Meeting the eye health needs of people who cannot leave home during the COVID-19 pandemic and winter flu

Guidance from the Primary Eyecare Sector’s Domiciliary Eyecare Committee (DEC)

23 September 2021

Summary

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

This risk has been significantly heightened by the COVID-19 pandemic responses, including shielding and lockdowns, which have often prevented direct access to eye care as well as adding to individuals’ isolation, loneliness and associated complications. Optometrists and dispensing opticians visiting patients after lockdown report far higher levels of impairment and sight loss than pre-pandemic.

It is imperative, therefore, that:

People who cannot leave home unaided have access to regular eye care as soon as possible
The sector follows relevant guidance to continue to keep patients, optical and care home staff, and third parties (for example, co-residents) safe from infection

To enable this to happen, continuing to observe the highest standards of infection prevention and control (IPC) and patient safety is at the heart of this updated advice. As part of this, personal protective equipment (PPE) with home-based patients and carers will remain a requirement for the foreseeable future.^1,2

The government has also decided that all staff working in care homes in England, including visiting professionals such as optometrists and dispensing opticians, must be double vaccinated against COVID-19 from 11 November 2021 (unless they are exempt under the regulations on health grounds).³ To prepare for this staff will need to have their first jab by 16 September 2021.

Then, as we move on through the later summer, autumn and winter of 2021–22, providers and front-line optometrists, ophthalmic medical practitioners and dispensing opticians will also need to be alert for and responsive to any changes in local public health advice and continue to make clinical judgement about risk and benefits to individual patients, and the risks to others in the same premises, on case by case and daily basis. This may include in responding to infection outbreaks, hotspots, new variants of COVID-19 and winter flu.

Risk and need

In common with other areas of healthcare, restrictions on access combined with a lower priority given to eye health by individuals during the acute phases of the pandemic, mean that eye health has worsened and that individuals who have not had access to eye care are at greater risk of poor vision and visual impairment.

This is particularly the case for domiciliary patients who are unable to leave their homes unaided. By virtue of age and other health factors, these patients most at risk of eye disease, visual problems and sight loss which, in turn, is correlated with falls, loneliness, isolation and loss of cognitive function. They have also been least able to access other health care and social support during the pandemic. This means that, despite the easing of lockdown, these risks will have been exacerbated by loss of social contact with family, friends and other carers.

However, the domiciliary eye care service is now in a much better position to meet those needs. We have a far better understanding of how COVID-19 is transmitted, risk, IPC and how to keep patients and staff safe. PPE is now readily available and patients are used to clinicians using PPE during visits, wearing masks and frequently washing or sanitising their hands and/or wearing disposable gloves.

The COVID-19 vaccination programme has also been a great success in reducing (although not eliminating) risk for patients and staff. The elderly and health workers were an early priority but now that all UK adults (including young adults) are being offered vaccination, risks are further reduced.

This means that the priority now is to catch up on the backlog of care and ensure that everyone who needs eye care has access to it as safely as possible unless the balance of risk to them or others outweighs the eye health need.

Infection prevention and control

In June 2021, the College of Optometrists, based on the best scientific evidence, advised: “As lockdown restrictions are in the process of being eased across the UK, there has been no indication from each UK nation’s health and government bodies of plans to step down IPC procedures or social distancing for primary or secondary healthcare settings in the coming months. While we constantly review our COVID-19 guidance to ensure it is up to date, we anticipate the ‘amber phase’ guidance will continue for some period of time, and potentially for the rest of 2021”.

We now know that the virus will be around for some time and that this will constitute their whole lifetime for some of our patients. It is important that the virus does not impact on their quality of life where that is not necessary.

We also know that vaccination is not suitable for, or does not work for, everyone and that Covid risk is reduced but not eliminated by vaccination. Despite a person being fully vaccinated, even a less serious COVID-19 infection can have very serious/fatal complications for vulnerable individuals (and care home workers).

For these reasons, continuing to observe the highest standards of IPC and patient safety is at the heart of this updated advice. PPE for face-to-face care of these groups will remain a standard requirement for the foreseeable future.

In July 2021 the College of Optometrists and the national optical bodies issued updated guidance for England reminding providers and practitioners to:

Follow current IPC guidance, including PPE
Ensure social distancing
Maintain patient triage and prioritisation
Sanitise frames and equipment
Maximise good ventilation

The UK Domiciliary Eyecare Committee fully supports this.

Throughout the summer, autumn and coming winter, providers will also need to be alert to and respond to any changes in local public health advice – including ensuring staff are vaccinated against winter flu as well as having any recommended Covid boosters - and continue to make clinical judgements about risk and benefits to individual patients, and the risks to others in the same premises, on a case by case and daily basis.

This will be particularly important as the UK nations move beyond national lockdowns and respond to new Covid variants and infectivity ‘hot spots’ in different ways based on local infection rates (‘R’ rates) and other factors.

To support domiciliary providers and practitioners, in line with General Optical Council (GOC), College of Optometrists, Association of British Dispensing Opticians (ABDO) guidance, the Optical Confederation’s Domiciliary Eyecare Committee makes the following recommendations for eye care providers, practitioners, patients, care homes, NHS commissioners and health authorities as the UK nations and local areas move through the next phases of the pandemic as well as the 2021–22 winter flu season.

This supersedes our guidance of 5 June 2020. Footnotes a) – i) show where updates have been made.

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
Only be remote where face-to-face would be unsafe
Observe social distancing, and maximising ventilation as far as possible, 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 College of Optometrists and ABDO (which will reflect the latest public health and NHS advice) especially in respect of rigorous infection control and the wearing and disposal of PPE
Consist only of clinically necessary tests [updated^a]
Be scheduled with the patient or their care co-ordinator at the safest possible time for them
Be based on liaison with the local ophthalmology department where appropriate so that as much eye care as possible can be completed in a single visit by the same clinician
Be clearly noted and the information shared, with permission, with care co-ordinators, GPs and other authorised persons and care givers

Providers

Providers should comply with the above principles and:

Expect staff to accept the offer of COVID and winter flu vaccination including any recommended Covid booster vaccinations
Expect patient-facing staff to undertake lateral flow tests every 72 hours and report the results as required in each nation
Ensure staff check and comply with official self-isolation advice [updated^b] 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 have been trained in its use, have clean clothes or 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 to perform a risk assessment of each location they visit – for example, 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
Ensure staff observe appropriate IPC in shared vehicles including ventilation, face coverings, cough, sneeze and hand hygiene and limitation on physical contact
Collaborate with individuals and care homes to schedule visits to minimise person-to-person exposure
Agree in advance how patient signatures on NHS forms (both paper and electronic) will be managed

Professionals

Professionals should follow the above and:

Accept the offer of COVID and winter flu vaccination (unless medically contraindicated) and make known their vaccination and lateral flow test status to employers, and to patients and care givers where appropriate, as part of good professional practice
Should self-certify if exempt from Covid-19 vaccination on medical grounds using the letter attached to this guidance Temporary medical exemptions for COVID-19 vaccination of people working or deployed in care homes – GOV.UK (www.gov.uk) until the new NHS COVID Pass system is in place in which case that should then be used
Take lateral flow tests every 72 hours and report the results as required in each nation
Never leave base without sufficient hand sanitiser and other infection control supplies
Ensure they have sufficient PPE and that it is packed correctly, including facilities for safe disposal
Check in advance preferred building entrance, exit routes and parking places to minimise risk (NB some care home may have [updated^c] entrances which are nearer to a particular patient’s room including garden doors, fire doors etc)
Follow useful College of Optometrists guidance on, “How should I don and doff outer wear and (PPE) when carrying out a domiciliary sight test?”⁵ [updated^d]
Maintain social distancing, maximise ventilation and avoid unnecessary contact with staff and other residents

Patients

Patients⁴, and carers where applicable, should:

Continue to look after your eye health, and clean and wear spectacles as advised
Contact your optical professional if there are any concerns about vision or eye health
Contact your optical professional if their glasses are broken, scratched or lost, or are not sure which pair to use
Contact your optical professional (or other eye health professional as directed) urgently if you have sudden:
- Blurred vision
- Ocular pain with or without discharge
- Light sensitivity
- Flashes of light in your vision
- Disturbances in your vision
- New floaters in your vision
Contact your optical professional or local A&E department immediately if you have sudden loss of vision or sudden onset of double vision [updated^e]
Be confident that your optical professional will use rigorous infection controls – including hand washing and hand sanitiser – and appropriate PPE such as masks, gloves (and aprons when necessary) to keep you as safe as possible
Understand that your optical professional will use their professional judgement to carry out all necessary tests to meet your eye care needs and to keep you as safe as possible

Carers

Carers can expect all eye care providers and professionals:

To comply with the principles above to meet the vision and eye care needs of the patient keeping them and the patient as safe as possible
Never to call without a pre-scheduled appointment, always to carry professional identity and be prepared to show evidence of their vaccination and lateral flow test status
To use rigorous infection control to keep patients and carers as safe as possible
To use appropriate PPE, such as type IIR masks, gloves and risk assess whether aprons and eye protection are required
To leave accurate records of the care the patient needed
To return to fit spectacles or, depending on the balance of risk to the patient or carer, to post them and advise on fitting remotely

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 and winter flu as advised by the government in each UK nation
To respond quickly to a request for advice, support or a visit from or on behalf of a resident about an eye care matter
[updated^f] To contact the care home in advance of any visits [updated^g] to confirm 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 and exit [updated^h] for a visit, and how to leave records, prescriptions and any necessary advice for the patient, relatives or care home staff
To provide evidence on arrival of their vaccination and lateral flow test status before providing care
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 visiting 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’s care
To raise with the care home any risks to patient safety they observe and will expect the care home to reciprocate⁶

NHS commissioners and health authorities

NHS commissioners and health authorities should:

Recognise the importance of eye care for [updatedⁱ] people unable to leave home unaided on ground of physical or mental health or disability and individuals isolating at home or being shielded on medical advice
Support optical professionals in meeting those needs safely and promptly
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 and winter flu period

Domiciliary Eyecare Committee
20 September 2021

Notes

www.college-optometrists.org/guidance/covid-19-coronavirus-guidance-information/covid-19-college-guidance/primary-eye-care-covid-19-pandemic-guidance.html
www.assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/878750/T2_poster_Recommended_PPE_for_primary__outpatient__community_and_social_care_by_setting.pdf
Vaccination of people working or deployed in care homes: operational guidance - GOV.UK (www.gov.uk)
www.assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/990923/
20210602_Infection_Prevention_and_Control_Guidance_for_maintaining_services_with_H_and_C_settings_1_.pdf
www.gov.uk/government/publications/coronavirus-covid-19-testing-in-adult-care-homes/testing-for-professionals-visiting-care-homes. Visiting eye care professionals fall within the category of ‘NHS professionals visiting care homes who are part of regular staff testing’ for the purposes of this
guidance
What to do if you are worried about your vision during coronavirus - RNIB - See differently
www.gov.uk/government/publications/coronavirus-covid-19-testing-in-adult-care-homes/testing-for-professionals-visiting-care-homes
College of Optometrists COVID FAQ How should I don and doff outer wear and personal protective equipment when carrying out a domiciliary sight test?

^a text removed about minimising contact time
^b text removed about daily checking
^c text removed about hot and cold entrances as there have in the main been discontinued
^d text removed about reassuring patients about people wearing masks which is no longer relevant
^e text removed about telephone or video triage and remote care which is no longer relevant
^f text removed implying visits will be exceptional
^g text removed about the Covid status of the care which is now standard practice
^h text removed about in-home guides
ⁱ text removed highlighting older people