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Take a moment to consider why you may want an examination. Is it simply to upgrade your spectacles or contact lenses or is there a more specific visual disturbance or a medical/health problem you wish to have investigated?

There are many things which an Optometrist looks out for during an examination – not just your prescription requirements – and each examination is tailored to every patient. Reasons such as glaucoma, diabetes and headaches all require something different from the exam and may even need additional testing to the main exam.

Here we have a few reasons which may call for tailored examinations and what we include in the test.

Traditional Examination

Historically the purpose of a ‘Sight Test’ was simply to test sight and prescribe spectacle correction if necessary.

The routine involved in delivering an NHS or private ‘Sight Test’ reflects this very limited scope of practice and has remained fundamentally unchanged for decades.

If during a routine ‘Sight Test’ a problem is detected warranting more in depth investigation a ’Medical Upgrade’ may be recommended.

Medical Examination

Specific presenting problems require more tailored assessments, often requiring much more time, skill levels on the part of the clinician and specific tests targeting the presenting symptoms.

Follow the tabs to investigate the clinical recommendations of a range of medical, ocular and visual conditions.

Charges apply for some of these services as the NHS can only fund a rudimentary ‘sight test’. Even privately, across the board fees are inappropriate as the tailored needs for one patient are unlikely to be identical to others.

Emergency - Out of schedule

Aarons should be the first stop for all emergency eye infections and inflammations.

With three full time, long term, Medical Optometrists, Aarons is the only practice in Northumberland able to offer a continuous and immediate access to medical optometry care in the community. Unfortunately, Northumberland has not yet funded these services and charges apply.

We also have our own ‘in-practice’ dispensary allowing the practitioner to dispense the most appropriate medication immediately.

NOTE: Unscheduled contact lens complications are covered via our ‘Clarity’ professional service, while all types of unscheduled checks are covered on ‘Insight’

Cataracts

Prior to referral for cataract surgery, it is recommended a more thorough investigation of eye health, beyond an NHS ‘Sight Test’ be completed. ‘High Contrast’ (Black on White chart) vision, spectacles powers, and any significant change from precious prescriptions, and recording Intra-ocular pressure are the only essential tests expected to be conducted by the NHS. Find more information in our cataracts leaflet.

Other tests and medical grade assessments, not funded by the NHS, are highly recommended to identify coincidental ocular conditions, potentially complicating surgery or affecting visual outcomes.

Recommended:

  1. An in-depth medical level assessment of general health and medications (medical history questionnaire).
  2. Additional to ‘High Contrast’ vision are ‘Low Contrast’ measures. People with cataracts know how vision in low light conditions can be severely affected. Specialist charts assess this visual ability.
  3. Assessment of lid health. Lids can be a source of infection during surgery and managing the risk is important.
  4. As cataracts develop and swell, they can restrict outflow of intra-ocular fluid. Specialist scans of the drainage ‘angles’ can highlight potential problems which forewarn the surgical team and may speed up the referral process.
    1. OCT scan of anterior chamber
  5. Scans are also recommended to ensure the retina itself is healthy. Very subtle problems, not necessarily visible through the cataract, may not stop cataract extraction, but may change visual outcome expectations.
    1. OCT scan of retina with epi-retinal membrane perhaps
  6. ‘Quality of Life’ questionnaires are also helpful and we request you see our ‘Cataract’ Fact Sheet to fill in an example questionnaire before referral and take to your hospital assessment (NHS ‘Quality of Life’ questionnaire for cataracts).

We highly recommend a ‘Medical Upgrade’ to ensure we can send all information to aid the surgeon, and ensure you, the patient, have the best visual outcome.

Diabetic

A diabetic retinopathy retinal photography screening service is available for all patients with diabetes, usually conducted at a GP surgery of local hospital.

This is funded by the NHS and more advanced assessments are not usually required.

Occasionally, unusual findings during a routine eye exam may prompt the recommendation for a Medical Upgrade, especially if there has been an unforeseen delay in your screening schedule.

We would advise as appropriate. Even when carry out more specific clinical techniques we always stress everyone must not omit their scheduled checks with the Diabetic Retinopathy Screening Service.

Dry Eye/Blepharitis

‘Dry Eye’ is a very poor term to describe ocular discomfort. ‘Dry Eye’ is actually an outcome rather than a cause and the role of ‘Medical Optometrists’ is as much about identifying what is not dry eye and managing that. Simply declaring everything feeling irritable as ‘dry’ and simply treating the symptom is not acceptable.

Unsurprisingly then, it is a big subject, so we have prepared a presentation to hopefully give those interested a much better insight into how we investigate and manage this range of conditions.

Blepharitis is an infection/inflammation of the eye lids. Glands in the lids produce an oil, vital to ensure the tears do not evaporate too quickly. Blepharitis stops the glands expressing this vital oil and is the primary cause of evaporative ‘Dry Eye’. Our ‘Dry Eye’ and ‘Blepharitis’ fact sheets are available via these links.

Dyslexia

The signs and symptoms of Dyslexia, include eye rubbing, poor concentration, difficulty keeping place, movement of print, sore eyes, headaches reading (click link to go to Dyslexia leaflet). However identical signs and symptoms are associated with uncorrected vision, particularly long-sight, inefficient focussing at near and poor eye coordination. (click link to go to ‘Non-Specific Reading Difficulty’ fact sheet).

Therefore, before tints or coloured overlays are considered a thorough eye examination is essential to identify other potential cause of poor reading efficiency.

These investigative eye exams carry no additional charges.  If an optical problem, explaining the symptoms, is identified spectacles, funded by the NHS, can be prescribed.

If no ocular explanation is identified then it may be recommended to have a full dyslexia assessment. The cost of a Dyslexia specific assessment is £50 as this is not within the NHS remit.

Glaucoma

Glaucoma is a broad term describing a huge range of processes within the eye resulting in, potentially, irreversible damage to the Optic Nerve which takes the retinal, light sensitive, nerves to the brain. It is not just about pressure inside the eye!

The damage usually affects peripheral vision and can be undetected by the patient for a long time. It is therefore essential the examining clinician offer a wide range of tests and skills to thoroughly investigate this group of diseases.

The tabs divide the investigation into

  1. Those requiring regular community bases monitoring
    1. Those with a family history of glaucoma
    2. Those with Ocular Hypertension
    3. Those interpreted by the examining clinician to be at risk of developing glaucoma.
  2. Those with a definitive diagnosis of glaucoma and under the care of ophthalmology within secondary care.

Family History of Glaucoma  (FHG)

Ocular Hypertension (OHT)

People with higher than normal intraocular pressure but in the absence of glaucoma, and those with a close Family History of glaucoma, have a higher risk of developing glaucoma.

For OHT: Referring solely on pressure, results in huge false positive referrals– unnecessary waste of the patient’s time and cost to the NHS.

A family history of glaucoma also increases the risk of developing glaucoma (Sibling 4X risk, Parent 2X risk).

A Medical Upgrade, incorporating tests specific for these two groups, is highly recommended to ensure absolute confidence no suggestion of primary or secondary glaucoma exists.

Diagnosed Glaucoma and under Ophthalmology Care

If you are already under the care of ophthalmology for glaucoma it is usually unnecessary for Medical Upgrades in the community. Your management will be dictated by hospital results, which are funded by the hospital system.

However, an unexpected result during routine assessment or significant delays in hospital reviews may prompt us to recommend medical upgrades.

Significant NHS delays are a cause for concern for many patients. In this case many request a fuller community assessment to either, give reassurance on stability, or triage and report to the hospital abnormal findings.

Floaters & Flashers

Floaters are Flashes are usually annoying but of no clinical concern. However, rarely, especially is of very sudden onset and if a large number of floaters are present in one eye, they could reflect more significant problems such as retinal tears or retinal detachments.

All episodes of new or changed floaters/flashes need to be fully assessed with a dilated volk/slit lamp examination of the retina as well as retinal scans and wide field photography.

Click on the link to read our ‘Floaters’ fact sheet.

Headaches

Many people report headaches. Our medical optometrists can usually assess quite quicky during the initial case history whether the headaches require more advanced investigation.

Medical Optometrists have a significant role assessing ALL headaches, not simply optical headaches. Especially when ‘Headache’ is he primary reason to seek our advice.

Optical Headaches:

Identifying and alleviating optical headaches should be part of all optometrists’ skill base. As such these headaches do not require a medical upgrade. The initial case history should identify a headache pattern indicating a simple vision problem and corrected with some form of optical aid.

Medical Headaches:

Especially if these are the primary reason for requesting an examination, or if recommended by your GP, a fuller investigation by a ‘Medical Optometrist’ to help support GPs identifying the underlying issue is warranted.

Within the investigation process we need to differentiate between ‘Primary’ and ‘Secondary’ causes.

Primary Headaches:

Primary headaches are those where there are no underlying health concerns. Migraine is the classic example. The patient is a perfectly healthy individual but is unfortunate to suffer migraine.

Some secondary (general health) problems can mimic the symptoms of Primary headaches such as Migraine. Primary headaches, therefore need to be what is termed a ‘Diagnosis of Exclusion’. That is to say, a clinician will diagnose a migraine once other possibilities are eliminated.

For a brief review of some of the Primary Headaches possible click on our ‘Headache Fact Sheet’.

Secondary Headaches:

As the name implies these headaches are present because of an underlying health issue.

An in-depth, general health case history, with a thorough assessment of current and past medications, is an essential first step.

Because these have underlying health causes, the clinician looks for general clinical ‘Red Flags’, linking a general health symptom or sign to the headaches.

Click on the link to go to our ‘Headache Fact Sheet’ to consider ‘Red Flags’ and also our Medical Headache Diary’

Hydroxychloroquine Screening

If you have been prescribed hydroxychloroquine it requires no introduction.

Anyone expecting to be on therapy more than 5 years should receive a specific baseline examination within six months of commencing hydroxychloroquine.

All individuals who have taken hydroxychloroquine for greater than five years should receive annual screening for retinopathy.

The complete screening protocol can be viewed here.

Screening is funded when completed under the hospital system.

The full screening protocol is also available at Aarons but is not funded by the NHS. Many patients still prefer a community screen, especially if secondary screens are delayed.

Myopia Control

The examination for short sightedness progression is covered within a child’s NHS funded eye exam.

We now have a range of options to suit the lifestyle needs of the child.

There are 3 techniques available to slow or control progression. Orthokeratology – rigid contact lenses worn while sleeping (Aarons was a founding member of the British Orthokeratology Society in 1996), MiSight daily soft contact lenses (introduced in 2017) and MiYOSMART spectacle lenses (Aaron’s became accredited to prescribe immediately after they were introduced in February 2021).

While no additional charges are made for our clinical expertise, the cost of the products themselves, contact lenses and spectacles are not covered by the NHS.

 

For more information please click on the link to go to our Fact Sheet and presentation on myopia control.

Stroke

The visual pathway starts at the eye but passes all the way through the brain to the occipital lobe, at the very back of the head. This means a problem, such as a stroke, inside the brain can affect vision and mobility, while the eye itself is totally unaffected. Ability to read small print may remain very good but the patient may not see off to one side making mobility very difficult.

Depending on which part of the brain the stroke affects the patient may have no visual problems at all but could also lose half of their fields of vision, for instance the left half of the left eye and the left half of the right. Please click the link to view the ‘Stroke Mobility Loss’ fact sheet.

It is recommended anyone experiencing a recent stroke should have a full ocular examination with pupil dilation and very specific ‘fields of vision’ tests to ascertain if vision has been affected.

The Medical Upgrade is to cover the clinical investigation and specific field assessment but also time is required for counselling which is usually very helpful.

Transient Vision Loss

Transient vision loss may be in one or both eyes and last from seconds to hours.

Some causes of transient vision loss, emboli or thrombosis, can be a symptom of a serious health issue requiring urgent investigation and treatments.

Visual Distortion & Unexplained Reduction

Macula degeneration, and many other less publicised retinal problems, can cause distortion of vision and potentially severe loss of vision.

While many conditions, such as ‘Dry’ AMD and Epi-retinal membranes do not require treatment it is vital to thoroughly assess the retina to identify those problems requiring Fast Track referral to ophthalmology.

A Medical Upgrade is highly recommended, including dilated volk fundoscopy and Ocular Coherence Tomography scan.

 

As each patient is individual and has different needs, we have options for different types of examinations to best suit.

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