The Routine Eye Examination ('sight Test') - College Of Optometrists

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1. Home
2. Clinical guidance
3. Guidance for Professional Practice
4. Knowledge, skills and performance
5. The routine eye examination or sight test

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The routine eye examination or sight test

Key points

• You must carry out such examinations as appear to be necessary to detect signs of injury, disease or abnormality in the eye or elsewhere.
• In addition to the minimum legal requirements, you should use your professional judgement to decide the format and content of the eye examination.
• You should record all clinical findings.
• You should tell the patient your findings and recommendations.
• The frequency of eye examinations depends on the patient’s clinical needs but there are recommended minimum intervals.
• The sale and supply of spectacles must not be a condition for performing a sight test.

A43 This Guidance does not change what you must do under the law.

Principles of the eye examination or sight test

A44 When conducting a sight test, which is defined in law,19 you must perform an internal and external examination and carry out such additional examinations as appear to be necessary to detect signs of injury, disease or abnormality in the eye or elsewhere 20 21. A45 When conducting an eye examination or sight test, the same optometrist should remain in control and responsible for performing the refraction, ocular health assessment and subsequent issuing of a prescription. Where it is not possible or in the patient's best interests to complete the episode of care on the same day, a transfer of care to another optometrist should be made. A46 You remain responsible for the interpretation and assimilation of all clinical findings required to conclude the eye examination or sight test. This includes utilising automated instruments such as, visual fields analysers, subjective and objective auto-refractors, and imaging devices - unless you have made a transfer of care to another optometrist. A47 Sale and supply of spectacles or contact lenses must not be a condition for performing a sight test. A48 You should use your professional judgement and the minimum legal requirements to decide the format and content of the tests. A49 You should allow sufficient time to perform the examination. A50 There is a suggested equipment list at Annex 1. A51 You must record all clinical findings. You must do this legibly and at the time of the examination, or as soon as possible afterwards. If making retrospective additions, you must make it clear when (date and time) these were added, by whom and why. FOOTNOTE: An episode of care in the context of an eye examination or sight test is a patient's entire care journey from the initial pre-test or triage, the performing of all tests and investigations deemed appropriate until the final prescription is issued. The patient should know when the episode of care starts and finishes, and who the responsible clinician is throughout.

References

19 Opticians Act 1989 s36(2) [Accessed 1 Nov 2023] 20 Opticians Act 1989 s26(1)(a) [Accessed 1 Nov 2023] 21 Sight Testing (Examination and Prescription) (No 2) Regulations 1989 SI 1230 s3(1)(a). [Accessed 1 Nov 2023]

Conducting the eye examination or sight test

A52 When conducting an eye examination, you should:

1. make it clear to the patient whether you will carry out the examination under the NHS or privately
2. agree payment for any private services in advance
3. use your professional judgement to decide how to serve a patient who is unable or unwilling to pay a private fee and is not eligible for NHS services. The lowest level of service that is acceptable is to direct them to emergency medical care. Record your actions and reasons for them.

A53 You must not charge for any procedure you undertake as part of a General Ophthalmic Services (GOS) sight test in England, Northern Ireland, Scotland and Wales, if the sight test is funded by the NHS. A54 You must conduct an adequate assessment for the purposes of the optical consultation22. This should normally include:

1. asking for and accurately recording:
   • full name
   • address
   • other contact details
   • date of birth
   • reason for visit
   • history including description of onset, character and duration of signs and symptoms
   • if relevant, history of ocular and general health
   • current general health, including whether the patient smokes if relevant. The GOS in Scotland requires that a record be made of whether the patient smokes23
   • medication
   • family history of ocular and general health
   • visual needs in terms of occupation, recreation or general activities
   • whether the patient drives, with or without prescription
   • details of previous optical prescription and date of last eye examination. Ask for the patient’s best estimate if the date is unknown
2. determining and recording the aided vision of each eye with the patient’s existing correction, together with the specific prescription used. If this is not possible, or inappropriate, you should determine and record the patient’s unaided vision of each eye

3. assessing and recording habitual ocular muscle balance and the method used, at least cover test, for distance and near. This should be done with the habitual prescription and/or without the prescription, if appropriate

4. examining the eye internally and externally. As a minimum for internal examination, you should use direct ophthalmoscopy on the undilated eye, although alternative methods may be used. If you cannot obtain an adequate view of the fundus, you should dilate the patient’s pupils and/or use indirect methods of fundal examination. You should use slit-lamp biomicroscopy, particularly where a detailed view of the anterior eye and adnexa is required. You should record the method of assessment used
5. establishing the prescription required and the visual acuity of each eye individually.

A55 If you feel it is clinically appropriate or your contract requires it, you may:

1. measure convergence
2. assess ocular motility
3. assess pupil reflexes
4. determine objective refractive findings, using autorefractor and/or retinoscopy
5. use fundal or other imaging
6. measure intraocular pressure for patients at risk of glaucoma, see Examining patients at risk from glaucoma
7. assess visual fields, especially for those patients who are at risk of glaucoma. See section on Examining patients at risk from glaucoma
8. repeat certain tests to eliminate spurious results
9. perform binocular balancing and measure binocular visual acuity
10. assess fixation disparity, for example if the patient has symptoms or shows a deviation on cover test
11. assess accommodation, for example to determine any reading additions for intermediate and/or near tasks.

References

22 General Optical Council (2016) Standards of Practice for Optometrists and Dispensing Opticians para 7.1 [Accessed 1 Nov 2023] 23 National Health Service (General Ophthalmic Services) (Scotland) Regulations 2006. SSI 135 Regulation 2(1) Schedule 5 [Accessed 1 Nov 2023]

After completing the eye examination or sight test

A56 When you have completed the tests you should tell the patient what you have found and what you would recommend. You should also recommend when they should have their next eye examination. A57 You should provide patients with leaflets about the most common eye conditions, as appropriate.24 A58 You must only issue a prescription for the correction of visual defects when it is clinically justified and in the best interests of the patient.25 In all other cases, give the patient a written statement confirming a correction is not required or that there is no change in the current prescription. You should note on the prescription whether the patient is registered as sight impaired or severely sight impaired. This is because their spectacles can only be dispensed by, or under the supervision of, a registered optometrist, dispensing optician or doctor. A59 If you examine a patient who might have an eye condition or eye surgery that may change the prescription in the short- to medium-term, you should consider carefully whether it is in the patient’s best interests to have new spectacles. You should explain the benefits and disadvantages of prescribing spectacles that will be appropriate only for a short time. A60 If you are referring the patient, see section on Working with colleagues for further guidance. A61 You should record any information you have given to the patient. A62 You may need to justify your actions at a later date, so if you decide not to conduct tests that would normally be expected, you should record the reasons for not carrying out those tests. You should remember that when conducting a sight test, certain tests are required by law, see section on The routine eye examination or sight test.

References

24 The College of Optometrists, patient leaflets [Accessed 1 Nov 2023] 25 General Optical Council (2016) Standards of practice for optometrists and dispensing opticians para 7.6 [Accessed 1 Nov 2023]

Frequency of eye examinations or sight tests

A63 You should examine patients at the most appropriate intervals, depending on their clinical needs. This applies to both private and NHS patients. You should consider each patient holistically when determining their clinical need, this should include factors such as whether a person is affected by dementia26,27, cognitive impairment, whether they are at an increased risk of falls27 and their general health.28 A64 Contact lens patients may need more frequent appointments for aftercare but are not entitled to more frequent NHS sight tests simply because they wear contact lenses. A65 In the absence of clinical indications, you should not recall patients more frequently than the following intervals:

Patient age and/or condition	Recommended minimum re-examination interval
The intervals given below should not be taken as applying automatically to all patients in a category.
Up to 16 years old, no binocular vision anomaly or refractive error	One year
Under seven years old, with binocular vision anomaly or corrected refractive error	Six months
Seven-15 years old, with binocular vision anomaly or rapidly progressing myopia	Six months
16 years old and over	Two years
With diabetes who are part of diabetic retinopathy monitoring scheme	Two years
With diabetes who are not part of diabetic retinopathy monitoring scheme	One year

A66 To ensure refractive error is optimally corrected, it may be appropriate to examine children who are myopic, or at risk for myopia, annually until the age of 12-13 years, and every two years thereafter’.29 A67 In the absence of clinical indications, you should not examine patients who are being monitored by the hospital eye service more frequently than every two years.

References

26 Bowen M, Edgar DF, Hancock B, Haque S, Shah R, Buchanan S, et al. The Prevalence of Visual Impairment in People with Dementia (the PrOVIDe study): a cross-sectional study of people aged 60–89 years with dementia and qualitative exploration of individual, carer and professional perspectives. Health Serv Deliv Res 2016;4(21) [Accessed 1 Nov 2023] 27 The College of Optometrists (2020) Dementia and the eye examination supplementary guidance, and the importance of preventing falls [Accessed 1 Nov 2023] 28 General Optical Council (2016) Standards of Practice for Optometrists and Dispensing Opticians para 7.6 [Accessed 1 Nov 2023] 29 The College of Optometrists (2016) Member briefing on The Northern Ireland Childhood Errors of Refraction (NICER) study on myopia [Accessed 1 Nov 2023]

Clinical reasons for earlier recall

A68 Clinical circumstances may justify recalling a patient earlier than the intervals set out above, including patients:

1. of any age with refractive error that is changing rapidly, or who are at risk of such changes, for example patients:
   • newly diagnosed with diabetes whose condition you have decided to manage, rather than refer
   • with a suspect visual field on one visit that is not confirmed on repeat
   • with abnormal IOP with no other significant signs of glaucoma
2. who are identified in protocols as needing to be seen more frequently because of risk factors, for example risk of developing glaucoma, or people unable to report symptoms of visual loss. See section on Examining patients at risk from glaucoma
3. with pathology likely to worsen.

A69 You should record reasons for early recall of any patient.

Patients requesting re-examination

A70 You may have patients requesting early re-examination because they:

1. have been referred by a GP
2. present with symptoms or concerns that you can only resolve with an eye examination.

A71 You should note the reasons for early re-examination of any patient. A72 There will be cases when patients have symptoms, for example headaches, where no ocular cause can be found after examination. A73 You do not need to re-examine a patient who has broken their spectacles and has no clinical need for examination. Guidance Home