Reflections on sight loss - RNIB

NB
The eye health and sight loss magazine for professionals
Pilot issue ● September 2009 ● £3.00 UK (£4.00 overseas)
<strong>Reflections</strong>
on sight loss
The challenge
for professionals
_______________
Cost oversight
Why sight loss could
cost billions
Food for thought
Eating for eye health
Glaucoma and
ethnicity
Increasing early
detection
Your health
Top tips for tackling
stress levels

New Beacon
NB
“What a long and lonely walk it is, down
the corridor and out into the real world.
As you leave the eye clinic, your mind is in
turmoil... All the words that you
understood a few moments ago are
forgotten, apart from the ones ‘I am sorry
but there’s nothing more I can do.’“
These are the words of Diane Roworth, chief
officer of York Blind and Partially Sighted
Society and one of three columnists from
different disciplines who have contributed to
our feature on the interface between
outpatient clinics and services for people with
low vision. How many people ‘fall through the
net’ and fail to make the connection with the
help that is available?
Among readers of this magazine are many of
the people whom the patient may encounter
on that journey from the moment of
diagnosis, including ophthalmic nurses, eye
clinic liaison officers, rehabilitation specialists
and other social care staff, workers and
volunteers from local societies – and other
people with sight loss.
The UK Vision Strategy is beginning to
demonstrate that all these groups – and
others – can come together to effect a major
transformation in the UK’s eye health, eye
care and sight loss services. NB magazine
supports this aim, and seeks to foster the
two-way flow of information and
communication that underpins it.
This pilot version of a newly focused magazine
is designed to facilitate that dialogue, as well
as giving practical support and encouragement
to people working in the front line. Whether
you are new to NB or a long-term reader,
please help us by giving us your feedback (via
the enclosed questionnaire) – and enable us
to provide an improved magazine that gives
you not only information but inspiration!
Ann Lee, Editor, NB
Pilot issue September 2009
NB is published by RNIB.
rnib.org.uk/nbmagazine
Reg charity no. 226227
ISSN 0028-4270
© RNIB September 2009
NB is available in print,
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and email.
The views expressed by
contributors may not be
those of RNIB
Editorial
Ann Lee, Editor NB, RNIB,
105 Judd Street, London
WC1H 9NE
Tel: 020 7391 2375
Fax: 020 7388 2034
nbmagazine@rnib.org.uk
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26
40
36
News
4 News
10 In the know
Talking point
12 Facing the emotional
challenge
Focus
16 Cost oversight
Why the UK is paying
billions for sight loss
Viewpoint
20 Working together
Janet Marsden,
Diane Roworth and
Simon Labbett discuss
the interface between
health and social care
Products
24 Product news from
RNIB
Career focus
26 Ophthalmic nursing: a
degree of change
29 New rehabilitation
worker degree puts
professionals on an
equal footing
32 What I do is... by Laura
Brady, learning disability
project assessment worker
What’s new
34 A new breed of CCTVs
A look at video magnifiers
In practice
36 Glaucoma and ethnicity
A new project aims to
increase early detection
Eye health
40 Food for thought – and
sight
Your health
44 Working with stress
Top tips for tackling those
tense moments
Experience
48 A patient’s eye view of
AMD treatments
Dates for
your diary
50 Upcoming courses and
events in your area of
work
Advertisements
54 Jobs for you
3

News
Health information is inaccessible, say patients
New research commissioned by RNIB has
found that patient safety, confidentiality
and choice are routinely compromised as
95 per cent of blind and partially sighted
people are never asked which reading
format they require by NHS staff providing
healthcare information. RNIB’s campaign to
change this situation, ‘Losing Patients’, was
launched in Sheffield in July with the
support of Sheffield Royal Society for the
Blind.
RNIB is working with local associations in
Sheffield and across the country to support
blind and partially sighted people to find
out about their legal rights in this area and
to feel empowered to ask for information in
a format they can read.
Links
➜ www.rnib.org.uk/losingpatients
Research also found that 72 per cent of
blind and partially sighted people reported
that they are unable to read information
from their GP, and 81 per cent are unable to
read medicine instructions and safety
notices. Details from appointment letters to
instructions for taking medication are
consistently provided in standard print.
Patients must then buy aids to read it or
lose their privacy and find someone else to
read it to them.
David Blunkett MP, Sheffield MP and Vice
President of RNIB, said: “I support RNIB’s
Losing Patients campaign because I believe
visual impairment isn’t the problem. The
problem is the culture of giving ordinary
print to people who cannot read it. No
patient should feel it’s too much trouble to
ask for accessible information or that a
special effort is needed to secure their right
to read.”
4

What would you lose?
Following certification at an eye clinic,
thousands of people with sight loss ‘fall
through the net’. Research points to
significant problems with the care and support
people receive when they first lose their sight.
A major new campaign by RNIB attempts to
address this situation by asking the public and
key decision-makers to consider what it means
to lose your sight. The campaign will also
highlight the fact that with the right support
in place, people can adjust to and accept a
diagnosis of sight loss.
The campaign is underpinned by a new report
from RNIB, ‘Lost and found’, which gives a
glimpse into the everyday lives of people who
have lost their sight.
The report has a
foreword by Sue
Townsend, author of
the ‘Adrian Mole’
books and herself
partially sighted,
who concludes:
“There is no magic
cure for blindness,
but there are things
that can be done to
make life easier for
blind and partially sighted people. RNIB aims
to do just that, and this is why I am fully
lending my support to this campaign.”
Links
➜ www.rnib.org.uk
Sue Townsend
Photo: Niall McDermid
New agreement between public and voluntary sectors
An agreement between the public and
voluntary sectors which outlines how they
should behave towards each other is being
overhauled to make it more concise and
reflect changes in policy and practice.
A draft version of the agreement, known as
the Compact, has been launched for
consultation following a debate which took
place last year. The draft is about a third of
the size of the original agreement and
replaces the original five codes of conduct (on
funding and procurement, volunteering,
consultation, community groups and minority
ethnic groups) with three sections on
involvement in policy development, allocating
resources, and commissioning and achieving
equality. The draft undertaking contains 96
undertakings for signatories, compared to
almost 500 in the existing Compact.
Andy Forster, head of policy at the
Commission for the Compact, said that the
Commission and Compact Voice, an
organisation representing the voluntary
sector, wanted the five codes to become
‘cross-cutting themes’ embedded in the new
agreement.
Consultation on the draft version closes on 12
October, and a final version will be published
in early November. Simon Blake, chair of
Compact Voice, said: “This is one of the best
opportunities we have to shape the ‘rules of
engagement’ between the Government and
the sector for the coming years.”
Links
➜ Commission for the Compact:
www.thecompact.org.uk
Compact Voice: www.compactvoice.org.uk
Office of the Third Sector:
www.cabinetoffice.gov.uk/third_sector
5

News
Scots celebrate free test
anniversary
Thousands of Scots may have had their
eyesight saved thanks to the free eye tests
first introduced in Scotland three years ago,
ahead of the rest of the UK. The latest figures
show that the numbers taking up the free
examinations have risen from 1.63 million
people in March 2008 to 1.73 million by
March 2009.
The new statistics also show increased
referrals to follow-on care by a GP or hospital
following the free eye test, from 3.5 to 4.2 per
cent of those tested. This means that 72,660
people in Scotland are now being referred for
potentially sight-saving treatment.
John Legg, Director of RNIB Scotland, said:
“We are delighted to see the increased uptake
of eye tests continue year on year. This makes
a crucial difference to the early diagnosis of
sight-threatening conditions – giving a much
increased chance of saving someone’s sight
through early intervention.
“Policies such as the free eye test contribute
to making Scotland one of the world’s leaders
in eye health.”
Big Care Debate
The Health Secretary, Andy Burnham, has
launched a ‘Big Care Debate’ following the
publication of the Green Paper ‘Shaping the
future of care together’, which presents the
Government’s vision for a National Care
Service. The Green Paper sets out radical
alternative proposals for funding the service,
including partnership and insurance models
and a comprehensive state insurance scheme.
The debate will run until mid-November, with
a variety of ways of contributing including a
series of public consultations.
Links
➜ www.careandsupport.direct.gov.uk
Alström Syndrome
Alström Syndrome (first described by CH
Alström in Sweden in 1959) is a rare and often
mis-diagnosed order, of which eye conditions
are an early feature. Alström Syndrome UK
(ASUK) has gained National Commissioning
Group funding for special multi-disciplinary
clinics to provide specialised help and support,
and has also produced a booklet to help raise
awareness of the condition, available from
www.alstrom.org.uk, email
info@alstrom.org.uk, telephone 01803 524238
6

New treatment tackles
river blindness
A clinical trial currently under way in three
African countries could help eliminate river
blindness (onchocerciasis), one of the leading
infectious causes of blindness in Africa. The
treatment, moxidectin, is being investigated
for its potential to kill or sterilise the adult
worms of onchocerca volvulus, which carry
the disease.
“This is a devastating illness that has plagued
30 African countries for centuries, in
particular the populations in the most remote
areas ‘beyond the end of the road’,” says
Dr Uche Amazigo, Director of the African
Programme for Onchocerciasis Control
(APOC). “Over 100 million people are at risk
of infection in Africa and a few small areas in
the Americas and Yemen.”
The trial will take place over the next two
and a half years. Currently, the disease is
controlled by ivermectin, which has been
Service for eye patients
launched in Wales
The first Eye Clinic Liaison Officer (ECLO)
service in Wales (funded by an NHS trust) was
launched at St Asaph Hospital, Clwyd, in July
by RNIB Cymru.
The hospital is the main treatment centre for
Lucentis (a new treatment for age related
macular degeneration) in North Wales. The
ECLO will initially be based in the Lucentis
donated for more than 20 years by the
pharmaceutical company Merck & Co, and
has led to significant progress in halting its
spread. However, ivermectin does not kill the
adult worms, so annual treatments for an
extended period of time are required.
Moxidectin has the potential to interrupt the
disease transmission cycle within around six
annual rounds of treatment.
The development of moxidectin for
onchocerciasis is being conducted through a
collaboration of the Special Programme for
Research and Training in Tropical Diseases,
executed by the World Health Organisation
(WHO/TDR) and Wyeth Pharmaceuticals,
working with African investigators and
institutions. Fifteen hundred people at four
sites in Ghana, Liberia and the Democratic
Republic of Congo will be enrolled in the
study.
Links
➜ www.who.int/tdr
www.who.int/apoc
clinic, which treats around 60 patients per
week. Patients will be able to access emotional
support and will benefit from timely referrals
to local services such as the local voluntary
organisation, Vision Support, and social
services.
By March 2010 RNIB Cymru aims to set up
services in Ysbyty Gwynedd (Bangor),
Singleton Hospital (Swansea), and Royal
Glamorgan Hospital (Rhondda Cynon Taff).
By 2013 there will be an ECLO service in every
main eye clinic in Wales.
7

News
Spanish team shows
potential of echolocation
A team of researchers from the University of
Alcalá de Henares (UAH) in Madrid has shown
that human beings can develop echolocation.
The team has been researching the use of
tongue clicks to help people identify objects
around them without needing to see them –
the system used by American mobility expert
Daniel Kish (see NB, May 2009).
The team, led by Juan Antonio Martínez of the
Superior Polytechnic School of the UAH, has
begun a series of tests, starting with the
physical properties of various sounds. “The
almost ideal sound is the ‘palate click’, made
by placing the tip of the tongue on the palate,
just behind the teeth, and moving it quickly
backwards”, Martínez explains. “These clicks
are very similar to the sounds made by
dolphins, although on a different scale, as
these animals have specially adapted organs
and can produce 200 clicks per second, while
we can only produce
three or four.” Using
echolocation it is
possible to measure
the distance of an
object based on the
time taken to hear
the echo.
The scientists are working on a method to
teach people how to emit, receive and interpret
sounds. They say that no special physical skills
are required. “Two hours per day for a couple
of weeks are enough to distinguish whether
you have an object in front of you, and within
another two weeks you can tell the difference
between trees and a pavement”, says Martínez.
References
Martínez Rojas, Juan Antonio; Alpuente
Hermosilla, Jesús; López Espí, Pablo Luis;
Sánchez Montero; Rocío (2009): Physical
analysis of several organic signals for human
echolocation: Oral vacuum pulses. Acta
Acustica united with Acustica, 95 (2): 325-330.
New guidelines on eye care for deaf children
Eye care professionals are being urged to
ensure that deaf children’s needs are not
overlooked. Forty per cent of children who
are born deaf also have eye problems. A new
set of guidelines has been produced to help
professionals who work in vision and hearing
ensure that deaf children receive good vision
care. ‘Quality standards in vision care for
deaf children and young people: Guidelines
for professionals’ has been produced by
Sense, the national charity for deafblind
people, with the National Deaf Children’s
Society (NDCS).
Good vision is especially important to deaf
children, so it is important that problems are
identified early. The guidelines aim to
promote good practice in eye care for deaf
children and contain recommendations on
identifying vision difficulties, assessing a
deaf child’s vision, providing support and
involving the child and the family.
Links
➜ www.sense.org.uk/publicationslibrary/
allpubs/professionals/deafblindness/
vision_care_deaf_children.htm
www.sensehub.org.uk
8

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9

In the know
Improving eye
health services
A new eye care guide, ‘Improving eye
health services’, has been launched for
senior managers responsible for
commissioning eye health services. The
guide, which will be part of the World
Class Commissioning (WCC) framework,
provides practical advice about how
primary care trusts (PCTs) can commission
services that meet the needs of their local
communities.
The world class commissioning programme
sets out a framework to support PCTs in
developing the competencies needed to
commission high-quality services that
improve health outcomes and reduce
health inequalities. As part of the WCC
programme, every PCT is developing a
five-year strategic plan, which sets out its
vision, its priorities and how these will be
delivered.
The new eye care guide is supported by
the Department of Health and UK Vision
Strategy. A guide offering practical advice
and tools on how PCTs can improve
primary care for excluded groups, is also
planned.
New guidance on
deafblindness
Guidance issued by the Department of Health
gives new rights to deafblind people and
places new duties on local authorities. It
applies to both children and adults, and
widens the definition of deafblindness to
include anyone whose combined sight and
hearing impairments cause difficulties with
communication, access to information and
mobility.
The guidance is relevant to all local social
services staff and requires specific actions to
be taken, such as identifying and keeping
records on deafblind people and providing
specialist assessments by people who
understand the efffects of dual impairment,
as well as trained one-to-one support. They
should ensure that services are appropriate
and that information is provided in ways that
are accessible to deafblind people.
The circular LAC(DH)(2009)6, issued in June
2009, replaces previous guidance on social
care for deafblind children and adults and is
available through the Department of Health
publications website at www.dh.gov.uk/en/
Publicationsandstatistics/Publications
Links
➜ http://snipurl.com/nv5ts
10

Health watchdog issues glaucoma guidance
The National Institute for Health and Clinical
Excellence (NICE) and the National Clinical
Guideline Centre have issued guidelines to
improve the diagnosis and management of
chronic open angle glaucoma (COAG) and
ocular hypertension (OHT).
Affecting an estimated 480,000 people in
England, COAG is a common condition that
can lead to blindness if is not diagnosed early
and treated promptly. Around 10 per cent of
UK blindness registrations are due to
In the know
glaucoma. There are usually no symptoms
until the later stages, though OHT (raised
pressure in the eye) is a major risk factor for
developing COAG. NICE recommendations
include a suite of tests for people suspected
of having COAG or who have OHT,
monitoring of people who are most at risk,
and treatment regimes to reduce high eye
pressure.
Links
➜ www.nice.org.uk/guidance/CG85
Advice for optometrists about
people with learning disabilities
There are well over a million people with
some level of learning disability in the UK.
People with learning disabilities are more
likely to have eye problems, yet
traditionally have problems accessing eye
care. A new Continuing Education pack
produced by Healthcall Optical Services in
collaboration with SeeAbility and Replay
Learning is aiming to make it easier for
optometrists to offer the eye care that this
group needs.
The charity SeeAbility is working to
transform eye care and vision for people
with learning disabilities through its eye 2
eye Campaign, which provides information
and advice. It also supports Look Up
(www.lookupinfo.org), an education
resource on eye care and vision for people
with learning disabilities.
The Continuing Education pack was sent
to every registered optometrist in the UK
during Learning Disability Week in June.
For further information visit
www.seeability.org.uk
AMD annual evidence update
The annual evidence update on age-related
macular degeneration (AMD), published in
June, presents a collection of evidence that
has emerged in the past 12 months.
The update covers both wet and dry forms of
AMD. Topics include epidemiology, genetics,
living with AMD, low vision aids, retinal
imaging for diagnosis, surgical and therapeutic
interventions, charitable organisations and
patient support groups.
Links
➜ www.library.nhs.uk/Eyes (follow the links
under ‘Annual evidence updates’).
Creutzfeld-Jacob Disease
The Health Protection Agency has issued
advice that patients about to undergo surgery
on the retina, choroid, posterior hyaloid or
optic nerve should be asked a number of
questions to ascertain whether they are at
increased risk of Creutzfeld-Jacob Disease
(CJD) or variant CJD (vCJD), in order to
minimise the risk of surgical transmission.
The advice can be found at www.dh.gov.uk/
ab/ACDP/TSEguidance/index.htm then follow
the link to Annex J (Assessment to be carried
out before surgery or endoscopy).
11

Talking point
Facing the emotional challenge
A diagnosis of sight loss can take a big toll on the emotions, quite apart from
the practical problems people face. Sarah Underwood asks who can provide
support, and what is the best way to deliver it.
Anger, grief, anxiety, isolation and a profound
sense of lost identity and independence are
some of the feelings that can overwhelm
people following a diagnosis of sight loss. In
some areas of the UK, emotional support is
available to help those who are losing their
sight, but elsewhere support is patchy – a
situation that several organisations are
resolved to put right.
“No one who is diagnosed should make the
sight loss journey alone”, says Carol Borowski,
chair of RNIB’s Early Reach Board, which has a
five-year strategy to improve access to
support. “It is very tough, and people need
both emotional and practical support. There is
a tendency for people to liken sight loss to
bereavement. It is a loss, but it is a loss of self
rather than of another person. This loss of
identity is not well understood.”
Borowski, like many of her peers, believes
both practical and emotional help should be
offered immediately after diagnosis of sight
loss, and also involve families and friends.
“We have notions of ourselves built around
what we have grown to be over time. Sudden
loss of sight can have traumatic
consequences, while those who see less and
less over time have to adapt again and again.
12
They need to constantly reinvent themselves,
and that takes a big toll on emotions”.
What support is needed?
While it is accepted that everyone deals with
sight loss in their own way and that there is
no single solution, there is a growing body of
opinion that more support needs to be
provided and that it should, ultimately, be
funded by the Government. There is also a
general feeling among blind and partially
sighted people that those providing support
services should be specially trained and have a
real understanding of their specific needs.
Mary Norowzian, who was until recently senior
manager of RNIB emotional support services,
says: “There are some pockets of good
practice, but if we don’t address the wider
need for emotional support we will leave
thousands of people unable to move forward
in their lives.”
Norowzian describes the need for a spectrum
of support that will cover the varying needs of
individuals. At the point of diagnosis, eye
clinic liaison officers (ECLOs), who are based
in some hospital eye clinics offer initial
support and signposting to services that can
help. Back in the community, support, if any is

Talking point
available, ranges from peer-to-peer
communication, such as RNIB’s Talk and
Support telephone-based befriending service,
to counselling services and one-to-one
psychotherapeutic interventions, although
these are rare.
Services that are proving successful include a
pilot project at Cam Sight, the local society
working with blind and partially sighted
people in Cambridgeshire, where informal oneto-one
emotional support is offered by
someone who has completed basic training in
counselling skills. More formally, RNIB has
counsellors working with clients at low vision
centres in London and in Gateshead.
“We are evaluating the benefits of counselling
alongside rehabilitation and low sight services
at these two sites”, explains Norowzian,
adding: “These are specialist services in the
sight loss sector. Clients report that they are
more meaningful than services from
counsellors who do not have experience of
sight loss.”
Presenting the evidence
Gathering evidence to support a bid for
specialist provision within the National Health
Service is no small task, requiring commitment
from a number of organisations, including the
Vision Impairment Network for Counselling
and Emotional Support (VINCE) and RNIB.
One counselling service that suggests a body
of positive evidence can be gathered is an
RNIB service in Bristol that offers counselling
as an outreach service to blind and partially
sighted people, both in their homes and at a
centre in the city. Sue Dale, head of the
service from 2005 to 2008, explains: “We had
a very enthusiastic response to the service.
Diagnosis and registration as blind or partially
sighted is a traumatic moment that triggers
the need to talk to people outside the family
and friends group. We provided a space in
which we could just listen or offer more active
counselling.”
Dale is herself partially sighted and worked
with another sight impaired counsellor and
two sighted counsellors. She says clients often
found her visual impairment helpful as they
shared a similar world and wanted to talk to a
counsellor who understood sight loss. In
surveys of her work, some 96 per cent of
clients achieved significant beneficial change,
while feedback from individuals in a
qualitative study stated that the service was
“invaluable”, and “a lifesaver”.
Structuring support – a new model
The Guide Dogs for the Blind Association is
also working to build the evidence. Its Middle
Step project is designed to offer help and
information as soon as possible after a
diagnosis. Initially, 10 pilot sites were set up
to discover whether a relatively structured
package of emotional support and trained
personnel could help people. These sites,
which essentially offered group peer-to-peer
work and introductions to useful services, ➜
13

Talking point
➜
were set against a quasi control group that
received only basic rehabilitation services and
had no focus on wellbeing.
“We are not yet ready to publish the results of
the project, but I am confident that the
outcome was better for people with the
emotional support component than for those
with rehabilitation services only”, says Carl
Freeman, health and social care policy
manager at Guide Dogs.
One suggestion emanating from Middle Step
that the Government would do well to note is
that people with little confidence and low
levels of emotional wellbeing do not perform
as well as others in rehabilitation. Many will
suffer clinical depression, and failure to treat
that will waste money that could be better
invested.
The success of Middle Step has led Guide
Dogs to make plans for more robust pilots,
aimed at building an evidence base that will
push emotional support up the agenda.
Freeman points out that while the National
Institute for Health and Clinical Excellence
(NICE) has guidelines for medical
organisations on how to deal with depression,
it fails to acknowledge the significance of
depression among those losing their sight.
“We need a system that provides the best
intervention for each person”, he says.
On the map
Dennis Lewis is also on the campaign trail.
Manager of the Macular Disease Society,
which has 17,000 members, he is also
chairman of The Vision Impairment Network
for Counselling and Emotional Support
(VINCE), set up in 2007 to foster joint
working between counsellors and emotional
support service providers. “At VINCE, our
emphasis is on facilitating emotional support
across the UK. That is a very wide brief and
14
could be a local volunteer popping in to see
someone, a professional counsellor offering
formal sessions and everything in between.
We also support the push to have an ECLO in
every eye clinic, although we are far from
there yet”, explains Lewis, who recently
worked with RNIB to make a ground-breaking
presentation on the need for emotional
support to the All Party Parliamentary Group
on eye health.
He concludes: “Getting to the next level will
be difficult, but I would like the Government
to improve services through mechanisms such
as primary care trusts and GP surgeries, as
many counsellors work through them and they
could be trained in the issues of sight loss.
“We have emotional support on the map,
which is wonderful, and now we need to
move on.”
Over to you
‘Talking point’ is a series featuring
discussion of key issues in eye care and
sight loss. A vital part of this debate is the
contribution of NB readers. Please send
your views (up to 250 words) to
nbmagazine@rnib.org.uk, or write to
NB Magazine, RNIB, 105 Judd Street,
London WC1H 9NE, marking your letter
‘Talking Point’.
The views expressed in this column do not
necessarily represent those of the publisher,
RNIB.
Links
➜ Macular Disease Society:
www.maculardisease.org
RNIB Talk and Support:
www.rnib.org.uk/talkandsupport
VINCE: www.vision2020uk.org.uk

Where’s the small print?
Where’s the small print?
The simple answer is there isn’t any. NB may
look a bit different to other magazines and
journals that you read because we have used a
clear print design throughout to make it easier
to read.
All of the print materials produced by RNIB
(publisher of NB magazine) are designed
according to clear print standards called “See
it right” as then we can be sure that more
people can read what we write. There are two
million people living in the UK with a sight
problem and just making simple design
changes means that more partially sighted
people can read the information.
What are the See it right guidelines?
See it right is a set of simple design standards
developed by RNIB. It’s an inclusive approach
to design which is both practical and
achievable. Accessibility does not just affect
people with disabilities, it has enormous
benefits and rewards for everyone.
Top 10 See it right tips
1. Use a minimum type size of
12 point
2. Ensure good contrast between
the text and background
3. Use non-glossy paper
4. Use a clear typeface
5. Avoid italics
6. Avoid large block of capital
letters
7. Left align text
8. Separate text from images
9. Keep text horizontal
10. Use a consistent layout
Why follow these guidelines?
● it’s fair – people with sight problems
should receive information that is accessible
to them. Access to information enables all
of us to make decisions and lead
independent lives.
●
●
it’s the law – the Disability Discrimination
means there is now a legal duty to meet the
information needs of your blind and
partially sighted customers.
it makes sense – meeting the needs of all
your patients and clients makes good
business sense.
More information is available at
rnib.org.uk/seeitright
15

Focus
Cost oversight
How many people in the UK are living with sight loss, and how will this figure
change in the next decade? What are the costs of sight loss both to society
and the individual? A new report from RNIB provides answers to these
important questions and looks at the implications for health and social care
professionals.
A few figures
‘Cost oversight’ is based on two research
studies which provide detailed estimates of
the number of people with sight loss and a
breakdown by age, gender, and ethnicity
(Access Economics, 2009 and EpiVision,
2009).
The ‘big picture’ figure is that in 2008 there
were 1.8 million people in the UK living with
sight loss: 1.6 million who were partially
sighted (visual acuity

Cost oversight
There are, in addition, very significant indirect
costs associated with sight loss, chief among
them being the costs associated with informal
care. In the absence of adequate statutory
care it is left to family and friends to provide
the support necessary for independent living.
This informal support costs in the region of
£2 billion a year, which includes such things as
help in the home, reading mail, shopping,
gardening and the provision of door-to-door
transport. The other major indirect cost is that
associated with loss of productivity, with the
significantly lower employment rate adding
£1.6 billion a year to the overall costs of
blindness.
“In the absence of adequate
statutory care it is left to
family and friends to provide
the support necessary for
independent living”
In addition, sight loss has a major impact on
quality of life, and this is measured for the
first time by the Access Economics research.
£15.5 billion is the monetary value put on the
quality of life lost due to sight loss, with
refractive error accounting for 29 per cent (or
£4.5 billion) and 31 per cent (or £4.8 billion)
due to age-related macular degeneration.
The EpiVision study looks at the cost of the
four main causes of serious sight loss in 2010
and the cumulative cost through to 2020. It
includes the cost of detection, treatment,
state and informal care but excludes costs
associated with lost productivity and reduced
quality of life. The baseline cost in 2010 of
AMD is estimated to be £1.60 billion, with
£0.99 billion for cataract, £0.68 billion for
diabetic retinopathy and £0.54 billion for
glaucoma. The cumulative total cost in the
period 2010 to 2020 for the four diseases
comes out at over £37 billion.
The EpiVision study focuses on the four
main eye diseases and the period 2010
to 2020. It also projects a sharp increase
in sight loss, with AMD the leading
cause.
The estimates for the four conditions are as
follows:
Age related macular degeneration: In
2010 some 223,000 people will be either
blind or partially sighted because of AMD
and this will rise by 31 per cent by 2020
(assuming that 75 per cent of those with
wet AMD are treated).
Glaucoma: A 25 per cent rise in the
numbers experiencing sight loss is
estimated over the decade, rising from
75,000 to 94,000.
Cataract: A 20 per cent rise is forecast,
from 234,000 to 281,000.
Diabetic retinopathy: Although a large
and growing number of people will have the
disease (over 1.04 million by 2020), a
relatively small number will be experiencing
sight loss as a result. In 2010 it is estimated
that some 66,000 people will be either
partially sighted or blind because of
diabetic retinopathy, rising to 76,000 by
2020 – a 15 per cent increase.
Spend to save sight and money
The overall message is clear. If society does not
improve early detection and treatment of eye
disease, the downstream support costs will
soar. Put another way, if we get early detection
and access to treatment right, then the burden
of sight loss, both to the individual and to
society, will be contained and possibly fall.
This is explored in some detail in both studies.
The EpiVision team looked at AMD over the
period 2010 to 2020 and found that by ➜
17

Cost oversight
➜
increasing the proportion of people having
treatment with Lucentis (the drug approved
by the National Institute for Health and
Clinical Excellence) from 50 to 90 per cent
there would be a big increase in the number
of people who regain some sight (from 73,000
to 121,000). Similarly, with glaucoma they
found significant savings from increased
detection and early treatment.
Rather than looking at the cost-effectiveness
of treatments for specific eye diseases, Access
Economics focused on four hypothetical eye
care interventions:
●
●
●
promoting the prevention of eye injuries
improving access to integrated low vision
and rehabilitation services
increasing regular eye tests for the older
population, over 60 years of age
Next steps
‘Cost oversight’ contains a powerful message
and a warning. Although sight is the sense we
most fear losing, as a society we spend
relatively little to prevent, detect and treat eye
disease – in total around £1.7 billion a year.
This is a modest fraction of total NHS
expenditure (1.9 per cent of the £89 billion
net NHS expenditure in 2007/8). It contrasts
strongly with the total cost of sight loss
(including reduced quality of life) that in 2008
was running at over £20 billion.
“There is not only a strong
moral case for investing in the
prevention and treatment of
eye disease but also a powerful
economic one”
●
improving access to eye care services for
minority ethnic groups
All four interventions consisted of an
education programme to increase knowledge
of the relevant eye health issues, although
each campaign targeted different at risk
groups.
The results indicate that the most
cost-effective campaign is likely to be one that
targets minority ethnic groups. This is because
their access to eye care services is lower than
that of the general population and undetected
eye disease is therefore likely to be more
severe. An educational campaign using a
variety of media and a roadshow taken to 10
locations heavily populated with minority
ethnic groups could result in a highly positive
cost-effectiveness ratio (£1,230 per disability
adjusted life year avoided).
18

Cost oversight
Given the massive cost to individuals and
society of sight loss, we should be spending
much more. It is also clear that the numbers at
risk of eye disease will rise sharply over the
next decade. To ensure that the burden of
sight loss, both to the individual and to
society, is contained, and has a possibility of
falling, we have to invest more in early
detection and access to treatment.
This is the message that RNIB will be taking
to both health service commissioners and
politicians over the coming months. There is
not only a strong moral case for investing in
the prevention and treatment of eye disease
but also a powerful economic one. In the past
we have had to rely mainly on the moral
argument. The new evidence that we have
from Access Economics and EpiVision provides
clear support for a ‘spend to save’ approach in
this area.
Key areas of concern are:
● While waiting times for first appointments
have eased due to the 18-week rule,
cancellation and delays of follow-up
appointments represent a major problem,
particularly in glaucoma. Take-up of
diabetic retinopathy screening in some
areas is poor, and the introduction of new
treatments for wet age-related macular
degeneration has created significant
capacity problems in some areas of the
country.
●
Low vision and rehabilitation services
remain of variable quality across the UK –
good in some areas and virtually
non-existent in others. There is concern
that the introduction of new resource
allocation systems associated with the
Government’s current proposals on the
future of social care may result in further
exclusion of blind and partially sighted
people from state-funded care.
●
Government continues to spend next to
nothing on ensuring that key eye health
messages are conveyed to the public. Most
people who do not have regular eye tests
are unaware that an eye test is a vital eye
health check that can identify disease well
before a person’s sight is affected. Few
people are aware of the proven link
between smoking and sight loss. And,
shockingly, almost one million people in the
UK live with varying degrees of sight loss
due to refractive error, when all they need is
an eye test to ensure they wear the right
prescription glasses or lenses.
We need greater investment in all of these
areas. No longer can we overlook the costs of
sight loss. The moral and economic case is just
too strong.
“The results indicate that the
most cost-effective campaign is
likely to be one that targets
minority ethnic groups”
References
Winyard, S. & McLaughlan, B, 2009: Cost
oversight? The costs of eye disease and
sight loss in the UK today and in the future.
RNIB.
Access Economics, 2009: Future sight loss
in the UK – The economic impact of partial
sight and blindness in the UK adult
population. RNIB.
EpiVision, 2009: Future sight loss in the UK
– An epidemiological and economic model
for sight loss in the decade 2010-2020
(2009). RNIB.
19

Viewpoint
Viewpoint:
working together
How can the interface between eye clinics and secondary care be improved?
Three professionals from different disciplines in the health and social care
sectors share their views
Janet Marsden:
“Timely support is essential”
How should the interface work for people who
are attending outpatient clinics with low
vision? My ‘model of care’ comes from the
Low Vision Pathway (DH2004) and starts at
the very beginning of the low vision journey
where a patient is referred to a low vision
service. The pathway says that the referral can
be from anyone, including the patient. The
‘new’ process for notification was introduced
in 2003 and includes a low vision leaflet (LVL)
for self referral, a Referral of Vision Impaired
Patient (RVI) for hospital eye clinics to use
before a Certificate of Visual Impairment (CVI)
is required and the CVI itself.
The Royal College of Ophthalmologists
published a statement in 2007 highlighting a
significant fall in the number of patients
referred using the CVI form. The Chief Medical
Officer reflected this, also in 2007, but went
further stating that neither health nor social
services staff were using the forms correctly.
20
My investigations have been informal but I’ve
found some interesting things. I spoke to a
number of nurses working in various eye
clinics, and none of them were aware of the
LVL or the RVI form, which can be filled in by
any eye health professional who feels, with
the patient, that some support is necessary.
This is an opportunity missed for linking with
social services and highlighting those patients
who have problems now and who may need
more support later.
“Information should always be a
two-way process and the
difficulties of running a busy
outpatient department are not
to be underestimated”
Not only don’t nurses know what the process
is, they seem to have little to do with it.

Viewpoint
Nurses reported that there were social workers
within the outpatients department but that the
nurses didn’t have much to do with them as
doctors did all the registrations! These might
be isolated cases, but I fear that they’re not!
There are many resources in outpatients. We
may have eye clinic support officers,
representatives from charities, counsellors,
ophthalmic nurses and ophthalmologists but
the system still seems very fragmented, with
things happening, but not in a joined up way,
and with the main signposters of the
department – the nurses – unaware of the
systems which should be in place.
Information should always be a two-way
process though and the difficulties of running
a busy outpatient department are not to be
underestimated. It’s sometimes surprising that
the nurses have time to breathe, never mind
know what everyone else around them is
supposed to be doing!
All this makes life very difficult for patients
though. Timely support for people with sight
loss is essential and if we can’t make the first
step smooth, the rest of the journey may be
very rocky indeed.
Janet Marsden is Professor of
Ophthalmology and Emergency Care at
Manchester Metropolitan University. She
specialises in Advanced Nursing Practice,
Ophthalmology and Emergency Care.
Diane Roworth:
“A long and lonely walk”
What a long and lonely walk it is, down the
corridor and out into the real world. As you
leave the eye clinic, your mind is in turmoil.
You went, expecting an explanation and
treatment that would restore your vision to
normal. But not so. All the words that you
understood a few moments ago are suddenly
forgotten, apart from the ones – I am sorry,
but there’s nothing more I can do.
On hearing those words, some people get
immediately upset, others put on a brave
smile and pretend its okay. Some people will
ask questions about why – will I lose more
sight, what does the future hold? Others will
be quiet, perhaps their carer asking all the
questions.
The one thing they all have in common is
that, after hearing those awful words, they
now have to go home and live their lives,
knowing they have a visual impairment for
which there is no ‘cure’. They will not regain
lost sight, and may perhaps lose more as time
goes on. How are they going to manage,
when the world as they know it seems to be
crumbling around them? ➜
21

Viewpoint
➜
Patient experiences vary so much. Those who
are lucky will have a compassionate consultant
who recognises the devastating effect that
sight loss can have on a person’s life. He/she
will think carefully about what they say, and
spend a few moments talking about their
social care needs. If they are very lucky, the
consultant will pass them onto an eye clinic
liaison officer (ECLO) or information and
support worker for the next, very important
part of the journey back into the real world.
The real world is immediately outside the
hospital. It is our home and local community,
where we live independently, being carers, or
cared for, working or retired, having active
social lives or in danger of slowly becoming
isolated through ill health and lack of
community facilities. And now, we have to
contend with visual impairment too. How are
we going to manage that which now threatens
life as we know it? What is there to stop us
becoming isolated, allowing our loss of vision
to impact negatively on everything we do?
These are the questions the ECLO can deal
with.
“How much better if they also
know that there is a local
society for visually impaired
people down the road, which is
there, willing and able to
support them now and for as
long as they want it”
There is so much help available, so many local
and national organisations, and a profession
whose role it is to help people to successfully
adjust to life with a visual impairment (ROVI).
Social services departments, local societies for
visually impaired people, employment,
education, arts, all there and able to help
22
anyone who has a visual impairment –
registered or not. And that is an important
point. Why should people have to wait for
registration before they are offered help? The
short answer is – they shouldn’t. As soon as
people are finding that their vision loss is
causing them problems, then they should be
offered a route into the services they need.
“The one thing they all have in
common is that, after hearing
those awful words, they now
have to go home and live their
lives, knowing they have a visual
impairment for which there is
no ‘cure’”
And where is the best place to offer that
route? – in the eye clinic. Every person who
experiences difficulties with their vision will
visit the eye clinic. Every person has a right to
whatever information, support and services
they need to help them adjust successfully to
a life with a visual impairment. Every person
has a right to talk to someone who
understands the emotional and practical
difficulties, who can ensure that they don’t
have to make that long and lonely walk down
the corridor – out into the real world – not
knowing that there is hope for the future, and
that life will be worth living. And how much
better if they also know that there is a local
society for visually impaired people down the
road, which is there, willing and able to
support them now and for as long as they
want it. Surely every person has a right to
that?
Diane Roworth is Chief Officer of York
Blind and Partially Sighted Society
(YBPSS). The society offers an eye clinic
and liaison officer (ECLO) service at York
Hospital.

Viewpoint
Simon Labbett:
“Referral routes are the acid test”
I think some people have this image of health
and social care workforces as like two
dysfunctional parents arguing over the best
way to look after their child and that
everything would be fine if we both just sat
down, listened to each other and talked.
Actually health and social care do talk to each
other. Ask any of us who work with Low Vision
Service Committees or on the UK Vision
Strategy.
For frontline workers the acid test of all the
fine rhetoric of joint-working is: do the
referral routes actually work? In this respect
the focus tends to be on the crucial liaison
between hospital and social work teams at
Point-of-Diagnosis (POD). This is where the
bulk of joint-commissioned sight services lies
and is evidently where RNIB sees the
strategic need. It would be foolish to argue
with this priority. There are also encouraging,
though rare, models of joint-commissioning
and co-operation in the field of low vision
provision. However, we neglect other
health/social care “border points” at our
peril.
Two spring to mind immediately: One is the
referral at hospital discharge i.e. from hospital
social workers, occupational therapists and
physiotherapists. This is problematic, in part,
because referrals often go to the older
people’s team, and not the sensory needs or
disability team. Second is the woeful liaison
between hospital stroke care and visual
impairment teams – in hospital and social
care. In both these situations the loser is often
a person without diagnosed sight loss or
someone with longstanding sight loss, and in
these situations the
solution lies not
through a new commissioned service: it lies in
old-fashioned cross-team talking and
awareness training – the sort of stuff most
workers never quite have enough time for.
And the reward for those that do make the
time is more referrals!
There are still plenty of indications that eye
clinic staff do not understand what social care
is about, and indeed you could argue that the
provision of eye clinic liaison officers (ECLOs)
or PODs run the risk of making consultants
and nurses less empathetic. But it works both
ways – I have to admit that, until I spent a day
shadowing an ophthalmologist’s surgery, I had
a rather false idea of what an outpatients
clinic was actually like. Suffice it to say, not
every patient they see actually needs social
care (or RNIB)!
Frankly, even if health and social care was
fully joint-funded there would still be
communication problems; wherever two
professions are gathered together their
training will lead them see “problems”
differently. Which leaves us wondering where
the visually impaired person comes in? I think
they are the ones to knock heads together. I
believe one good outcome of rehabilitation
work is to empower people to get involved in
decision-making that affects them. To stretch
the parenting analogy a bit, it’s a bit like when
your teenage children start pointing out your
own poor parenting.
Simon Labbett is a rehabilitation worker in
Bradford
23

Products
Product news from RNIB
A range of products supporting independent living for people with sight loss
Product catalogues
Product catalogues for 2009/2010 are now
available to order and contain all the latest
products to be introduced to RNIB’s range –
as well as some favourites. The catalogues can
be ordered individually in large print, braille
and audio CD. You can also order our
multimedia catalogue (IP415) containing both
catalogues on one disc, in a variety of formats
– ideal for DAISY and computer users.
Everyday living (IP413) contains over 70 new
products as well as a host of everyday
practical products and essentials!
You can find the complete range of tactile,
talking and easy-to-see clocks and watches
in the catalogue along with:
●
●
●
●
●
24
an extensive range of mobile phones, from
easy-to-use with basic function to others
with large operating buttons, text
messaging facility and bluetooth options.
As well as a comprehensive range of
landline telephones.
a fantastic range of kitchen equipment and
utensils, including the new RNIB Vocal
talking kitchen scale which has been
developed in conjunction with RNIB and
Hanson UK Ltd
lighting options
the full range of Big print stationery,
including wall calendars and diaries
a new range of UV eyeshields that actually
look more like sunglasses.

Products
Mobility, braille and audio (IP414) contains
an exciting range of new products, including
the next generation Perkins brailler,
PenFriend – a new audio labelling pen – and
a host of others.
You can browse through the range of products
supporting production and reading of braille
and Moon, an extensive selection of canes,
walking sticks and replacement tips and
ferrules, recording devices and labelling
options, including MP3 players.
RNIB Vocal talking kitchen scale
Using feedback from customers, RNIB has
been working with a commercial company
(Hanson UK Ltd) to develop a set of low-cost
talking kitchen scales (DK131). The scales
have a clear English voice and announce the
weight in both grams/kilograms and
ounces/pounds. They are being sold through
retail outlets such as John Lewis as well as
through RNIB’s new catalogue. Priced £34.99
and £40.24.
Doro PhoneEasy 410
This new compact clamshell mobile phone has
the latest phone features yet remains
easy-to-use. The phone flips opens to
reveal a full colour screen and
large, raised buttons. It has
Bluetooth built-in for
hands-free calling, and is
also compatible with
hearing aids with a rating
M3/T4. Available in black
(HM21K) or white
(HM21W). Priced £130.43
and £149.99.
●
Where two prices are
quoted, the lower one
excludes VAT and
applies to people who
are exempt from
paying VAT on such
items. A delivery
charge may apply.
For your copy of a catalogue or information about other items, telephone 0303 123 9999,
email shop@rnib.org.uk or visit rnib.org.uk/shop
25

Career focus
Ophthalmic nursing:
A degree of change
While the advantage of professional development in ophthalmic nursing is
clear, the education path doesn’t always benefit from the same clarity.
Sarah Underwood reports that a change for the better is on the horizon
As the number of patients attending hospital
eye clinics escalates, it may seem fair to
assume that the number of suitably qualified
ophthalmic nurses who can meet their needs
is rising in proportion. In fact, this is not the
case, but the discrepancy is beginning to be
addressed by nursing degrees and
post-graduate masters courses designed for
continued professional development (CPD) in
ophthalmic nursing.
At the moment, the baseline for higher
education is low. There are only a handful of
master’s level nursing courses with
ophthalmic elements offered across the UK,
potential candidates frequently have funding
issues and may have to study in their own
time, hospitals have varying commitments to
professional development, there is no
automatic promotion for those gaining a
masters degree and, at the other end of the
spectrum, no requirement for qualified nurses
working in hospital eye clinics to have
specialist ophthalmic qualifications.
A wide variance
Mary Shaw, a senior lecturer at Manchester
University and a practising ophthalmic nurse,
says: “CPD varies widely across the UK. Some
nurses have good access to degree level
courses, then little support to go on to
masters courses, even though the Nursing and
26
Midwifery Council recommends that people in
advanced roles should be educated to master’s
level.”
“Opticians can develop the
necessary skills, but it may come
down to ophthalmic nurses to
actually carry out treatment”
Yvonne Needham, a senior lecturer at the
University of Hull who has a master’s degree
with an ophthalmic focus from Manchester
Metropolitan University, and is helping to
develop an advanced practice MSc with an
ophthalmic pathway at Hull, adds: “Everyone
in ophthalmic nursing should have the basic
information and knowledge delivered by a first
degree. Beyond that, education to master’s
level means nurses can better synthesise
information and put information together to
find patient solutions when things are not
straightforward.”
Demand for skills
While some nurses seek CPD opportunities,
the development of ophthalmic services and
advances in ophthalmic nursing in themselves
demand higher levels of education. Needham
notes expanding glaucoma services in
response to guidelines on treatment from the

A degree of change
National Institute for Health and Clinical
Excellence (NICE). She explains: “The
guidance includes checks, processes,
procedures and detailed examinations.
Opticians can develop the necessary skills, but
it may come down to ophthalmic nurses to
actually carry out treatment.”
At Manchester University, Shaw teaches on
two glaucoma training modules that can be
studied by themselves or as part of a masters
degree. “The NICE guidelines suggest people
should have studied the theory and practice of
diagnosing and managing patients with
glaucoma. To fulfil the NICE guidelines staff
need to be at master’s level. We believe our
modules meet the NICE requirements,” she
says.
A more structure approach?
In the past, one of the difficulties in
increasing the community of master’s qualified
ophthalmic nurses was a shortage of courses.
Some ran only intermittently and most nurses
had to travel a long way to study at
universities in Manchester and London. Both
Hull and Manchester universities have tackled
these problems, by offering online e-learning.
A more pressing problem in professional
development is a lack of standard content in
training programmes, which often leads to
poor recognition of higher education, varied
service type and quality in different regions
and a less than obvious education path for
ophthalmic nurses.
“The education path for ophthalmic care
should be better structured. We need to
identify standards for ophthalmic nurses, and
these standards should be adopted by
universities. We should know what skills
qualified ophthalmic nurses have. They should
all have the same skills, but at the moment
skills vary,” says Shaw.
Needham agrees, saying the competencies
that ophthalmic nurses require could provide a
steer for a standard curriculum at degree level
that would be recognised across the country.
“Medical training has a clear structure, which
is what we are aiming for for ophthalmic
nurses. There is a long way to go, but it is all
about standardised training and a willingness
to fund training that is not there at the
moment. Many nurses take responsibility for
their own professional development – each
module of a master’s degree costs about £750
– while others may get funding or time, or a
mixture of both from their hospital trust,”
comments Shaw.
Delivering improved patient care
Julia Swann, nurse practitioner at
Gloucestershire Hospitals NHS Foundation
Trust, is an ophthalmic nurse who received
both funding and time to complete a
part-time MSc in Practice Development:
Ophthalmic Route at Manchester Metropolitan
University. She describes access to CPD as
‘pot luck’, but was fortunate to have a lead
nurse who promoted the importance of
developing nurse practitioners and a manager
who recognised that nurses needed greater
status and recognition, and that this could be
achieved, in part, through the completion of a
master’s degree. ➜
27

Career focus
➜
In practice, many nurses enter higher
education on the basis of their own and their
managers’ interest in CPD. They don’t need
academic qualifications to embark on a
master’s degree, but they do need bags of
determination and colleague support to last
the course.
Swann says the master’s course did not
necessarily broaden her knowledge, but
greatly increased its depth, giving her the
ability and confidence to challenge individual
patient care plans and procedures. She moved
on from simply doing tasks to thinking about
best care routes and delivering improved
patient care. Gaining a master’s degree was a
prerequisite to becoming a nurse practitioner
in Gloucestershire, but the effort has paid off
for Swann in terms of career development,
increased respect from medical colleagues and
the feeling that her opinions count.
Continuity of care
For hospital eye clinics, the benefits of
employing highly educated, specialist
ophthalmic nurses are also significant. Patients
receive better continuity of care and education
as extended skills mean nurses can do more for
them. In turn, this improves the patient’s
experience, leading to fewer cancelled
appointments and improved efficiency.
As Shaw concludes: “While this is not
evidenced, continuous patient care usually
means better care and patients who feel they
are getting a better service. Nurses who
engage in CPD see the benefits for themselves
and their patients, and this can encourage
them to evaluate their role in the hospital on
an ongoing basis and consider further
training.”
“For hospital eye clinics, the
benefits of employing highly
educated, specialist ophthalmic
nurses are also significant.
Patients receive better
continuity of care and education
as extended skills mean nurses
can do more for them”
Taking it to the next level
Where to study ophthalmic nursing at
master’s level or as flexible distance
learning
1. City University/Moorfields
Modules at masters level
Carol.Cox@moorfields.nhs.uk.
2. University of Hull
Flexible distance learning: Ophthalmic Care
(E-Learning)
Contacts: 01482 463342 or
fhsc.admiss@hull.ac.uk
Yvonne Needham, Senior Lecturer,
Y.Needham@hull.ac.uk
3. The University of Manchester
Master’s modules in glaucoma
Contacts: 0161 306 0270 or
graduate.nursing@manchester.ac.uk
Mary Shaw, Senior Lecturer, 0161 306 7655
or Mary.Shaw@manchester.ac.uk
4. Manchester Metropolitan University
Full master’s: MSc Practice Development
(Ophthalmic Route)
Contact: 0161 306 0270 or
graduate.nursing@manchester.ac.uk
Janet Marsden, Professor of Ophthalmology
and Emergency Care, 0161 247 2508 or
j.marsden@mmu.ac.uk
28

Career focus
New rehabilitation worker degree puts
profession on equal footing
A new training option being offered by Birmingham City University will
give rehabilitation workers the opportunity for equal standing with other
professions. Jo Hook explains.
The new qualification is a Foundation Degree
in Rehabilitation Work (Visual Impairment),
with the first two years of full-time study
equating to the previous diploma and the
third layer (designed as part-time study)
forming a top-up for those who wish to obtain
a BSc or BSc (Hons) in Rehabilitation Work.
It will also provide continuing professional
development (CPD) for rehabilitation workers.
Foundation Degree in Rehabilitation
Work (Visual Impairment)
The major changes to the Rehabilitation Work
qualification from September 2009 are:
●
●
●
Instead of a long (75-day) placement
towards the end of the second year,
students will do 60 days of work based
Learning in each academic year, spaced
between group learning weeks at the
university. This gives all students the
opportunity to put into practice the skills
that they are learning at the university in
group learning weeks.
Modules are now in multiples of 15 credits
(rather than the old system of 12), with all
modules at level 4 and 5 being equivalent
to 30 credits.
Rather than being a diploma, the course is
now a foundation degree, but all the
modules are still specifically designed
containing the core elements of the
rehabilitation worker job role.
●
There is a greater concentration of time
spent on skills teaching and experiential
learning in the group learning weeks.
Students will now study:
In year 1 (level 4)
● Moving into higher education (equips
students with skills for lifelong learning
both academically and personally)
●
●
●
Foundations of activities of daily living and
communications (to enable students to
support blind and partially sighted people
to live as independently as possible)
Foundations of orientation and mobility (to
enable students to teach someone who is
blind or partially sighted to travel as
independently as possible in their
environment)
Low vision, blindness and impairment (to
give students basic knowledge of the eye
and how it works, functional vision with eye
conditions, theories of disability and
additional disabilities)
In year 2 (level 5)
● Practice debate (focusing on contemporary
issues in rehabilitation work, including
legislation and policy)
●
Activities of daily living and communications
for practice (this module includes teaching ➜
29

Career focus
➜
strategies for those with more complex
requirements than the year-one module)
●
●
Orientation and mobility for practice
(dealing with more complex environments
and public transport)
Low vision therapy (a range of low vision
teaching techniques)
Students will be required to attend the
university for seven weeks of study in year
one and year two of the course.
Full details of the course changes are on the
course website www.sightlossmatters.com
BSc/BSc (Hons) Rehabilitation Work
(Visual Impairment)
The degree level is a top-up degree
programme for people who already hold
qualifications in rehabilitation work and have
relevant experience. The course will take new
students in February each year, starting from
February 2010. It is anticipated that students
will study the degree level over two years,
with a maximum study length of four years.
Rehabilitation workers who want to attend
certain lectures to gather knowledge but do
not wish to study for the credits will be
welcome to attend (for a fee) and treat their
learning as CPD.
The modules offered to start in February 2010
will be:
● Person-centred practice and psychology (a
compulsory module for the BSc/BSc (Hons)
of 30 credits)
●
Working with people who have complex
needs and impairments (a compulsory
module for the BSc/BSc (Hons) of 15
credits)
This core module includes examining and
evaluating methods of effective
communication with people who have
additional and complex needs.
●
Advanced orientation and mobility (an
optional module of 15 credits)
This module will include addressing travel
needs for people that have complex needs.
The other four modules offered from
September 2010 will be:
This core module includes applying
psychological and person-centred theories to
practice, enabling students to develop their
knowledge and skills of enabling,
empowerment and advocacy.
30
●
Evidence-based practice (a compulsory
module for the BSc/BSc (Hons) of 30
credits that will enable the student to gain
knowledge and competence in using
evidence based practice.

Career focus
●
Risk and negligence (an optional module of
15 credits) which will enable the student to
gain knowledge and competence in how to
asses and minimise risk.
Learning (AP(E)L). This includes a
Rehabilitation Officer Certificate or dual
Qualified Mobility Instructor Certificate and
Technical Officer Certificate.
●
●
Low vision training, including eccentric
vision (an optional module of 15 credits).
This module will include lighting, contrast
sensitivity, and application of viewing
strategies.
Techniques and approaches to management
and supervision (an optional module of 15
credits). This includes coaching, and
motivational strategies.
Entry requirements
The entry requirements for either the BSc or
BSc (Hons) are that the students must already
hold one of the following qualifications:
●
●
Foundation Degree in Rehabilitation Work
(Visual Impairment)
Diploma of Higher Education in
Rehabilitation Studies (Visual Impairment)
or Foundation Degree in Health and Social
Care in Rehabilitation Studies (Visual
Impairment)
Consideration will also be given to those
applicants who already hold a Rehabilitation
Officer Certificate or have a dual Qualified
Mobility Instructor Certificate and Technical
Officer Certificate.
Additional entry requirements:
● Prospective students should demonstrate
the ability to undertake studies at level 6
●
Personal experience, or experience of
working with blind and partially sighted
people. Relevant experience will also be
taken into consideration, being assessed
through Accreditation of Prior (Experiential)
●
●
All applicants must have access to, and be
able to use, broadband, internet and email
facilities, as a proportion of this course is
delivered through these media.
The course requires students to have access
to people of all ages with a visual
impairment through appropriate
employment (such as social services
departments, educational establishment
and voluntary sector organisations who
provide rehabilitation services).
A BSc in Rehabilitation Work (Visual
Impairment) will be awarded if the student
completes 60 credits at level 6 and a BSc
(Hons) in Rehabilitation Work (Visual
Impairment) for 120 credits at level 6. The
main difference in content of the two awards
is the additional amount of analysis and
research included within the BSc (Hons).
A range of assessment types, including
presentations, assignments and vivas linked to
the student’s current practice, will be used in
this course. Some attendance at the university
will be necessary, the amount depending on
the module. The teaching for different
modules will be arranged so those students
can attend the university for a few days in the
same week to study two modules.
Further information
Details for the third year degree top-up will
be available on www.sightlossmatters.com
shortly, and an application form will be
available before the end of the year.
31

Career focus
What I do is...
Laura Brady is one of three learning disability
project assessment workers in Scotland, and
is part of the RNIB Visual Impairment and
Learning Disability Services (VILD)
Many people with learning difficulties have
never had their sight tested, and others are
not happy with the outcome, or don’t really
know what it means. My role as project worker
picks up on that need.
Arranging my diary is something I’ve
become very good at. I often go out and see
three or four people in a day, covering a huge
area.
I’m based in an NHS office in south
Glasgow, alongside the national consultant
for learning disabilities and five of the nurses
working on offering health checks to people
with learning disabilities.
I started with a biology degree and went on
to do nursing, then became a support worker
with adults with learning disabilities. When I
came across VILD, it really made an impact.
I’ve been doing this job for two years.
The post was originally funded for only
two years, but we’ve demonstrated the
positive outcomes and the difference it’s made
to people with learning difficulties and sight
loss. Later this year we’re hoping to get
additional funding from the Scottish
Government.
There are many barriers for people with
learning difficulties to accessing health
32
care services. The project works in
conjunction with the health checks set up by
the NHS in Glasgow and Clyde to address this.
If a nurse finds an issue concerning sight
during a health check, they refer the person
to me. I also receive referrals from learning
disability teams in Glasgow and Clyde and
from other support providers, so there are
many routes into our service. One of our main
jobs is getting the service known, and it’s an
ongoing process.
When I visit a person, my first task is a
functional vision assessment. This usually
takes around an hour. I have a ‘vision
toolbox’, including picture cards or sticks,
which are more useful for people with learning
difficulties than spelling charts. It may also
include flashy toys, mirrors, or when you are
out and about you may spot something at
Tesco that might be suitable! Sometimes you
don’t even get the box open because people
are just not keen or they are having an
off-day. A lot of it comes down to observation
and just asking the right questions of the
people who support the service user.
Often the sight problems we identify are
correctable – the person just needs glasses or
a little bit of advice and support. To prepare
someone for an eye test with an optometrist I
try to demonstrate what will happen, so for

What I do is...
example I’ll shine the pen torch on my hand
and on their hand and then shine it in my eye
and ask if I can shine it in their eye.
The first sight test can be a very scary and
daunting experience for someone who has
limited understanding. We also use a lot of
real-life photographs that VILD have
developed. We might arrange for the person
to visit the optometry practice once just to sit
in the waiting room, before the sight test
itself. Eye tests can be done at home or at a
day centre to avoid disruption to the person’s
routine. It’s part of my job to find out what
suits people and where they feel comfortable.
We’ve built up a very good rapport with
optometrists in the area, including
domiciliary services. At the moment
optometrists do not have special training to
work with people with a learning disability. We
have received a grant from the Scottish
Government to develop training for
optometrists and are in the process of
developing a DVD and a learning and training
pack. VILD also runs training sessions for
rehabilitation workers.
Other issues may arise as a result of the
functional vision assessment or sight test.
We recently had a gentleman in his 40s who
had a cataract. My role also includes
supporting people to attend hospital
appointments, helping to interpret clinical
information and giving them follow-up
support.
What makes the job worthwhile to me is
meeting someone who can’t see 10
centimetres in front of their nose, and
knowing that can be fixed. Every day is
satisfying, and every different person has a
different outcome. People with learning
disabilities tend to have many health issues
and quite often vision problems are
overlooked. I think it’s just that feeling that
you made a difference to someone that
counts.
“The first sight test can be a
very scary and daunting
experience for someone who
has limited understanding”
About learning disability
At least one in three people with a learning
difficulty will also have serious sight loss,
although the figure may be significantly
higher. Often this sight loss goes
undetected.
The RNIB Visual Impairment and Learning
Disability Services aims to identify sight
loss and create opportunity by increasing
awareness of the prevalence of
under-detection of sight loss and the
consequences for people with a learning
disability. The service also has specialist
expertise in providing sight tests for people
with a learning disability.
VILD provides services across the UK for
services users, parents and carers, and also
supports professionals and organisations
working with people with a learning
disability and sight loss.
For further information, visit
www.rnib.org.uk/learningdisability or
contact Visual Impairment and Learning
Disability Services, RNIB Scotland,
Springfield Road, Bishopbriggs, Glasgow,
G64 1PN – telephone 0141 772 5588
33

What’s new
A new breed of CCTVs
Sight Village, the country’s leading exhibition of products and services for people
with sight loss, is held annually in Birmingham by Queen Alexandra College. This
year’s exhibition in July had the usual buzz. With scores of exhibitors vying for
attention in its new venue at New Bingley Hall, RNIB’s digital accessibility expert
Steve Griffiths chose to concentrate on the latest in video magnifiers for people
with low vision, which have come a long way in versatility and portability since
the first desktop models were introduced last century
It’s been a while since I looked in detail at
video magnifiers (also known as closed-circuit
televisions or CCTVs). So it was interesting to
see the changes that have occurred over the
last few years.
Video magnifiers are the devices which enable
you to place printed material and objects
under a camera and gain a magnified image –
a simple way of producing large text, images
and maps for people with low vision. They are
mainly used for reading, although they have a
variety of other uses, and their advantage
over other types of magnifier include the fact
that they are capable of varying degrees of
magnification.
The main thing I noticed at Sight Village was
how much smaller and lighter the majority of
the models now are. Desktop units often
produce their display on a flat screen or
laptop. They are portable, often with a handle
incorporated into the design so they can be
easily carried. There is also a good range of
handheld units – so there should be one to
meet everyone’s needs.
Here are some of the features I noticed were
widely on offer – although not all on one
model!
Small, hand-held units.
While these have a reduced range of
magnification and colour settings, their main
benefit is that they can be carried in a bag or
pocket. Many of them have a swivel handle
that, when extended, enables them to be used
like a magnifying glass. This is great for
shopping, menus, or reading bus and train
timetables.
On many of these units you can now press a
button to capture the image, and then zoom
in and explore it. On some devices you can
save the image to disk, and one device, the
MagniLink Student Pro, even allows you to
save videos.
Desktops – portable and flexible
Many of the desktop units now consist of a
small camera mounted on an arm connected
to a flat screen. These are easy to pack up and
move around.
Often the camera can be swivelled on its arm
so that it can be focused on a newspaper on
the table or a blackboard far away. On some,
different settings can be chosen for each
situation and the CCTV will remember these
between sessions.
34

A new breed of CCTVs
Remote controls or separate keypads are fairly
common too, allowing the basic camera unit to
be kept small. One way of keeping the price
down in the past has been to have a unit that
can be connected to a standard television
rather than a specially supplied screen, but this
has previously been at the cost of a degraded
image. With wide-screen high definition TVs
now available – at a price – it’s possible to
have very large, crisp images. On one stand
(Visualeyes) – there was a 32-inch screen!
My favourites
Pick of the bunch for me was the Eye-Pal
SOLO LV for its ease of use. It’s basically an
OCR (optical character recognition) reading
machine with an overhead camera and a
monitor attached for low vision users. Just
putting something on the base triggers the
camera to take its picture, scan it, put the
result on the screen and also read it aloud.
Sweeping your arm under the camera pauses
the reading or starts it again. To stop the
reading, you take the book or piece of paper
off the unit. It may need a PhD to set it up in
the first place, but the demo was impressive!
(There is also a more basic version of the
Eye-Pal which gives speech or braille output
alone.)
It’s difficult to choose from such a wide
variety, but I’ve always thought the ClearView
range from Optelec, and Low Vision
International’s MagniLink range, were
impressive and well-designed.
before purchasing. The only problem is finding
a resource centre with a good range to play
with. One solution may be to visit the Sight
Village London exhibition, to be held on 11
November at Kensington Town Hall (see
www.qacsightvillage.org.uk). It’s also worth
contacting your local society for people with
sight loss to get news of special events,
exhibitions and demonstrations to be held in
your area.
Contacts
● Eye-Pal SOLO LV: Humanware,
www.humanware.com, 01933 415800
●
LVI’s MagniLInk: Professional Vision
Services, www.professional-visionservices.co.uk,
01462 420751
● Optelec: www.optelec.co.uk, 01923 231313
●
●
Visio: Pamtrad Customs Ltd,
www.pamtrad.co.uk, 0115 981 6636
Visualeyes: www.visualeyesuk.com,
01623 754646
For more about video magnifiers, see
rnib.org.uk/technology
Eye-Pal Solo LV
The Visio slimline CCTV magnifier has two nice
non-standard features: it can embolden faint
text; and its autofocus ignores pointed
objects, so if you put a pen under the camera
it stays focused on the background.
A final word of warning. For the potential
user, there’s no substitute for trying them out
35

In practice
Glaucoma and ethnicity – what we
are learning
By Kirstie Newson, RNIB Service Development Manager
A project to increase early detection of glaucoma, boost the number of referrals
for early treatment, and explore reasons for the low uptake of primary care eye
health services by people of African and Caribbean origin is being piloted in
south London.
The project by RNIB and the Organisation of
Blind Africans and Caribbeans (OBAC) also
aims to raise awareness of glaucoma, reduce
health inequalities resulting from late
detection and presentation and increase the
uptake of eye tests, particularly in these
communities, where there is a higher
prevalence of glaucoma.
Up to 50 per cent of sight loss in the UK is
estimated to be preventable. With the impact
of sight loss resulting in huge costs – both
directly and indirectly in the health and social
care systems, there is a real need to target
work into preventing avoidable sight loss. One
of the priorities for RNIB’s new five-year
strategy is to stop people losing their sight
unnecessarily, especially those who are most
at risk.
Glaucoma is a major cause of sight loss and
can cause up to 40 per cent of sight loss
before it is noticed. Research indicates that
people of African and Caribbean origin are
four to five times more at risk of developing
chronic glaucoma, with an increased risk if a
close relative has the condition. According to
prevalence figures for the three boroughs we
are working in, Lambeth, Lewisham and
Southwark, between 42 to 52 per cent of the
people who have glaucoma are of African or
Caribbean descent. Research has also shown
36
that this group is more likely to develop the
condition at an earlier age, experience it more
severely, and go blind as a result of it.
To inform our work, we held focus groups with
community members to understand their views
on eye health issues, their perceptions of eye
tests and eye health services, and the best
ways to deliver eye health messages.
Eye tests
Although the consensus in the groups
appeared to be that eyesight and eye tests
were important, this was not reflected in
actual behaviour. Most people felt that unless
they experienced a functional problem with
their eyes they would not go for an eye test.
Some people indicated that they were more
likely to soldier on without seeking help, and
preferred to use self-medication.
It was clear that perceptions of sight loss
varied across different age groups, with
middle-aged and older people having more
negative perceptions about the impact of
blindness: “In Africa we believe that if you are
blind you are finished”, was one comment.
This was often reinforced by the observation
that blind people are not seen within their
communities, suggesting either that they
believe that African or Caribbean people do
not experience sight loss, or that if they do
they are not able to lead normal lives within
the community.

Glaucoma and ethnicity
The biggest barrier to visiting an optician was
cost, and there was a general lack of
awareness about exemptions from payment.
Communities are also suspicious of opticians
acting more like commercial enterprises than
health care providers are “I don’t see them as
health people”, said one participant.
It was a commonly expressed fear that people
would be pushed into buying glasses that they
didn’t want or need. It was also noteworthy
that respondents who previously had concerns
over their eyes had gone to their GPs first,
before being referred to optometry. This
demonstrates the value placed on health
professionals who are known and trusted by
individuals. Although people who had been to
high street opticians were satisfied with the
service provided, a preference was generally
expressed for optometry to be delivered in
community or health settings.
Members of these communities felt there was
a need for information about the importance
of eye health and eye tests. “GPs have leaflets
about general health issues but nothing about
what to do for your eyes. If you already have
eye problems, there is no information on what
to do,” said one person. Language was also a
barrier for some people, who commented that
there wasn’t any literature that they could
read.
Understanding glaucoma
With increased risk of glaucoma in people of
African or Caribbean descent, it was important
to establish what people knew about it
already. We found that understanding of
glaucoma was limited and often inaccurate,
even when family members had the condition.
And it did not always lead to any action.
“My father-in-law was taken to hospital, but it
was too late to get his eyes repaired due to
glaucoma. My GP asked me to get my eyes
tested”, said one participant – but at the time
of the focus group he had not yet done so.
Symptoms were often accepted as a sign of
getting older, rather than something that
could be prevented.
Focus group participants and stakeholders
were supportive of the need to raise
awareness in at-risk communities. The findings
from the focus groups were the starting point
for this, but we also need to continually learn
from the communities about the work we are
doing.
Building relationships
When the pilot was started, we spent some
time mapping community networks. However,
this was only a beginning, and it has proved
essential to move on from there and develop
partnerships with community and faith ➜
37

In practice
➜
leaders, to enable us to reach members of the
communities. While the outreach worker
supplies the knowledge regarding eye health
and glaucoma, these community leaders have
been providing their expertise on how and
when the outreach session should take place,
what works for their specific group and what
to avoid. Their endorsement of eye health
messages helps reinforce their importance.
And developing these relationships often
leads to introductions to other organisations,
enabling expansion of the networks.
It was also clear from the focus groups that
people respond to ‘experts through
experience’, so where possible we will
encourage members of the communities who
have glaucoma to share their experiences
around diagnosis and treatment, and the
impact it has had on their life. It will not
always be possible to do this, so we will try to
include real-life stories as case studies where
appropriate. This will help raise the profile of
blind or partially sighted people within their
communities, something that is currently
limited.
We are also investigating other routes to
reaching those who do not visit community or
religious centres, including places of work,
libraries and shopping centres. Instead of
going to places where people are prepared to
talk to us, this will entail directly approaching
community members to share the messages.
Tools to help
With key health messages tested within the
focus groups, we have been developing
appropriate leaflets and posters to support the
outreach delivery. Examples have been tested
within focus groups to ensure that the
messages we want to deliver are presented in
a way that is engaging and meaningful to the
members of the communities we most want to
reach.
38
Other stakeholders
Throughout this pilot, we have worked closely
with the local optical committee to ensure
that optometry practices in the boroughs are
aware of the project and will test and refer
people appropriately, and with primary care
trusts (PCTs) in the boroughs.
Health trainers
Working closely with the PCTs has led to
Lewisham agreeing that their health trainers
will be trained in delivering eye health
messages. This will benefit the pilot but also
leaving a legacy of eye health promotion after
the pilot finishes. All three PCTs, health
trainers will be provided with the leaflets and
posters for use in their community sessions.
Continually learning
Apart from raising awareness of glaucoma to
those most at risk, one of the aims of the pilot
is to ensure that we learn from this work. This
is in part for our own benefit, to ensure a
more informed approach to future work to
prevent avoidable sight loss. But we also want
to share our learning with partners in the
voluntary and statutory sector and enable
others to learn from it as well.
Further information
If you have any questions or want further
information, please contact Kirstie Newson
on 020 7391 2193 or
kirstie.newson@rnib.org.uk

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39

Eye health
Food for thought – and sight
Radhika Holmström looks at the latest findings on the way that diet
affects vision
“It’s surprising that so many
people don’t realise that what we
eat may affect the health of our
eyes. Most of us are aware of the
link between a poor diet and
conditions such as heart disease,
but sadly we often take our eye
health for granted”
Dr Rob Hogan, president of the College of
Optometrists
Research conducted by the College of
Optometrists has found that two out of three
respondents (out of over 2,000) did not
realise there was any connection between diet
and eyesight.
Is Dr Hogan’s surprise really justified? After
all, we’re bombarded with messages – often
conflicting ones – about what we should and
should not be eating for good health in
general. Fat, carbohydrates, salt and fibre are
all the subject of hot debate.
The way we eat now
The most recent National Diet and Nutrition
survey (commissioned by the Departments of
Health for England, Wales and Scotland, along
with the Food Standards Agency) suggests that
the ‘five a day’ message for fruit and vegetable
intake still has not sunk in for many people.
Only 13 per cent of men and 15 per cent of
women consumed the recommended amount.
Indeed, 21 per cent of men and 15 per cent of
women actually ate no fruit at all during the
seven days that the survey took place.
Although older people do appear to be eating
slightly more fruit and vegetables than young
ones, even people in the 50 to 64 age group
were only averaging under four portions a day.
Confusion about what this recommendation
covers certainly doesn’t help. In reality,
however, the ‘five a day’ campaign was
And despite Hogan’s assertion that most of us
are aware of the links between diet and
health, many people are still remarkably
reluctant to put that knowledge into practice.
In many ways, it would be more surprising if
the average person did realise that food and
eye health were related – and even more
surprising if they followed this up by eating
appropriately.
40

Food for thought – and sight
Five a day
The ‘five a day’ recommendation is often confusing. Some of the important points are:
● Fresh, cooked, tinned and frozen produce all count.
● One glass of juice counts, but it should be pressed rather than made from concentrate.
Further glasses won’t count, because juice has very little fibre and is high in sugar.
● One serving of pulses (such as lentils and chickpeas) count, and this includes baked beans.
Further servings won’t count, because pulses do not have the same nutrient mix as other
vegetables. They are a good source of low-fat protein, though.
● Potatoes don’t count at all, as they are considered to be a source of carbohydrate rather
than of vegetable nutrients.
Links: www.5aday.nhs.uk
introduced mainly as a convenient hook for
raising fruit and vegetable consumption.
Pretty well all dieticians recommend that five
should be a minimum. And this only serves to
underline the fact that, as a nation, we simply
aren’t eating many fruit and vegetables.
On the other hand, we are making a conscious
effort to cut down on red meat, and older
people are leading the way. Following a report
from the World Cancer Research Fund in 2007,
which linked these to an increased risk of
cancer, a report from the same organisation a
year later showed that one in 10 people had
made an effort to reduce their red meat intake.
Eyes in particular
Cutting down on red meat is good news for
eye health. The most common cause of
blindness in the UK is age-related macular
degeneration (AMD), which is the only eye
condition that has substantiated links with
diet – and this was the subject of the research
by the College of Optometrists.
The researchers from the University of
Melbourne followed 5,600 middle-aged
people for 13 years and found that those
eating red meat 10 times a week were nearly
one and a half times as likely to have early
AMD than those who ate it fewer than five
times. In addition, those who ate chicken
frequently – at least seven times a fortnight –
were significantly less likely to have developed
late AMD.
This was only a first study. But it is significant
in that it supports wider evidence that a
‘Mediterranean diet’ – high in fruit and
vegetables and oily fish, low in red meat – is
as effective in cutting the risk of AMD as it is
in cutting the risk of heart disease, diabetes
and cancers. Another study published in the
British Journal of Ophthalmology, June 2009,
backs up these findings – and even suggests
that these fatty acids can slow (or in some
cases halt) the progress of AMD. ➜
41

Eye health
➜
Oily fish is useful because it is usually the best
dietary source of Omega 3 fatty acids. The
specific AMD link was the subject of another
study from same University of Melbourne
team, published in Archives of Ophthalmology
last June, which found that eating a diet rich
in Omega 3 acids could reduce the likelihood
of developing the disease by 38 per cent.
They think that this is probably because those
fatty acids act to protect nerve cells, including
those in the retina.
The big link, for many, is with foods that
contain the ‘carotenoid’ anti-oxidants lutein
and zeaxanthin. “It’s logical that a diet rich in
those anti-oxidants should be shown to be
effective”, points out Professor Ian Grierson of
Liverpool University. “Lutein and zeaxanthin
protect the macula and come exclusively from
the diet.” In fact, unlike other dietary
carotenoids, these selectively accumulate in
the retina to make up the yellow screening
pigment in the macula. “If someone with early
AMD takes these anti-oxidants, they can slow
down the development of their disease,
particularly if it is the ‘dry’ form of AMD – for
which there is no other treatment as yet”,
Grierson adds. Green leafy vegetables are
most frequently cited as a good source; but
eggs are also a particularly good source of
lutein. It’s also crucial, Grierson stresses, to
remember that that these anti-oxidants will
not be absorbed without some fat – which is
why one egg is actually a much more effective
way to get lutein into the body than a much
bigger pile of steamed spinach.
A whole diet
Yet even these studies are still at a fairly early
stage, points out Adnan Tufail, consultant in
medical retina at Moorfields. “I don’t
discourage patients who want to consume
more lutein or zeanthin – unless they have
conditions like retinal dystrophy, which can
actually be made worse; but I don’t actively
encourage them either.” Tufail is embarking on
a wider study into nutrition and sight.
Equally, specialists like Grierson who do link
diet to eye health stress that diet alone
cannot eliminate absolutely everyone’s chance
of developing AMD. “When you tackle risk
factors, unfortunately that does mean that not
everyone is going to benefit. Some people’s
risk is simply too high in the first place”, says
Grierson. “What we do know is that across the
population, tackling diet works to reduce the
incidence of AMD.”
The issue on which both camps do agree is
that a ‘healthy diet’ is sadly lacking across a
lot of the UK.
Links
➜ Five a day: www.5aday.nhs.uk
Eggs explained
Eggs have been the subject of much bad
press over the years, and many people still
avoid them on the basis that they contain
cholesterol. However, specialists including
the British Heart Foundation now agree
that it’s saturated fat in general (from fatty
meat and full-fat dairy) that affects
cholesterol levels. In fact the foundation
dropped its recommendations to limit eggs
to three a week back in 2007. As Professor
Grierson says, the small amount of fat that
eggs do contain makes them a very
effective vehicle for lutein.
42

Your health
Working with stress
Health and social care workers frequently work in challenging and stressful
situations. Sarah Underwood identifies problems and offers solutions
In a hectic working world, stress, anxiety,
confusion and depression can be frequent
visitors, but they can be challenged and
managed to deliver a better personal
experience of work and a listening employer
dedicated to sustaining a satisfying and
efficient working environment.
Nick Johnson, chief executive of the Social
Care Association, a professional organisation
for people who work in all aspects of social
care, says: “Stress is not necessarily bad. Some
stress can be healthy, increasing adrenalin and
helping us achieve what we need to do. But
when people are unsure of their job role, don’t
know whether or not they are valued, face
demands beyond reasonable expectations, are
not well managed, or have a case load that is
too large and too much documentation to
complete, then stress creeps in.”
Johnson believes good management and
leadership are critical to stress management,
as well as the strength and support that is
derived from staff teams that function well.
Communication is key (which raises questions
about the health of increasing numbers of
people working at home without structured
support), and chats around the water cooler
can be brief, unacknowledged counselling
sessions.
On a larger scale, with 35,000 registered
employers of social care staff across the
country, most of which are small to
medium-sized businesses, there is a need to
network.
“Small companies don’t think of themselves as
part of a network of 1.5 million workers. All
they can manage is keeping afloat locally. To
get more support, employees need to be
connected outwards. We need a social care
equivalent of Facebook, but probably a closed
community, so that workers can share their
views and problems,” says Johnson.
Time, often in short supply, is also of the
essence in stress management. Many social
care employees work beyond contracted hours
and have a greater commitment to service
users than to their managers, but any
management withdrawal of time and money
leads to a feeling of failure, even if it is
beyond the employee’s control.
Johnson adds: “Time to reflect – as in the
plan, do, evaluate and reflect cycle – has
diminished or been lost altogether. Less time
to reflect means less capacity to learn from
mistakes and avoid stress. Many managers and
workers feel they are on a hamster wheel and
can’t stop running, but they need to get off
and look at how they are doing things.”
Johnson says there is little that keeps him
awake at night, but acknowledges self-induced
stress around deadlines and an abiding stress
in the long-term leadership of an organisation
that he wants to be credible and successful.
44

Working with stress
Lance Clarke, chief executive of Surrey
Association for Visual Impairment and former
chairman of the National Association of Local
Societies for Visually Impaired People, is
equally comfortable with his stress catalysts,
particularly taking on too much work, and
tries to be realistic about what he can and
cannot do, taking responsibility but not
allowing it to become stressful.
“We carry out a risk assessment
and understand potential stress
in the organisation. We make
sure we deal professionally and
properly with stress”
He is keenly aware, however, of the stresses
that can affect those working for the local
society, which includes a team of 24
rehabilitation workers, 20 sessional workers
working with deaf and blind people, and over
300 volunteers making home visits to blind
and partially sighted people.
Clarke explains: “On a formal basis, we have a
stress policy. We carry out a risk assessment
and understand potential stress in the
organisation. We make sure we deal
professionally and properly with stress.
Managers and senior workers use the processes
outlined in the policy, but it is also vital that
supervisors do a good job of supervision,
identifying stress, taking time to talk to people
about their problems and helping them
understand that their boss is concerned.”
The local society, including Clarke, takes an
open door approach to employee
communication, offers the services of an
external agency helpline to those who don’t
feel comfortable talking to someone internal
and also allows staff to appoint a
representative they can talk to and who
attends executive meetings to discuss and find
solutions to staff issues.
Similarly, if something is decided at an
executive meeting that will affect staff,
perhaps a reduction in working hours, the
information will be relayed to staff within 12
hours using a Talkback email service that
allows them to respond, perhaps saying they
are worried about their jobs. Management
must then reply to staff concerns. “Sometimes
we have to make tough decision, but they are
all transparent. Recently, I had to make
someone redundant, which was horrible,” says
Clarke. ➜
45

Your health
➜
The association encourages staff to let
managers know if they have a problem at
home and to deal with it first before catching
up with work. As well as understanding
problems at home, Clarke and his
management team also try to anticipate issues
that can add to stress at work.
“Rehabilitation workers are worried about
their future because of personal budgets and
articles they may read in the media. Locally,
a number are also affected by contracts
between societies and local authorities, as
local authorities can sometimes be sloppy,
make late payments, don’t pay enough, and
on occasion contract specification can be
unclear. This can and does cause stress,”
says Clarke.
If these kinds of stress are familiar to social
care workers, there are methods that can be
used to manage stress and alleviate at least
some of the anxiety it provokes. Professor
Stephen Palmer of City University and director
of the Centre for Stress Management, explains:
“Achieving a balanced lifestyle is not as
straightforward as it seems, but it is possible to
reduce stress by being aware of your thinking
processes and understanding what triggers a
stress response. For example, if you think a
46
situation is awful, challenge your thinking. A
reality check will probably show that the
situation isn’t awful, just difficult.”
Similarly, Palmer suggests trying to change
levels of frustration tolerance in stressful
situations. “If someone says ‘I can’t stand
this’, the reality is the living evidence that we
withstand most things. Perhaps better is ‘I
don’t like this, but I can stand it’. If you think
differently, you can become more resilient and
less stress,” he says.
“A useful approach is to think
of solutions, which will lift your
feelings, rather than of problems
that will take you down”
He also counsels that stressful tasks should be
tackled as they arise and not be put off, since
taking responsibility can reduce stress and
prevent a situation that becomes so stressful
that the ability to seek solutions is lost.
Palmer argues that failure, too, if blamed on
oneself, can cause stress and depression. His
advice is to remember that we all have skills
deficits and should encourage self-acceptance

Working with stress
as we are all fallible human beings. On a
practical level, perhaps if you feel personally
to blame for making someone redundant, you
can draw a circle and divide it into your
responsibilities, those of your organisation and
those of the individual. This gives a clear
picture and shows that you were not solely
responsible and to blame for the redundancy.
With a focus on social care workers, Palmer
says: “Helping professionals often feel stress
as situations they are in are not easy. A useful
approach is to think of solutions, which will
lift your feelings, rather than of problems that
will take you down. Sometimes there are no
easy solutions. Then it may be time to stand
back, think about the situation and consider
how you would advice a friend in the same
situation.”
Like Johnson and Clarke, Palmer also notes
time issues. “People give up if they are
stressed. They need breaks, a lunch break
away from what they are doing, not a
sandwich in front of their PC. The break will
lower blood pressure, stress levels will go
down and when they return to their desks
they will work more efficiently. It can also be
beneficial to leave work stress at work when
you go home at the end of the day.”
While stress management mechanisms can
help many individuals, there will be those who
find stress is more difficult to alleviate. Palmer
points to the importance of preventive
measures including assessing organisations to
discover whether the work environment is
stressful and could be changed, and training
and coaching individuals to deal with stress.
If these approaches fail to derail stress, he
advises working with a registered therapist
who offers cognitive behavioural therapy or
solutions-focused therapy.
Top tips to tackle stress
●
●
●
●
●
Be aware of your thinking process and
make frequent reality checks – your
thinking may not be right and your
thoughts may be contributing to stress
Focus on solutions not problems
If you fail in a task do not blame and
berate yourself – everyone has skills
deficits and we are all fallible human
beings
In a difficult situation stand back and
think how you would advise a friend in a
similar situation
Do not personalise stress – in many
situations you will not be alone in having
responsibility for a difficult task. Consider
who else is responsible and do not take on
all the blame
●
●
●
●
●
●
●
Use colleagues as a buffer – talk to peers
and managers who share your issues
Tackle stressful tasks as they arise – do
not put them off
Do not mind read – always check out what
others are thinking
Ensure proper breaks during working
hours – do not eat lunch at your desk
Leave work stress at work – unless you
have a partner who can help you
Encourage both formal and informal stress
management in your organisation
Seek external help if stress cannot be
managed within the organisation.
47

Experience
A patient’s eye view:
AMD treatments
While sight-saving treatments for age-related macular degeneration were
approved only a year ago for NHS provision in England and Wales, Scots have
had longer to appreciate the benefits, following approval by the Scottish
Medicines Consortium in 2007. Journalist Dick Barbor-Might gives his own view
of the difference they can make to individual lives.
The first time I realised that anything was
wrong was when I poured a glass for my
partner, missed and ended up with a pool of
wine on the table. “Clumsy”, I said to myself.
“Could it be your eyesight?” queried our
philosopher friend Bill. So I took myself off to
the optician’s, from where I was referred to
Edinburgh’s Princess Alexandra Eye Pavilion.
The eye tests, which are free in Scotland,
revealed that I had developed a condition
called macular degeneration.
Speedy and correct diagnosis is absolutely
essential with this condition. Nowadays this is
precisely what eye patients can expect to
receive, but it was not always like this. George
Kay, who chairs the Macular Disease Society in
Edinburgh, tells how back in 1959 he was
alarmed when the straight line he was cutting
in a slab of cake seemed to wobble. A few
weeks later, as he was walking home after his
night shift at the bakery, he found that he
could no longer see properly with his right
eye. Thereafter he made do with the left.
None of the doctors mentioned macular
degeneration. Thirty years later he mistook a
red traffic light for a green. He gave up
driving, but week by week the good left eye
deteriorated until the TV screen in the corner
was just a blur. Still the doctors said nothing
about macular degeneration.
48
Nowadays things are very different. In the
summer of 2006 the eye tests revealed that I
had both versions: dry in the left eye and wet
in the right. The right eye was past saving.
However, I still had 80 per cent vision in the
left. For the time being I could still make out
faces, still delight in a landscape, still watch
TV and still use the computer. I was given
excellent clear information and advised to do a
regular check on the Amsler grid. If and when
the lines and squares started to distort I
should go for an immediate eye test.
A year later, in July 2007, vision in the good
left eye began to rapidly deteriorate. This was
confirmed by the eye tests. Thanks to a
generous friend I prepared to go for a first
injection of a new drug, Lucentis, at a private
hospital in Newcastle. Then, just three days
before the Newcastle appointment,
Dr Armbrecht phoned up from the Eye
Pavilion to offer me a place on their newly
started Lucentis programme. The treatment
would be free, on the NHS.
For a specialist such as Dr Ana Maria
Armbrecht, Lucentis is a genuine
breakthrough, even more so than another
recent introduction, Macugen. She has
specialised in macular degeneration ever since
1997. Yet never before have she and her

A patient’s eye view: AMD treatments
colleagues in the medical and nursing team –
led by Dr Bal Dhillon, who is also an Honorary
Professor at Heriot Watt University – been
able to achieve so much for patients with
macular degeneration.
“He never loses an opportunity
to point out just how serious the
consequences can be of failing
to provide the treatment for a
person who stands to lose his
or her sight”
John Legg, the Director of RNIB Scotland,
regards all of this as a striking achievement.
Just like the consultant ophthalmologists with
whom he stays closely in touch, he looks
forward to the continued funding of Lucentis
injections and to the prospect of a growing
number of people throughout Scotland
gaining access to this vital treatment. He
never loses an opportunity to point out just
how serious the consequences can be of
failing to provide the treatment for a person
who stands to lose his or her sight. These
negative consequences can include loss of
confidence, social isolation, falls and eventual
residential or nursing care.
Along with a growing number of other
patients I now go to the Eye Pavilion every
four weeks, sometimes dropping into the very
helpful RNIB Visual Support Centre on the
third floor. My left eye is examined and –
usually – I receive an injection. It sounds
rather alarming since the injections are given
by needle directly into the eye. But everything
possible is done to minimise the risk of
infection and it is all carried out with
consummate skill by the surgeons,
complemented by exemplary nursing care.
What with all the antibiotics, anaesthetics and
bright lights I hardly feel a thing and am fit to
go home a couple of hours later.
For the vast majority of people the injections
halt the downhill slide towards blindness, and
in about 30 to 40 per cent of cases some of
the lost sight is regained. Dr Armbrecht
estimates that about 400 people in Edinburgh
and the Lothians stand to benefit every year.
For me the treatment has worked, brilliantly.
I have not regained all my lost sight and will
be going to the Eye Pavilion for some time to
come as the surgeons try to stabilise the
macula. But the overall improvement is
remarkable, which is why I was able to read a
poem at a Burns supper this January – and
why I am able to write this article.
This article is based on an article which
appeared in the Scotsman, 4 March 2008.
NICE – the final hurdle
There are 26,000 new cases of ‘wet’
(leaking or bleeding) AMD in the UK each
year. The condition can lead to blindness in
as little as three months if left untreated.
NICE (the National Institute for Health and
Clinical Excellence) issued its final guidance
on sight-saving drugs on 27 August 2008,
recommending that the NHS in England
and Wales should cover the cost of the first
14 injections of ranibizumab (Lucentis),
while the manufacturer, Novartis, has
undertaken to cover the cost of further
injections. Another drug, pegaptanib
(Macugen), was not approved for use on
the NHS. Since then, a growing number of
Lucentis clinics have been set up, including
a number of nurse-led clinics.
49

Dates for your diary
Dates for your diary
NB looks at the upcoming courses, services and events
in your area of work
RNIB Technology Courses
RNIB offers technology-related training
courses at various locations across the UK.
Courses cost £130-£160 per person.
Forthcoming dates include:
2 October, Birmingham: Supernova
workshop – supporting users of Supernova
access technology software
2 October, London: Throw away the mouse
– using computers without the mouse
7 October, London: JAWS workshop –
supporting users of JAWS screen reading
software, Wednesday
16 October, Birmingham: ZoomText
workshop: supporting users of Zoom Text
access technology software
27 October, Liverpool: ZoomText workshop:
supporting users of Zoom Text access
technology software
28 October, Liverpool: JAWS workshop:
supporting users of JAWS screen reading
software, Wednesday
Contact: visit rnib.org.uk/technologycourses
or email DSTraining@rnib.org.uk
Professionals Working with Children
Training opportunities for professionals in
education, health and social services, and
parents of blind or partially sighted children.
Courses cost £130 per person.
2 October, Leeds: Aromatherapy and
massage for children with complex needs:
part two – developing good practice
6 October, Greater Manchester: Tactile art:
teaching art to children who are blind or
partially sighted
8 October, Bristol: Visual conditions in early
childhood
8 October, Leeds: Introduction to working
with blind and partially sighted children
8 October, London: Music, visual impairment
and autism: developmental consequences
and strategies for specialist and non
specialist teachers
12 October, London: Reading difficulties in
braille readers
13 October, Stockport: Braille maths and the
adaptation of diagrams for the tactile user
20 October, London: Roles and
responsibilities of teaching assistants of
children who are blind or partially sighted
A brochure with the full list of short courses
for summer is available now, along with the
national programme for 2009-2010. For
further details, visit
rnib.org.uk/shortcourseschildren or email
DSTraining@rnib.org.uk.
50

Dates for your diary
Cornwall’s Right to Read Show
17 September, New County Hall, Truro
Organised by Cornwall Blind Association,
this show will demonstrate what local and
national organisations can offer to assist
blind and partially sighted people to read.
There will also be a programme of readings
from celebrity authors (including local
author Patrick Gale) and a chance to sign
the Right to Read Declaration, expressing
concern about the lack of books in
accessible formats.
Further information: Kerry Keast,
01872 266708
Grade 2 Braille Refresher Course
7 October, Birmingham (book by 23
September)
4 February 2010, London (book by 21
January)
‘Brush up your braille’ is a one-day
interactive workshop.
Cost: £150 including lunch and
refreshments. Contact Jen Morton on
telephone 0121 665 4212 or email
DSTraining@rnib.org.uk or visit
rnib.org.uk/brushupbraille
Look to the Future Exhibition 2009
8 October, 10am to 4pm
County Hall, Durham, DH1 5UG
An exhibition of equipment and services for
people with low vision, focussing on eye
health, including presentations, hosted by
County Durham Low Vision Services
Committee. Admission free and sighted
guides are available. Further information:
Andy Nuttall, 0191 3876181 or email
andrew.nuttall@durham.gov.uk
Ophthalmic Nurses Interest Group
14 October, Warrington
North West Ophthalmic Outpatient Nurses
Interest Group meeting
Outpatient Department, Ophthalmic Centre,
Warrington Hospital, Lovely Lane,
Warrington, WA5 1QG.
Contact: Siobhan Clarke,
telephone 01925 662403,
email Siobhan.clarke@whh.nhs.uk
Managing Visual Impairment Services
15 October 2009, Birmingham (Sutton
Coldfield)
3 February 2010, London (Euston)
‘Seeing sense’ is a one-day workshop for
managers and commissioners working in
sensory services. The workshop leaders are
Richard Cox and Hilary Young, who work in
this field and contributed to the UK Vision
Strategy. Closing date for applications: one
month in advance of each event.
Workshop fee: £270 including ongoing
access to web-based support materials.
Download an application form at
www.seeing-sense.com
London Rehabilitation Workers Forum
30 October, 2 to 4.30 pm
The London Rehabilitation Workers Forum
(LRWF) meets six times a year at the RNIB
building in Judd Street (near King’s Cross
station).
As the face of social care is changing the
Forum wants to be actively involved with
the change and be a voice for rehab
workers in London.
Contact londonrehabworkers@yahoo.co.uk
for full details.
51

Dates for your diary
Age Related Eye Disease Conference
15 and 16 October
A major conference on age-related eye
disease at the Institute of Physics in
London.
The event would be of particular interest
to:
● Ophthalmologists
● Specialists in neurology and
neurophysiology
● Commissioners and managers of elderly
care services
● General practitioners with a special
interest in ophthalmology, optometry or
elderly care
● Optometrists
● Clinical nurse specialists in
ophthalmology or optometry
● Nurse practitioners in ophthalmology or
optometry clinics
● All trainees in this discipline
12 CPD points and 12 CET points applied
for.
Further information:
www.mahealthcareevents.co.uk,
telephone 0207 501 6762
Local-Eyes Open Day and Exhibition
21 October, 10am to 3pm
UK Paper Leisure Club, Avenue of
Remembrance, Sittingbourne, Kent,
ME10 4DE
An exhibition of equipment, advice and
information by Kent Association for the
Blind. Admission is free and refreshments
are available. Wheelchair access and parking
available. For more information call the duty
officer, Kent Association for the Blind, on
01227 763366
Hearing and Sight (HAS) Centre Annual
exhibition
22 October, 10am to 4pm
Plymouth
This annual exhibition will provide blind and
partially sighted people with the
opportunity to try out the latest equipment
provided by nearly 60 exhibitors.
Professionals are also welcome to attend.
Contact Andy Moyes, Local Events and
Activities Assistant, 01752 201766,
andy@hascentre.org.uk
The 2009 Eye Day
28 October
South Cheshire College, Dane Bank Theatre,
Cheshire, CW2 8AB
Topics include: Acquired brain injury and
visual impairment, cancers of the eye and
treatments, Charles Bonnet Syndrome,
hysterical and psychological blindness.
Applications are invited from
companies/organisations wishing to exhibit
at the lunchtime exhibition
Fee: £90 per delegate (including lunch and
refreshments). Exhibitor’s fee to be
confirmed. Closing date: 1 October
Further details/booking forms:
Hilary Rowlands, 01244 973087,
hilary.rowlands@cheshire.gov.uk
Visual Aids Exhibition
28 October, 10am to 3pm
Hosted by Beacon Centre for the Blind,
Wolverhampton
Further information: Telephone
01902 880 111, www.beacon4blind.co.uk
52

Dates for your diary
Southern Rehab Workers Forum
30 October, 10am to 3pm
St Dunstan’s, Ovingdean, BN2 7BS
Open to all Rehab Workers/ROVIs,
assistants and trainees/students, this event
is a chance to network with colleagues,
covering medical updates, visual
hallucinations, stroke-related blindness,
music therapy and equipment
demonstrations and updates.
Contact Ian Hebborn 01273 391476,
ian.hebborn@st-dunstans.org.uk
Focus on Opportunities Conference 2009
17 November 2009
Aberdeen Exhibition and Conference Centre
An international conference by RNIB
Scotland and Grampian Society for the
Blind, covering best practice and new
employment initiatives for blind or partially
sighted people, and considers lessons
learned and planning for the future.
Key speakers include Karen Wolffe,
American Foundation for the Blind and
Jonathan Shaw MP. Cost: £95 per delegate.
Concessions available.
Contact Ruth Morrell or Liz Redpath on
0845 271 2345 or
workfocus@grampianblind.org
Pioneers Conference and 6th BCLA
Pioneers Lecture
26 November
Royal Society of Medicine, London.
Hosted by the British Contact Lens
Association. Contact: www.bcla.org.uk or
Vivien Freeman on 020 7580 6661, email
vfreeman@bcla.org.uk
Deafblind awareness training
The following courses are available
through Deafblind UK:
Deafblind Awareness 1 day training
Signature CDC Level 2 training, taught over
4 days plus half a day for
practical assessments
Contact: Julie Brown, 01733 358100
extension 256 voice, 01733 358100
extension 215 minicom,
Julie.brown@deafblind.org.uk
RNIB Certificate in Grade 2 English
Braille course
RNIB runs a popular distance learning
course for people wishing to learn to read
and write grade 2 braille, including
teachers, teaching assistants, support/care
workers and parents. It leads to the award
of a BTEC Advanced Certificate at level 3.
There are two intakes every year, in
February and October.
Further information:
rnib.org.uk/grade2braillecourse or Jen
Morton, telephone 0121 665 4212, email
DSTraining@rnib.org.uk
Would you like to add a date
to NB’s diary?
Entries for the October issue should reach
us by 6 September. If you would like to
submit a notice, please contact
Parminder Sangha at Ten Alps Publishing
on 020 7878 2367 or
Parminder.Sangha@tenalpspublishing.com
For a listing of up to 50 words, the fee is
£30.00+VAT, and for 50 words and above,
it is £35.00+VAT. We are also offering a free
coloured box to enhance your listing.
53

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Contact Parminder Sangha, 020 7878 2367
Services
Experienced braillist/proofreader
offers transcription service. For further
information please contact: Judith Furse,
23 Masefield Avenue, Swindon, SN2 7HT.
Telephone 01793 644346.
E-mail: info.swindonbraille@talktalk.net
54

Appointments
Vacancies at RNIB
All vacancies that are advertised
externally can be found on the RNIB
website rnib.org.uk/jobs
You will be able to download the job
description, person specification and
application form. You can also hear the
vacancies on the Recruitment
Freephone line, 0800 195 4135.
55