Where should we go for an eye test? What will it cost?

There is no charge for an eye examination for children under 16 and under 19 in full time education. The fee is paid by the NHS. There are many groups that qualify for NHS eye examinations including those on income support - for the full list see the NHS Patients page. All optometrists working in high street opticians practices should be able to examine people with learning disabilities, and certainly those with a mild learning disability should have no problem finding a suitable practitioner. People with moderate to severe learning disabilities, or those with challenging behaviour can sometimes need a different approach to achieve a successful outcome. Charities such as SeeAbility are developing a list of optometrists who are interested in examining people with learning disabilities, and who would have contacts with other professionals in arranging referrals and multidisciplinary assessments. Many of the optometrists at Linklaters and Leslie Warren are familiar with examining patients with learning disabilities; however, if you feel there are likely to be any difficulties such as access to consulting rooms with wheelchairs, need for extended examination times, unfamiliarity or fear of strange environments then please contact us for further advice.

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