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Factsheet Eye Care Series

Glasses for adults with learning disabilities

Authors: Gill Levy, Maggie Woodhouse, with help from Laura Berryman, John Donnelly, Craig Colahan and Joy Myint

  Click here to download this factsheet as a PDF

 
June 2007

Listen to the Accessible Summary

Introduction

People who have worn glasses since childhood may regard their glasses almost as an integral part of their face - their image of themselves includes their glasses.  When they look in the mirror or see photographs of themselves they expect to see their glasses, framing their eyes and sitting so comfortably on their nose that they are barely aware of them.  Glasses also change the way people see the world; they make detail clearer, but also slightly change the size of everything see.  By wearing glasses over the years they have become familiar with seeing their world in a particular way.

It may not be the same for people whose first glasses are prescribed in adulthood.  They may initially regard glasses with hostility - after all, they have managed a long time without them.  They may question why they need glasses, taking time to adjust to these strange objects which transform their world into something different and unfamiliar.  Yet glasses have helped millions of people, most of whom have had few problems adapting to them.

When the wrong lenses have been prescribed, they can be changed without harming the person.  The same is not true for laser eye surgery, which cannot be reversed easily.  Laser surgery is not a solution for people who are reluctant to wear their glasses.

Adults with learning disabilities

People with learning disabilities are prone to eye problems but many do not have regular eye examinations.  They need to use their sight as much - if not more - than the “general population”, as they may spend much of their lives acquiring new skills.  The more people can see the easier it is for them to learn.

People with learning disabilities are more likely to need to wear glasses than the “general population”.  A study in Kent organised screening for 264 adults attending local day centres; of these, 148 people were prescribed glasses - with 50 per cent of them being recommended to wear their glasses all the time.     

We hope staff will find this factsheet useful, but we would stress that people are individuals and factsheets can only generalise.  We would therefore recommend that staff approach the optician/optometrist for a written statement about why glasses have been recommended, when they should be worn, and how they might help an individual. 

When planning an “adaptation programme” to help people become comfortable wearing glasses, it is important that staff and carers who know an individual really well are involved.  This is because they are most likely to know what will motivate that person to wear their glasses, and to look after and clean them regularly. 

We are very well aware that arranging eye examinations for people with learning disabilities may prove a challenge for staff in some parts of the country.  For this reason we published our factsheet, 'Eye tests for adults with learning disabilities'.

Understanding eye defects and why people need to wear glasses

Optometrists use specialised terms to describe the conditions helped by wearing glasses.  It is important for staff to understand why a particular person needs glasses and how glasses will help that individual.

Accommodation - is the ability of the eye to change focus to see near objects clearly.  Many people with learning disabilities (even very young people) are unable to accommodate properly and may need glasses to see intermediate tasks (40-60 cms from the eye) - such as using a computer, painting etc and near tasks (20-40cm) clearly.

Presbyopia - is a normal process of ageing that we all experience from age 40-45 onwards.  As we grow older most of us struggle to read at arm’s length.  This is when we start to wear reading glasses or bifocals.  People with learning disabilities also age and lose their natural focus when viewing near objects.

 

Reading glasses - glasses for “near” are often described as “reading glasses”.  Just because someone does not read it does not mean they do not need reading glasses.  Glasses for near tasks can help with writing, drawing, doing puzzles, crafts and even eating one’s food.  Spectacles for near use should therefore be considered for all people who are middle-aged or approaching middle age.

Emmetropia - is when glasses are not required to correct sight.  It does not automatically mean that sight is good, since any diseases of the eye or damage to the nerves will limit the chances of having good sight.  (In fact, true emmetropia is quite rare and the majority of young people who do not wear glasses are actually slightly longsighted).  

Short sight (myopia) - this condition, which affects up to 20 per cent of the “general population” in the UK, means that near objects are seen clearly without active accommodation, and distant objects are blurred.  The further away objects are, the more blurred they will be.  The close distance at which objects are clear will depend on the extent of short sight.

Amongst people with learning disabilities, myopia can be very severe so that, for some people, objects are clear only within five to ten centimetres of their face.  A person who is short sighted may need (or choose) to wear glasses just for distance use - such as television, cinema or going out.  Others, especially people with high myopia, may benefit from wearing their glasses for more general use, but may still wish to remove them for very close work.

Long sight (hypermetropia/hyperopia) - people with long sight find it harder to see near objects and are better at seeing objects far away - i.e. more than 6 metres, though the distance depends on the degree of hypermetropia and their age.  Whilst high amounts of long sight are more common amongst people with learning disabilities, poor accommodation is also more common, so that the defect is much more significant.

Some people with long sight will need (or choose) to wear glasses only for close work, others for constant use.

Astigmatism - causes distorted vision because the front surface (the cornea) of the eye is more curved in one direction (more like a rugby ball in shape than round like a football).  This condition can exist alone or, more commonly, in addition to short and long sight.  The eye is more powerful in one direction than the other, so that objects held in different positions are focused differently.  

It may be, for example, that someone with astigmatism looking at the letter H will see the verticals (the strokes of the letter which go up and down) clearly, while the horizontal stroke (which goes across) is blurred.  Another person may see the reverse, and yet another person may see the diagonal of the letter N clearly, while the verticals are blurred and so on.  

A person with a high amount of astigmatism will benefit from wearing glasses for all tasks.

However, glasses to correct high astigmatism introduce distortions and are, therefore, more difficult to get used to than glasses that correct short or long sight.

Fitting glasses

Glasses should always be fitted by an optometrist or dispensing optician.  They must fit snugly and comfortably, as this reduces the possibility of their being rejected.

Some frames can be adjusted to fit the person before the lenses are added and so can be posted to a person who cannot easily get to the practice.  Other frames become distorted when lenses are inserted so the glasses need to be fitted by an optometrist/optician.  The ideal is always for the person to collect their own glasses from the practice so that the fit can be finalised.  If distance is a real problem, then a local optometrists/optician will usually do an adjustment.

Adjustments over time and repairs

Glasses need to fit to improve vision.  Some people’s glasses require adjustment every few weeks, especially if they are not worn constantly.  Putting glasses on, taking them off and leaving them in odd places is harder on the frame than leaving them on the face.  Frames may distort over time, so glasses often need regular adjustment to ensure they still fit.  This is a service many local optometry practices provide free.

The ideal is to return to the optometrist who provided the frames, so that a rapport is maintained and replacement parts are easier to obtain.  However if distance is a problem it is worth staff and family carers developing a relationship with a local optometrist - even if this practice did not carry out the person’s eye test.

When glasses have been repaired it may be necessary for them to be fitted by the optometrist/optician.  It is important to discuss this with the practice.

Replacing nose-pads on glasses

Nose-pads should be replaced when dirty and discoloured.  Apart from this affecting people’s appearance, nose-pads can harbour dirt and grease.  Most optometrists/opticians are willing to replace nose-pads, and make a charge for this - in the region of £5 - £10.

Rejection of glasses

There are many reasons why people who have been prescribed glasses are reluctant to wear them.  While there may be “technical” problems that cause adults with severe learning disabilities to reject glasses, there also are some basic issues that staff may be able to resolve. 

• Glasses are uncomfortable or badly fitting

No-one is going to want to wear glasses that rub ears or nose, or that continually slip down.  Ensure that glasses are properly fitted by the optometrist/optician when they are collected, and adjusted regularly.  Pay particular attention to eye-lashes; if glasses sit so close to the eyes that the eyelashes rub against the lenses, the lenses get very messy, or worse, the person cannot open or close their eyes easily!  Check that glasses do not cause soreness - especially above, behind or near people’s ears.

• Staff give different messages about spectacle wear

Some staff may understand when the glasses are needed; others may not and encourage people to wear them at unsuitable times.  Some staff may not know that the client has glasses and they stay in the drawer.  Always ensure that everyone, at home and at college, day centres and so on, knows about the glasses and understands how they will help the person.

• The person does not like their appearance in glasses

People may be more willing to wear their glasses if they have chosen them, and if staff have made a point of showing individuals that other people, including family and friends, also wear glasses. 

• The person has involuntary movements and the glasses move out of place or fly off

Some people who use wheelchairs find that the headrests knock their glasses out of place.  Ensure when the glasses are chosen that the optometrist/optician knows about the involuntary movements, and if appropriate, sees the person in their wheelchair with the headrest.  Glasses that fit snugly against the side of the face may help, or sports bands to hold the glasses more firmly.  Some adaptations to the glasses are possible, such as loops at the ends of the “side arms”, which allow a ribbon to be threaded through to keep glasses in place. 

• The person has two pairs of glasses and never remembers which pair to wear for which activity

Glasses for close work may make distance vision blurred and moving around difficult.  Glasses for distance wear may make near tasks difficult or impossible.  Ensure that all supporters are aware of the purpose of the two pairs.  Ask the optometrist/optician to mark the sides of the frames, and provide distinctive labelled cases.  Discuss whether bifocals (which incorporate lenses for near and for distance) or varifocals (which incorporate near, middle and distance lenses) may be a more suitable solution to the problem. 

• The person is not motivated to wear their glasses 

Some people are in places where there is nothing interesting to look at, so they just don’t bother! 

Discuss the environment and how it can be improved.  There may need to be real rewards for seeing particularly if seeing - can be hard work.  One man found that he could differentiate between the various chocolate biscuits on a plate when wearing glasses - he now refuses to go anywhere without them. 

• The person cannot tolerate the feel of something touching their face or head

This is not uncommon amongst people with learning disabilities and people on the autistic spectrum.  Staff will know, because the same person will reject hats or scarves in cold weather.  This should not deter staff from trying glasses, because the person still deserves to have the best vision possible.  The person may need to become comfortable initially wearing a simple pair of frames without lenses.  If introduced sensitively and systematically, this can reduce the chances of the glasses being rejected later on when lenses are fitted. 

• The person cannot tolerate the way the world looks through the glasses

This is probably the most common reason for rejection of glasses, and is dealt with in the next section.  Use the adaptation programme outlined below.

Wearing glasses

In the general population people tend to begin wearing glasses when their eyesight is only slightly affected by long or shortsight.  If the defect gets worse, new glasses are regularly prescribed, so for each new pair, there is only a small change in the prescription.  Getting used to the glasses is fairly easy because it is done in small stages.  Many adults with learning disabilities, on the other hand, have substantial refractive errors (short sight, longsight or astigmatism) at their first eye test.  The glasses therefore represent a big change in the way people experience their world.

It is important for all of us to be aware that placing glasses on the face of someone with a refractive error does not give them a “normal visual world”.  There are several important issues to consider.

Living in a blurred world

However blurred the world is to someone with uncorrected long or shortsight, it is a familiar world, especially if we are dealing with an adult who has grown up seeing the world that way.  To provide someone suddenly with a clear image (which we assume must be “better”) gives people a totally different world.  They may not, at first, be able to interpret images in this new world, which they may find terrifying.  

Making the eyes work differently

Prescribing glasses to correct refractive errors places strange new demands on the parts of the eye which control focusing and positioning.  This means that the eye muscles of the person wearing glasses have to work differently to give clear vision or to scan the environment. 

Correcting short sight with glasses forces the eyes to make an effort to focus on near objects, when previously close objects were clear without effort.  This is why people who are short sighted may take off their distance glasses to read.

By contrast, correcting longsight with glasses means that the person now has to exert less effort focusing at all distances.  So the effort that the person makes feels very different.

Distortions and magnifications

Those of us who wear glasses know the rather “strange” sensations when we put on a new pair of glasses.  These are caused by the distortions inherent in all lenses that are slightly different from one pair of glasses to another.

If a large refractive error is suddenly corrected, the distortions can be terrifying.  The entire world changes shape, with floors sloping, doors and walls curving; furthermore, because of magnification (making things larger) or minification (making things smaller), distances become almost impossible to judge. 

To make matters worse, these distortions and magnifications vary across the lens, so any head or eye movement results in a world which swings about in an intolerable way, and the apparent distance of an object will change if viewed through a different part of the lens.  This means that a stationary object can appear to zoom towards or away from you if you move your head.  Even your own body image is dramatically altered, because looking downwards at your own body gives rise to huge distortions.

Some research carried out in the 1960s, looking at how people adapt to distortions, suggests that people can only adapt (or find life much easier) if they can make active, deliberate hand-eye co-ordination movements while wearing the glasses.  In the experiment, people who were not allowed to move their hands voluntarily, or who were pushed around in a wheelchair, never adapted to glasses.  These experiments were carried out using prisms, not high-powered spectacle lenses, but the principle is similar. 

People who have severe physical impairments may find it impossible to cope with the distortions caused by their glasses.

Solving the problems

If a person has a large refractive error, it may be best to start off with a “reduced” correction; that is, glasses that correct some of the error in order to improve sight, while minimising the unacceptable changes described above.  Once the person is used to the glasses the lens power can be increased in small steps, over many months or even years.  In this way, we try to “open up” the person’s visual world in small and tolerable stages, and always at their own pace.

An adaptation programme

This programme is designed to introduce the new spectacle wearer to the new sensations gradually and in a positive way.  Don’t start the programme until you are certain that the glasses fit well and are comfortable.

Choose an activity that the person enjoys, and one for which the glasses will help.  If they are shortsighted, glasses improve distance vision, so the activity may be watching TV.  If the person is long sighted, the greatest benefit will be for near tasks, so the activity may be drawing, looking at magazines, or eating.

The activity chosen should be safe and not involve any risk to the person who may have initial problems in judging depth or distance.  For this reason glasses should not be worn in the beginning for mobile activities such as walking.  Make this a supervised activity - this way the staff member can help the person to appreciate how much better or easier the activity is with the glasses.  Put the glasses on at the start of the activity and make the activity very short at first.  If they take the glasses off, simply stop the activity without comment if this is appropriate.  Alternatively, encourage them to put the glasses back on for a short time with lots of encouragement.

Persevere slowly, increasing the length of time, and/or introduce a second “spectacle-wearing” activity.  Don’t worry if it takes a long time (weeks or even months) to build up to an appreciable time.

Remember that the ultimate choice of whether to wear the glasses has to lie with the individual.  Although we believe that improved vision improves the quality of life, it is unlikely that an adult will do harm by rejecting glasses.  If you are concerned about long-term consequences discuss this with the optometrist.

Individual story - It’s more than meets the eye

Laura Berryman - who got her first correct glasses, aged 48

“When I started to hold my daily newspaper a good yard away from my face I realised that something was wrong.  The letter ‘a’ looked like an ‘o’ and I was beginning to misread the clues in my crossword.  It caused all kinds of havoc on the London underground for I had become a real menace to other passengers”.

A quick visit to a local optometrist put matters right.  All my life I had been one of those lucky people with twenty/twenty vision and now as middle age advanced, I had become longsighted.

A few months ago I decided to have another check, at a new optometrist.  After all, it had been three years since I first started to wear glasses for reading.  This time the test seemed more sophisticated.  “Focus on the red light” said the optometrist, “and say when it becomes clear”.  He held a vast collection of lenses for me to peer through and when it was all over he pronounced “You think you only have long sight, but I am telling you that you have a mild astigmatism and we need to adjust your glasses for long and short vision”.  Was this serious?  How long had I had the astigmatism?  I was anxious to know.

Apparently I was born with astigmatism, but it had never been discovered, as something like ten per cent of children who can read a card in an eye test slip through the net.  I was prescribed glasses that would accommodate my vision for long and short distance and correct the astigmatism.  I was to wear bifocals with a specially curved lens.  “It might take a few days getting used to them”, the optometrist warned me, “but I know that you will feel more comfortable”.

My world was the one I had seen through my eyes and it made sense to me.  But when I wore my new glasses I was instantly plunged into a world that was constantly sinking.  Tables sloped away from me, my plates assumed an oval shape, the steps in my house became a real hazard as I failed to judge their distance and I began to feel physically nauseous.  It was as if my house was the Titanic, battering against the waves and sinking into oblivion.

I had begun to rely on glasses for reading, but I could not adjust to the demarcation in my lenses in order to read with ease.  If I looked through them, nothing was clear on the page.  When I lifted my head, the floating sensation returned.  I gained some relief by fishing out my old glasses, which acted like large magnifying glasses.  But it was not satisfactory.  I returned to the optometrist, who told me I would adjust, and that what I was experiencing was not uncommon - maybe, but it felt alarming.

I persevered with the glasses and after about two weeks they began to work well for me and I developed my own modus operandi.  I wear them for reading, writing and looking at a computer screen.  The television too has a crisper image.  On all other occasions they remain in their case, or on a table, or near the bookcase... well I am not really sure.  They are my trusty companions and go where I go and get left where I’ve been.  The main trouble now is not failing sight, but failing memory for I am always saying, “What did I do with my glasses?”

Individual stories - sample programmes

The following sample programmes are from staff members in Bedford and Shires Health and Care NHS Trust - Clinical Services: Sensory Impairment Unit - one of the few services we found who have actually recorded this work. 

Some people may feel that these programmes seem rather “regimented” - but they have worked and helped people enormously.  However, they are offered as examples only.  Each person is unique, so each person may need a different approach if she is to become comfortable wearing her glasses and seeing the world in a new and different way.

Incidentally, the frequent calling of a person by name during a teaching programme may help retain their attention - particularly in noisy or distracting environments.

Guidelines for Mabel

Mabel is very myopic (short sighted) and would benefit from wearing her glasses constantly.  She needs encouragement to wear her glasses, as she will remove them.

She should be given her glasses to wear at meal times, when having a drink, and during sensory activities.

Approach Mabel from the front.  Tell her you want her to wear her glasses and show them to her.

Explain to Mabel you want her to keep her glasses on whilst she is eating, drinking, and so on.

Hold the glasses with both hands and place them on Mabel’s face.

Give Mabel lots of praise for wearing the glasses.

Involve her in the activity to divert her from removing her glasses.

If Mabel removes the glasses, replace them until she has finished her drink/meal etc.

Record if Mabel wore the glasses, and for how long.

Joan’s programme

Goal:                 

For Joan to wear and care for her glasses appropriately and independently.

Sub-goal:                    

For Joan to wear her glasses whilst participating in an activity in the day centre.

Method

1. Encourage Joan to participate in an activity with you.
2. Ask Joan to clean her glasses and put them on before starting the activity.
3. Tell Joan how nice she looks wearing her glasses.
4. Encourage her to wear them throughout the activity.
5. Ask her to remove them and put them away safely at the end of the activity.
6. Record the activity Joan participated in and the length of time she wore her glasses during this activity.

 To be carried out daily for one month, then review progress.

Warren’s glasses-cleaning programme

Goal:                  

For Warren to clean his glasses independently.

Sub Goal:          

For Warren to clean his glasses with physical prompting.

Method

1. Say "Warren, your glasses are dirty, shall we clean them?”
2. Prepare some warm water and cleaning cloths.  (Note:  do not use materials that will scratch the lens).
3. Ask Warren to put his glasses into the water.
4. Say “please clean your glasses, Warren”.
5. If necessary, physically prompt him by guiding his hands whilst carrying out the task.
6. When the glasses are clean, say “Well done, Warren, now dry them please”.
7. Prompt Warren physically to dry his glasses (if necessary) using the method as above.
8. When the task is completed, praise Warren and ask him to put the glasses back on.
9. Carry out the programme each time the glasses are dirty. 

Recording

Cleaned glasses independently, or

Needed physical prompt, or

Refused to co-operate.

Who is eligible for free NHS sight tests?

People in Scotland and Wales receive free eye tests.

In certain circumstances, it is possible to obtain free NHS sight tests and full or part help with the cost of glasses or contact lenses.

For people who do not automatically qualify, applications for a free NHS sight test should be made on form HC1, which is available from optometrists/opticians, chemists, dentists or the Department of Social Security.

People automatically qualify for a free NHS sight test if:

• they are over 60 years old
• they are under 16, or under 19 and still in full-time education.
• they are registered as blind or partially sighted; or
• they have been diagnosed as having diabetes or glaucoma; or
• they are considered at risk of glaucoma by an ophthalmologist; or
• they are aged over 40 and are the parent, brother, sister or child of someone who has been diagnosed as having glaucoma; or
• they need powerful or complex lenses - they will be told if this is the case; or
• they or their partner receive Income Support, income-based Job Seeker’s Allowance, Pension Credit guarantee credit or Tax credit (with Exemption certificate).

Details of eligibility for free eye tests can be found here:

http://www.rnib.org.uk/xpedio/groups/public/
documents/PublicWebsite/public_gettingeyetest.hcsp

 

Assistance with the cost of glasses

To help pay for the glasses, some people can receive a voucher, which has a monetary value.  The value of the voucher depends on the strength and type of glasses needed.  Remember that the voucher may not cover the full cost of the glasses, which depends on the style of frame and lenses that the person chooses.  Glasses do not have to be bought from the same optometrist who conducted the sight test.  If the optometrist/optician is unable to provide glasses within the value of the voucher, the person may wish to shop around and find an optometrist/optician who can.  If she cannot find a pair of glasses within the voucher value, the person will have to pay the difference herself.

If a person needs complex lenses, she automatically qualifies for a voucher towards the cost of the glasses, but this voucher is only worth a nominal amount.  In addition to this, she may qualify for another voucher under the ordinary rules if she meets any of the following circumstances.

A voucher will be awarded if the person:

• is under 16, or under 19 and still in full-time education; or
• receives Income Support, income-based Job Seeker’s Allowance, Pension Credit guarantee credit or Tax credit (with Exemption certificate); or
• needs powerful or complex lenses.  The optometrist/optician should explain this and mark the prescription accordingly; or
• qualifies for assistance via the low income scheme.  Applicants should use form HC1.

Inform the optometrist/optician if the person falls into any of the above categories before choosing the glasses and before payment is made.  Refunds are only possible in very limited circumstances (apply on form HC5). 

People under 16 or registered blind or partially sighted can take their voucher only to an optometrist or registered optician (not to an unregistered outlet).

People who are registered blind or partially sighted do not automatically receive assistance towards the cost of glasses. 

Help with the cost of repair or replacement of glasses

Children and young people under 16 can get a voucher for the repair or replacement of their glasses.  Adults will only receive help if they are entitled to a voucher and the loss or damage has occurred as a result of their disability, e.g. a visually impaired person may damage his/her glasses if he/she cannot see them; or a person with severe learning disabilities may be unable to take proper care of glasses. 

No help will be given if the full cost of replacement or repair is covered by an insurance scheme or warranty.

Spare pairs

There is no automatic entitlement to spare pairs of glasses, but Local Health Boards are often sympathetic in special cases in which the glasses are essential and the person cannot be expected to manage without them if lost or broken.  The optometrist can only issue a voucher for a spare pair with prior approval of the Board.

Help us to improve!

We would welcome your feedback and comments about this factsheet.  This will help us to improve the information that we provide.

Tell us what you think of our factsheets by sending us a feedback form or you can e-mail info@lookupinfo.org or phone us on 0800 121 8900.

 

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