When I was at uni, we had a variety of clinics in our final year.  There was a general clinic where we spent upwards of two hours giving unsuspecting people the most thorough and chaotic eye examination of their lives.  There was a contact lens clinic where we would take turns as patients for our partners and where, almost every week, someone would tell me I wasn’t suitable for lenses.  We had low vision clinic, colour vision clinic, visual stress clinic and finally, special needs clinic.

In uni, when you are still forming as an optometrist, testing someone with special needs is daunting.  It’s even more terrifying when your patient is non-verbal – how will you know if you are improving your patient’s vision if they can’t tell you? Are you upsetting them with your dithering? Is your ret really as bad as you think?

Add the fact that you are crammed into a small room with your patient, their parent or carer, your clinic partner and your supervisor.  I would assume my patient was stressed because I was, myself.

One of the patients I saw in special needs clinic was a young girl with Rett Syndrome, whom I’ll call R.  Now, I wasn’t familiar with Rett at all.  Before the clinic, my partner and I were given a little booklet about R that her parents had made.  It told us a bit about Rett but, more importantly, it told us about R: what she liked, disliked and how she communicated.  I really couldn’t have asked for a better first (non-verbal) patient.

Since then, I’ve seen many children with special needs, most of them on the autistic spectrum.  There’s a great saying about autism spectrum disorder: when you’ve seen one person with ASD, you’ve seen one person with ASD*.  When you are testing anyone on the spectrum, you need to tailor your routine to them.  If you are lucky, their parent or carer will help you along the way.

Anyway, sometimes we forget that an eye examination is quite stressful to non-optics people – by sitting as patients for our colleagues, we’ve pretty much desensitised ourselves to the process.  We also know what each part of the test is for, how long it will last and why it is important.  Imagine, though, that you were walking in to an opticians for the first time ever:

The lights are bright and there is so much visual clutter: hundreds of frames on frame racks or shelves, the mirrors, display cases, desks, chairs, strange machines in the corner, the other patients and staff moving around.  It’s also a riot of noise: the phone ringing, lots of different voices speaking at different levels, beeps, coughs and sneezes, doors opening and closing.  Other senses are engaged: the smell of someone’s lunch, strong perfume from the lady sitting near the door, the cold, dry air from a fan or the warm air from the heater.

You wait in the chaos until your name is called then you are led to the machines and asked to put your chin here and forehead there.  Then you are in a small room with a person you don’t know, being interrogated and having bright lights shone in your eyes. **

Basically, there’s a lot going on.  There are a couple of things, though, that will really help all your patients:

  1. Think about appointment times. If someone would benefit from a calmer, quieter environment, book them in at a quiet time (perhaps first thing in the morning or on a day where there’s only one person testing in a large practice).
  2. Build a seamless patient journey. Ideally, this would involve no waiting around.  Unfortunately, this is real life so giving someone an idea of how long they will wait is the next best thing.
  3. Introductions.  Amazing how something so small can make a massive difference: taking a moment to introduce yourself to the patient.  After saying my name, I usually smile and say, “I’m the optometrist so I’m going to be having a look at your eyes today.”
  4. Sign-posting. Tell your patient what you are going to do, and why, before you do it.  This can be as simple as saying, “I’m going to ask you a few questions about your health and your eyes” before starting history and symptoms or telling someone when you are about to turn the light on or off.
  5. Giving time limits. I do this mainly when I’m doing ret or Volk.  I will tell someone when we’re half done or nearly finished with different parts of the test.  This helps with anxiety.
  6. Positive talk. Most people love positive re-inforcement: I tend to say “you’re doing great” while doing something like ret or cover test and “that’s it, well done” when I’m moving on to the next bit.  Also, if someone has great eye sight – tell them! Everyone likes a compliment.
  7. Handovers. I like to speak to the patient about their eye health and have a discussion about glasses before the handover.  It means that, when the optical assistant comes in, I can summarise what I’ve recommended and any preferences the patient has.  In the best case scenario, the same OA who did the prescreening is the one to dispense (they’ve already built up a bit of a relationship with the patient).
  8. DIY. Sometimes doing the prescreening, test and and resulting dispense yourself is the best way to support your patient.  In a busy multiple, this may be difficult but, if you’ve picked the right appointment time for that patient, it’s possible.

I’ve recently started working with patients living with dementia.  This patient group can also experience a type of sensory overload.  I will be writing another post about dementia and working in a domiciliary setting soon.

Finally, and I’ll say this loudly for those in the back, JUST BECAUSE SOMEONE IS NON-VERBAL DOESN’T MEAN YOU CAN TEST THEM SILENTLY.  Talk to all your patients, no matter how one-sided the conversation.


* Autistic spectrum disorder (ASD from now on) is a very wide diagnosis.  It’s usually seen as a male condition but affects both sexes.  In fact, researchers believe that “high functioning” girls escape detection/diagnosis through their ability to mimic their peers (and also, because of the perception that autism mainly affects boys and men).

I think calling it a “spectrum” is a bit of a misnomer.  When I think of a spectrum, I think of a line, a change in colour from blue to red.  It’s a two dimensional thing.  If you think of the line of ASD, does it go from few autistic traits to many? Or does it go from “high functioning” to “severely impaired”? I’ve always questioned the term “high functioning” since someone can be fine in one situation yet severely impaired in another. There’s a lot of interesting articles on autistic identity so I’m not going to delve into that here.

** The National Autistic Society released a video at the beginning of April 2017 to try and show what sensory overload looks and feels like (https://youtu.be/Lr4_dOorquQ).  They’ve missed out the sound of high heels, which is probably the worst sound in the world.