“To achieve such a seismic change in practice is no small feat”

The Certificate of Vision Impairment plays an important role in the life of a person with vision impairment. 

Certification enables collection of data on the prevalence and causes of sight loss to inform the effectiveness and planning of services, and in England has an additional role as a public health indicator. It is the precursor to Registration of Vision Impairment with the local authority – a process which ensures access to support and services for people with a vision impairment.

However, research suggests that up to 50% of those eligible for certification are not certified, and that the rates of certification can vary, depending on whether treatment is being sought, the cause of sight loss, ethnicity, geographical variation and practitioner variation. 

The Low Vision Service Wales (LVSW) is the national primary care-based rehabilitative service, provided across Wales by accredited practitioners (optometrists and dispensing opticians) who hold the College of Optometrists professional certificate in low vision.

Annually, over 10,000 LVSW assessments are performed.

Many of the people seen within the service have a vision impairment that would warrant certification. However, despite this, the majority of people report not being certified.

Professionals who provide low vision rehabilitation will know that this is not an unusual situation. Many people with low vison do not routinely attend the hospital eye service. Therefore, certification often necessitates a referral to secondary care – something which people are not always keen to accept. This situation is compounded by the fact that hospital eye service clinics are busy, and people can experience long waits.

Potential for change

Currently, only consultant ophthalmologists are able to complete the certification process. A potential solution to ease the burden on secondary care is the expanded role of the low vision optometrist in the certification process. The benefit to patients would be access to certification in a timely manner, closer to home.

A study I worked on sought to assess the agreement between LVSW optometrists and a consensus panel, in identifying patient eligibility for certification, relative to the agreement between ophthalmologists and the consensus panel.

The consensus panel was formed of consultant ophthalmologists and LVSW optometrists. Ninety-nine LVSW optometrists and 30 consultant ophthalmologists completed an online task, in which they were asked to categorise the eligibility for certification of 40 patient case records.

LVSW optometrists demonstrated a comparable agreement relative to ophthalmologists, with the consensus panel on the eligibility for certification. The median (IQR) number of cases in which there was agreement with the consensus panel was 33.0 (31.0, 33.0) for ophthalmologists and 36.0 (34.0, 36.5) for LVSW optometrists.

A certification pathway introduced into primary care must meet the needs of people with a vision impairment, and be deliverable by LVSW optometrists in a manageable way

Although the cases included a range of causes of vision impairment, agreement between professional groups and the consensus panel was greatest for those cases in which the cause of vision impairment was atrophic AMD.

The findings were therefore supportive of the clinical decision-making ability of LVSW optometrists in the certification of vision impairment and provided evidence in support of policy change to allow low vision optometrists to certify individuals with atrophic AMD. The full paper, Evidence of agreement between ophthalmologists and optometrists in the certification of vision impairment, can be accessed here.

Meeting the needs

As a result of the research, the Wales Eye Care Services committee, which oversees delivery of primary eye care in Wales, instructed a task and finish group to be established – the aim of which was to explore how certification could be offered for people with atrophic AMD, within the primary care setting. Members of this group include people with a vision impairment, the third sector, social care, optometric representation and ophthalmology representation.

To achieve such a seismic change in practice is no small feat. The process of certification is engrained in the role of the consultant ophthalmologist, and in Wales, a Welsh Health Circular outlines the role of the consultant ophthalmologist in this process. A certification pathway introduced into primary care must meet the needs of people with a vision impairment, be deliverable by LVSW optometrists in a manageable way, and the quality of data collected as part of the process, which is so valuable in informing our knowledge regarding causes and prevalence of sight loss, must be maintained.

Of course, the needs of people with vision impairment who are eligible for certification must drive and be central to any change which is implemented. In recognition of this, not only does a patient voice exist on the task and finish group, but exploratory qualitative patient interviews are being performed in a research project, supported by the Macular Society and Wales Council for the Blind.

About the author

Rebecca Bartlett is optometric advisor for the Hywel Dda University Health Board, and clinical lead of the Low Vision Service Wales.