Meeting the eye health needs of shielding, isolating and domiciliary patients during the coronavirus (COVID-19) pandemic

Summary

Individuals, particularly older adults, who are unable to leave home unaided owing to physical or mental illness or disability, or who are isolating or being shielded from COVID-19, are potentially at higher risk of eye disease and vision problems than the general population.

Vision and eye health problems in turn exacerbate the effects of isolation and impact on other serious conditions such as cognitive impairment and dementia. This is why NHS eye care should be resumed for these patients as soon as possible observing the highest standards of infection prevention and control (IPC) and patient safety. Personal protective equipment (PPE) for face-to-face care of these groups will remain a standard requirement for the foreseeable future.^{1, 2}

Groups advised to self-isolate or shield might change over time and in response to local risk levels. The provision of eye care, in particular face-to-face care, will need to be responsive to these changes based on local public health advice and clinical judgement about risk and benefits to the patient and risk to others in the same premises.

Risk and need

As the UK countries move out of the lockdown at different speeds based on local infection rates (‘R’ rates), a particular challenge is how best to meet the eye care needs of patients who are most at risk from COVID-19. This includes individuals classified as clinically vulnerable and clinically extremely vulnerable.

Patients classified as clinically extremely vulnerable are the group that are being shielded on medical advice. This includes 2.5 million individuals.³

These individuals are by age and other health factors most at risk of eye disease, visual problems and sight loss which are in turn correlated with falls, loneliness, isolation and loss of cognitive function, all of which are exacerbated by loss of social contact with family, friends and carers. That is why it is important that, when making decisions on who will benefit from eye care, COVID-19 risk is balanced against non COVID-19 risks on a case-by-case basis.

Whilst stopping all but remote care was the correct public health response in phase one of the pandemic when we knew little about the virus, we now know much more about COVID-19, how it spreads, and how to mitigate the risks through social distancing, rigorous infection controls and PPE. We also know that the virus will be around for some time and possibly for the whole lifetime of some vulnerable patients. 

This means that the balance of risk has now shifted towards meeting each individual’s eye care needs based on the principles of informed consent and respecting protected characteristics of each patient. The goal is now to preserve sight and independence and ensure no-one is denied the care they need when this can be provided safely.

The Optical Confederation Domiciliary Eyecare Committee considers that eye care for these priority groups should resume as soon as possible in line with General Optical Council (GOC), College of Optometrists (CoO), Association of British Dispensing Opticians (ABDO) guidance and sets out the following recommendations for eye care providers, practitioners, patients, care homes, NHS commissioners and health authorities as the UK countries and local areas move out of lockdown and through the health system recovery phases of the pandemic.

Principles

Eye care for vulnerable patients should always:

• Be clinically necessary
• Be consistent with the Equality Act 2010 – not making decisions on who can access care based solely on disability, age or another protected characteristic
• Respond to a need identified by the patient, a carer or a clinician or social worker appropriately registered with a health or care regulator
• Be remote wherever possible
• Observe social distancing
• Be based on a risk assessment for each individual patient and any other people who may be at risk of infection
• Comply fully with GOC standards and up-to-date advice from the CoO and ABDO especially in respect of rigorous infection control and the wearing and disposal of PPE
• Consist only of clinically necessary tests to minimise examination time
• Be planned with the patient or their care co-ordinator (especially for shielded patients) at the safest possible time for them
• Be based on liaison with the local ophthalmology department where appropriate so that care can be completed in a single visit
• Be clearly noted and the information shared, with permission, with care coordinators, GPs and other authorised persons and care givers

Providers

Providers should comply with the above principles and:

• Ensure staff check and comply with official self-isolation advice on a daily basis before leaving work and before visiting any patient in line with local public health and NHS advice
• Ensure all staff visiting patients have equipment for rigorous infection control and use of PPE and been trained in its use, have clean uniforms daily, have bare forearms and clean and disinfect equipment and other electronic devices as appropriate at each use
• Provide additional training for all staff so that they know how perform a risk assessment of each location they visit, e.g. how to enter and exit the location with minimal contact with fixtures or other people, discontinue a visit if they have concerns about a patient’s, present third party’s, or their own health and seek appropriate advice
• Limit to one person per vehicle and send only one person on a visit
• Collaborate with individuals and care homes to minimise visits

Professionals

Professionals should follow the above and:

• Never leave base without sufficient hand sanitiser and other infection control supplies
• Ensure there is sufficient PPE and it is packed correctly
• Check in advance the safest and least contact entrance and exit routes, parking places etc (NB some care home may have cold and hot entrances or there may be entrances which are nearer to a particular patient’s room including garden doors, fire doors etc)
• Reassure patients (who may be less used to strangers than usual) about how their eyes are being checked and using hand hygiene and PPE to keep them safe
• Maintain social distancing and avoid all unnecessary contact with staff and other residents

Patients⁴

Patients and carers where applicable, should:

• Continue to look after eye health, and clean and wear spectacles as advised 
• Contact their optical professional if there are any concerns about vision or eye health
• Contact the optical professional if their glasses are broken, scratched or lost, or are not sure which pair to use
• Contact their optical professional (or other eye health professional as directed) urgently if they have sudden:
  • Blurred vision
  • Ocular pain with or without discharge
  • Light sensitivity
  • Double vision
  • Flashes of light in your vision
  • Disturbances in your vision
  • New floaters in your vision
• Contact their optical professional or local hospital’s A&E department immediately if they have sudden loss of vision or double vision
• Expect to discuss their symptoms over the phone or video-link in the first instance in case the optical professional can advise or treat them remotely⁴
• Be confident that their optical professional will use rigorous infection controls and appropriate personal protective equipment (PPE) such as masks, gloves and aprons to keep them as safe as possible
• Understand that the optical professional will use their professional judgement to meet the patient’s eye care needs but might not carry out all tests they would normally use in order to keep the patient as safe as possible

Carers

• To comply with the principles above to meet the vision and eye care needs of the vulnerable person whilst keeping them and the patient as safe as possible 
• Never to call without a pre-scheduled appointment and always to carry professional identity
• To use rigorous infection control to keep the patient and carers as safe as possible
• To use appropriate personal protective equipment (PPE), such as masks, gloves and aprons, to keep the patient and themselves as safe as possible
• To leave accurate records of the care the patient needed
• To post new or repaired spectacles and advise on fitting remotely wherever possible

Care homes

Care homes can expect all eye care providers and professionals to comply with the above principles and:

• To continue to support residents in respect of their eye health and vision in safe and appropriate ways throughout the next phases of the pandemic
• To respond quickly to a request for advice, support or a visit from or on behalf of a resident about an eye care matter
• If a visit is necessary, to contact the care home in advance about the COVID-19 status of the home and the resident population and to check that it is acceptable for optical professionals, observing strict infection control and using PPE, to visit
• To agree with the care home an optimum time, location, entrance, exit and guide for a visit, and how safely to leave records, prescriptions and any necessary advice for the patient, relatives or care home staff
• To be showing clearly visible professional identity on arrival and to be happy to be photographed rather than using sign in and sign out books
• To expect to have access to hand-washing facilities before and after seeing a patient - the optical professional will bring soap, paper towels and hand sanitiser for personal use
• To take any PPE and clinical waste away with them for safe disposal 
• Not to bring into or leave anything in the home which is not directly related to the patient visit
• To raise with the care home any risks to patient safety they observe and will expect the care to reciprocate

NHS commissioners and health authorities

NHS commissioners and health authorities should:

• Recognise the importance of eye care for older people unable to leave home unaided on ground of physical or mental health or disability and individuals solating at home or being shielded on medical advice
• Support optical professionals in meeting these needs safely
• Be flexible over notification requirements and prior approvals where need is urgent or can only be provided safely at specific times or within tight timescales
• Put individual patients’ and all patients’ needs and safety ahead of routine contractual requirements for the duration of the pandemic

Domiciliary Eyecare Committee
5 June 2020

Notes

1. College of Optometrists COVID-19 traffic light guidance table
2. Recommended PPE for primary, outpatient, community and social care by setting, NHS and independent sector
3. Composite approximate figure. Sources: The Ministry of Housing, Communities and Local Government
   (England), Welsh Government, Scottish Government and NI Government. May 2020
4. What to do if you are worried about your vision during coronavirus. RNIB advice