Changes to ophthalmic clinical practice to help reduce trips and falls
Submitting InstitutionUniversity of Bradford
Unit of AssessmentAllied Health Professions, Dentistry, Nursing and Pharmacy
Summary Impact TypeHealth
Research Subject Area(s)
Medical and Health Sciences: Clinical Sciences, Ophthalmology and Optometry, Public Health and Health Services
Summary of the impact
Falls are a common and serious health risk for older people and reducing
falls is a priority for the NHS. Research at the University of Bradford on
the link between vision and falls has led to new healthcare guidelines,
specifically those from the College of Optometrists and the British
Geriatrics Society and endorsed by Age UK and the Royal College of General
Practitioners. Continuing professional development practices have changed
and public awareness of this health risk has been raised by Which?
reports and subsequent media coverage. These developments have impacted on
the health and welfare of older people, particularly those at risk of
Falls and fall-related injuries are a common and very serious problem for
older people. Approximately 33% of people aged over 65 and 50% of those
over 80 fall at least once a year. Falls cause bruising, fractures, loss
of confidence and independence and are the leading cause of accidental
death in older people. They are estimated to cost the NHS more than £2.3
billion per year.
Research conducted in the vision and mobility laboratory at the
University of Bradford assessed how safely older people can negotiate step
and stair ascent and descent (adaptive gait), which is highly dependent on
good visual information. We investigated adaptive gait in well-adapted,
long-term wearers of bifocal or varifocal spectacles (1,2,5) and showed
that they: i) did not show the safety precautions we had reported
previously in subjects with blurred vision in the lower visual field; ii)
did not follow professional advice to "tuck their chin in" so that the
lower visual field would be seen clearly through the distance part of
their spectacles; iii) had more variable adaptive gait; iv) were more
likely to hit a step edge when stepping up; v) were more likely to `drop'
onto the step during step descent. Importantly, despite being adapted to
bifocal or varifocal spectacles for many years, these subjects showed
safer adaptive gait when switched to single vision distance lenses
(1,2,5), did not hit the step when stepping up and showed more controlled
step descent. Our laboratory-based studies supported other
epidemiological, clinical and randomized controlled trial evidence from
In addition, research has indicated that visual impairment is a
significant risk factor for falls suggesting that updated spectacles and
cataract surgery would reduce the falls rate. However, randomized
controlled trials have not shown the expected benefits and indeed, one
study by an Australian group found that updated spectacles increased
falls. Given the known effects of a visual illusion on adaptive gait (3),
this unexpected finding led us to investigate whether spectacle
magnification could be the cause of the problem with updated spectacles
(4). We found that adaptive gait was driven by changes in lens
magnification, with the highest magnifications causing potentially unsafe
adaptive gait changes. Other studies from our team with Canadian
collaborators have shown that partial prescribing of refractive change is
less likely to lead to problems, particularly in older patients (e.g. 6)
and this is what is now recommended to clinicians. Dave Elliott (Senior
Lecturer 1995-1998, Reader 1998-2003, Professor 2003-present) began gait
and vision studies with Patla in Kinesiology, Waterloo, Canada in 1993 and
set up a vision and mobility laboratory in Bradford in 2001. The team
includes Dr John Buckley (PDRA 2002-2005, Research Fellow 2005-2007,
Reader 2007-present), Andrew Scally (Lecturer 1996-2005, Senior Lecturer
2005-present) and Dr Sarah Louise Johnson (University Teacher 2000-2002,
Lecturer 2005-present). The papers listed included contributions from
David Whitaker (Senior Lecturer 1995-1996, Reader 1996-2000, Professor
2000-present), and research assistants Harley (2006-2007) and Chapman
References to the research
1. Johnson L, Buckley JG, Scally AJ, Elliott DB. (2007) Multifocal
spectacles increase variability in toe clearance and risk of tripping in
the elderly. Investigative Ophthalmology and Visual Science 48:
2. Johnson L, Buckley JG, Harley C, Elliott DB. (2008) Use of
single-vision eyeglasses improves stepping precision and safety when
elderly habitual multifocal wearers negotiate a raised surface. Journal
of the American Geriatrics Society 56: 178-180.
3. Elliott DB, Vale A, Whitaker D, Buckley JG. (2009) Does my step look
big in this? A visual illusion leads to safer stepping behavior. PLoS
One 4(2): e4577. doi:10.1371/journal.pone.0004577
4. Elliott DB, Chapman GJ. (2010) Adaptive gait changes due to spectacle
magnification and dioptric blur in older people. Investigative
Ophthalmology and Visual Science 51: 718-722.
5. Timmis MA, Johnson L, Elliott DB, Buckley JG. (2010) Use of
single-vision distance spectacles improves landing control during step
descent in well-adapted multifocal lens-wearers. Investigative
Ophthalmology and Visual Science 51: 3903-3908.
6. Howell-Duffy C, Hrynchak PK, Irving EL, Mouat GSV, Elliott DB. (2012)
Evaluation of the clinical maxim: "If it ain't broke, don't fix it". Optometry
and Vision Science 89(1): 105-111.
Evidence of quality:
The papers are either published in multidisciplinary journals (Plos One,
2012 impact factor 3.73, ranked 7th of 56 in Multidisciplinary
Sciences; Journal of the American Geriatrics Society, 2012 impact
factor 3.98, ranked 9th of 46 in Geriatrics & Gerontology)
or one of the leading international ophthalmology journals Investigative
Ophthalmology & Visual Science (2012 impact factor 3.44, ranked
5th of 58 in ophthalmology). Individual paper citations are
good and typically in the top 10-25% for the discipline.
Evidence of the quality of the research is also demonstrated by the award
of the following research grants:
The PPP Foundation, 2001-2004, £150K. Falls in the elderly: the link
with visual impairment and ophthalmic intervention. PI: Elliott, CI:
The Health Foundation, 2004-2008, £150K. Impact of correctable visual
impairment upon balance control and stepping strategies. Training
Fellowship for Buckley, sponsor: Elliott.
Nursing & Allied Health Professions Award Scheme, Research Capacity
Development, (a predecessor of the NIHR Doctoral Research Fellowship
award), 2005-2008, £211 K. Effects of common forms of visual
impairment upon gait biomechanics during stair/step negotiation in the
elderly. Research Fellowship for Johnson; sponsors: Elliott and
National Institute for Health Research, Public Health Research Programme,
2012-2014, £200K. Manipulating the appearance of steps and stairs to
make them safer for older people to negotiate. PI: Elliott. CIs:
Buckley, Scally, Whitaker.
Details of the impact
Research at Bradford has led to changes in healthcare guidelines and
healthcare training guidelines particularly regarding the prescribing of
bifocals and varifocals and the need to prescribe refractive correction
to older people at risk of falling.
The Importance of Vision in Preventing Falls guidelines (a) were
produced by the College of Optometrists and the British Geriatrics Society
and endorsed by Age UK and the Royal College of General Practitioners in
2011. They are provided on each of these organisation's websites plus
those for Vision2020, the Macular Disease Society, Visibility, the
Glaucoma Association, local NHS falls prevention teams, local optometric
committees and a variety of health-related consumer websites. Elliott was
co-author and lead expert and the guidelines include reference to several
publications from the group (1,4,5). The guidelines have been provided to
~10,000 optometrists practicing in the UK. (b). The significance of the
research was also highlighted in a 2013 review of the literature by the
Thomas Pocklington Trust (c) which explains the scale of the problem of
falls in the elderly and the importance of the research at Bradford
(1,4,5) in the understanding of the role of vision in relation to falls.
Outcomes for older patients at risk of falls due to poor vision have
improved via input into the development of NICE guidelines for falls by
Elliott on behalf of the College of Optometrists (b). In particular, the
new addition of "visual impairment" as a key part of multifactorial
assessments to the June 2013 NICE guidelines for the assessment and
prevention of falls for older people is a significant step forward (d). In
May 2013 the College of Optometrists developed a "Watch your Step"
campaign, which created significant media interest and included College
members sending out 16,000 patient leaflets highlighting the link between
vision and falls (b). A College of Optometrists "Falls Pathway Policy"
steering group (July 2013-present), of which Elliott is a member, is
currently contacting falls teams across the UK to develop links and
determine whether vision measurements, determination of multifocal wear
and optometric referral are part of their assessments (b).
Dissemination of the recommendations in the fall prevention guidelines
(a) to clinicians has occurred via continuing professional development
(CPD) articles in professional journals (e, f), a best-selling clinical
textbook (g) and in CPD lectures. Feedback regarding the usefulness of
these articles was received from a large number of clinicians, who
reported that they were highly relevant to their daily work (e, f).
Invited CPD presentations about "how to help prevent falls in your older
patients" have been given in Hull & East Riding (2008), North Midlands
(2009), Aintree (2010), Royal Society of Medicine, London (2010),
Manchester (2010), Sheffield (2011) and Phoenix USA (2012). Attendance
levels were between 60-150, with very positive feedback regarding
relevance to clinical practice (76-86% either `good' or `excellent'). It
would be fair to say that the understanding of the link between vision and
falls by optometrists, dispensing opticians and orthoptists 10 and even 5
years ago was negligible (b). The efforts described above have made a big
improvement in a short period of time. Hospital optometrists and
clinicians helping visually impaired patients are using the
recommendations provided in the guidelines widely (h) and a recent
independent survey of high street optometrists has indicated a growing
number of optometrists in high street practice feeling able to
appropriately manage older people at risk of falls (i).
We have made considerable efforts to improve public understanding of the
risks of wearing bifocal and varifocal spectacles and the publicity our
work has received has stimulated public debate. Magazine and online
articles in the Consumer Association Which? in 2010 and 2012
highlighted the unsafe practice of buying varifocals and bifocals online
and the problems associated with higher-powered ready readers (j). The Which?
reports led to 18 pieces of media coverage, including a Pugh cartoon in
the Daily Mail and articles discussing the issues in The Daily
Mirror, The Telegraph, the Express and a wide range
of websites (j). The Which? reports also led to two online
companies (Select Specs, Spec Superstore) changing the way that varifocals
and bifocals were ordered online to make provision safer and several
stores, including Poundland, launched their own audits of their ready
readers stock, while Which? also reported some companies to
trading standards, who investigated (j).
Sources to corroborate the impact
a. The Importance of Vision in Preventing Falls (2011).
Guidelines produced by the College of Optometrists and the British
Geriatrics Society and endorsed by Age UK and the Royal College of General
b. Clinical Advisor to The College of Optometrists — impact of `Vision in
Preventing Falls' guidelines, `Watch Your Step' campaign and `Fall Pathways
Policy' steering group.
c. Falls in older people with sight loss: a review of emerging
research and key action points (2013). Thomas Pocklington Trust,
Research Discussion paper 12; June 2013.
d. Falls: assessment and prevention of falls in older people (2013).
NICE clinical guideline 161, June 2013. http://www.nice.org.uk/nicemedia/live/14181/64088/64088.pdf
e. Elliott DB (2012). Falls and vision impairment: guidance for the
optometrist. Optometry in Practice 13(2): 65-76. This
article was received by ~ 10,000 optometrists who are members of the
College of Optometrists. 671 gave feedback on the article and 67%
indicated that it had `good' relevance (97% good or average relevance) to
their work. www.college-optometrists.org
f. Elliott DB (2012). Ophthalmic interventions and advice to help prevent
falls in older patients. Dispensing Optics (December 2012: 4-10).
This was an invited CPD article for the Association of British Dispensing
Opticians and was received by 8,537 dispensing opticians. The article
received feedback from 1,353 of them, of whom 88% indicated that it had
"good" or "excellent" relevance to their work. For readership and feedback
figures contact the CET Co-ordinator at the Association of British
g. Elliott DB. Clinical procedures in primary eye care. 3rd
edition, Elsevier, 2007; 4th edition, Elsevier, 2013 (ISBN:
9780702051944). This is a bestselling textbook used widely by optometrists
and ophthalmologists in the UK and internationally: over 6,000 copies have
been sold since 2008, with average yearly sales of ~ 1,200 and sales by
region of UK & Ireland 49%, USA 22%, Western Europe 14%, Australasia
8%, rest of the world 7%. www.Elsevier.com
h. Chief Optometric Advisor to the Welsh Government, Clinical lead for
the Welsh Low Vision Service.
i. School of Life and Health Sciences, Aston University. This recent
survey of high street optometrists indicated that 36% (75 of 209) felt
confident to assess their patient's risk of falls and of these, 82% stated
that separate single vision distance and near lenses were their lens
design of choice for those aged 65 or over, who were at risk of falls.
j. Which? Consumer Association (http://www.which.co.uk/).
Senior Health Researcher, Which? can confirm the details of the
impact discussed above and the following:
The magazine is sent to 625,000 members whose average age is 60 years and
Which? online has 235,000 members. A subsequent Which? survey indicated
that 45% of members read the article about selling multifocals and other