People with learning disability in England number ~1.2 million [1]. They face significant health inequalities [2]: people with a learning disability are ten times more likely to have vision problems than the rest of the population [3]; over fifty percent of those with learning disability who died prematurely had a visual problem [4]. Compounding this increase in prevalence of eye disease is research showing that people with learning disability are less likely to have access to eye care than the rest of the population [5, 6]. There are several reviews in the ophthalmic and optometric literature which detail the prevalence and incidence of specific conditions in both paediatric and adult populations with learning (or intellectual) disability [5, 7-11]. People with learning disability have a right to equal standards of health care by law [12]. Several groups, including the Royal College of Ophthalmologists, have called for changes to policy and the whole eye care pathway to allow patients to access services and receive equality of care [13, 14]. In order to address this, the Local Optometric Support Unit have published their refreshed clinical pathway for eye care for people with a learning disability [15]. The document sets out the adjustments to practice that a community optometrist might make in order to provide optimal care for patient with learning disability attending routine primary eye care. A key difference with this refreshed guideline compared with its predecessor is the ambitious aim to improve integration between primary eye care and hospital eye services. By providing services through the LOCSU scheme, the optometrist is agreeing to use their professional judgement and reasoning, drawing on their training and relationship with hospital eye services to determine if the patient would benefit from further assessment by the hospital eye services. When a local pathway is newly established, it is anticipated that for the majority of patients, the optometrist will be meeting the patient for the first time and there will be little in the way of previous records. Few patients with learning disability achieve 'normal' vision [9, 16-19] and it is likely that a high number of ocular abnormalities will be detected [9, 20-22]. Some patients will require hospital eye services for assessment, treatment or registration for sight impairment; but for others with long-standing or congenital ocular abnormalities, referral into the hospital eye service will add little value and be stressful for the patient and carer. Within the LOCSU pathway lie key performance indicators (KPIs) which are to be reported quarterly. These include the percentage of patients referred from the LD community eye care service into secondary eye care, the target for which is set locally. In order to facilitate this, dialogue between primary and secondary care will need to take place to establish what referrals would be considered to add value to the patient or carer. There are few ophthalmologists nationally who frequently encounter patients with a learning disability in their hospital practice and knowing where to start when creating referral criteria or KPIs may create a barrier to services becoming established. In order to address this gap in experience, we set about developing a set of consensus statements regarding referral thresholds for ocular conditions commonly encountered in adults with learning disability.

The introduction cites several studies highlighting the health inequalities faced by people with learning disabilities, particularly regarding access to and prevalence of vision problems. References [1-14] support the claims of increased prevalence of visual problems, reduced access to eye care, and the need for improved pathways and equitable healthcare for this population. The review also acknowledges existing literature detailing the prevalence and incidence of specific eye conditions in both pediatric and adult populations with learning disabilities [5, 7-11], indicating a foundation of prior research informing the current study's objectives.

Eye Health Professionals known to be involved in the community and hospital management of adults with learning disability were approached and invited to participate. The group comprised two specialist learning disability optometrists, two community optometrists and two consultant ophthalmologists. A series of telephone and video interviews were undertaken by one of the authors (RP). A baseline for referral thresholds was drawn up, based on those previously agreed by consensus for the NHS England Special School Eye Care Programme (unpublished). Each member of the group commented on the usability and clarity of each element of the referral criteria and any additional research or evidence which might support the referral threshold. In addition, each contributor was asked to express the overriding principles by which they make decisions regarding referral thresholds for patients with learning disability. Individual comments were collated into the final document which was circulated and agreed upon by all participants.

The study established a set of consensus statements regarding referral thresholds for common ocular conditions in adults with learning disabilities. These statements were developed through a consensus-building process involving a diverse group of eye health professionals. The key findings are presented in a table that outlines referral thresholds for various conditions, including considerations for lids (ptosis, entropion, ectropion, chalazion, trichiasis), anterior segment issues (red eyes, blepharitis), microphthalmos, coloboma, corneal opacity/irregularity, glaucoma, raised intraocular pressure, atypical visual fields, fundus abnormalities (swollen optic disc, diabetic retinopathy, drusen/AMD), ocular motility, nystagmus, and strabismus. For each condition, the table specifies a referral threshold and provides accompanying notes offering practical guidance on assessment and management in community settings, emphasizing the use of alternative communication methods (video/telephone consultations) and leveraging existing schemes like the Minor Eye Condition Scheme (MECS). The overriding principles guiding referral decisions include considering new findings, changes in function, impact on daily living, condition progression, and the availability of community-based management options.

The consensus statements provide a valuable starting point for developing locally agreed referral criteria, aligning with the LOCSU pathway guidance. This addresses the existing gap in experience among ophthalmologists regarding the management of eye conditions in patients with learning disabilities. The study acknowledges the limitations of not offering a comprehensive management review for each condition, but emphasizes the value of the consensus statements in facilitating improved integration between primary and secondary eye care. The focus on using existing schemes, community management options and less invasive diagnostic procedures highlights a patient-centered approach that prioritizes minimizing unnecessary referrals.

This study successfully created a succinct set of consensus statements for referral thresholds for common eye conditions in adults with learning disabilities in the UK. These statements, derived from the collective experience of eye health professionals, serve as a foundation for the development of locally agreed criteria. Future work could involve evaluating the effectiveness of these criteria in improving patient care and reducing inappropriate referrals to secondary care. The development of more detailed clinical guidelines for specific conditions, based on further research and evidence, could be a beneficial next step.

The study's limitations include the relatively small number of participants in the consensus-building process and the reliance on the collective experience of the participants rather than a comprehensive systematic review of the literature. The consensus statements may not be universally applicable across all settings or populations. Further research is needed to validate the effectiveness and generalizability of these criteria.