Sight and StrokeEducational Presentation Pack on Visual Defects

Associated with Stroke

Produced by the Scottish AHP Practice Development Network-Orthoptics

Presentation Aims & Objectives

• To educate health professionals about the range of visual defects that affect patients following a stroke

• This presentation will help health professionals identify those patients suspected of having orthoptic and/or visual field defects

• Raise awareness within the stroke MDT of identified defects and how these contribute to a patients rehabilitation

• Increase awareness of the range of assessments and treatments used by Orthoptists if someone has visual difficulties associated with stroke

Role of the Orthoptist

• Specialise in assessment of visual function• Monitor visual development• Assess, diagnose and treat ocular muscle

defects (congenital/acquired)• Assess visual fields• Work closely with Ophthalmologists• Hospital based but also work in community

and school settings

Guidelines

• British and Irish Orthoptic Society- Standards of Proficiency 2006

• SIGN guidelines- recommend visual assessment

• NICE -National clinical guidelines for stroke do not mention the assessment of vision

Sight and Stroke Facts

• Many patients suffer from visual difficulties following stroke (70% SIGN)

• Strong link between visual problems and outcomes of rehabilitation (Rowe 2003)

• Early diagnosis, treatment and visual rehabilitation is important (Rowe 2003)

• Benefits of orthoptic treatment well recognised (Rowe 2003)

• Evidence suggests that persistent visual difficulties related to attention may continue even though rehabilitation is considered complete. These may not be detected by standard tests (Cunningham et al 2004)

• Orthoptic services are currently provided throughout Scotland

Common Symptoms of Visual Difficulties in Stroke

• Reduced vision and loss of vision• Ghosting of images• Hallucinations• Visual Agnosia (visual neglect)• Eye movement defects• Eye strain• Frontal Headache• Diplopia• Oscillopsia (apparent movement of objects)

Common Signs of Visual Difficulties in Stroke

• Loss of awareness of people and objects especially on one side

• Poor orientation• Patients closing one eye• Apparent visual discomfort• Eye-hand co-ordination difficulties• Clumsiness• Spatial awareness difficulties• Compensatory head or body posture• Nystagmus

Visual Field Defects

• Variable in nature/severity• In the literature the incidence of visual field

defects ranges from 50% - 72% (Freeman 2002, MacIntosh 2003, Clisby 1995, Freeman and Rudge 1988).

• The most common condition is homonymous hemianopia with an incidence of 30%

• Very slight visual field restoration can occur naturally. Recovery is often within the first month after onset

• Few therapeutic approaches exist

Why identify visual defects?

• Important for rehabilitation

• Ward position may aid resolution

• Driving standards

• Blind/partial sighted registration

Visual Pathway

Prism Therapy for Hemianopia

• Fresnel prisms placed on patients glasses

• Creates a visual displacement of peripheral field on the “blind” side

• “extends” patients functioning visual field

Homonymous Hemianopia Handy Hints

• Clear explanation of defect important for patient safety

• Improved communication can be achieved by addressing the patient on sighted side

• Typoscope/bright targets aid reading activities

• Steady eye strategy can help reading activities

• Prism therapy can enhance use of existing visual field

Diplopia (Double Vision)

• Diplopia can occur following stroke in the presence of cranial nerve palsies, supranuclear and infranuclear ocular motility defects

• Disruption of vascular supply to ocular nerve or muscles can result in diplopia

• Abducens (VIth Cranial Nerve)• Oculomotor (IIIrd Cranial Nerve)• Trochlear (IVth Cranial Nerve)• Diplopia often results following transient ischemic

attack (TIA)• Diplopia may be intermittent or constant• Diplopia may be horizontal, vertical or tilted and may

be distant dependent

VIth nerve palsy/Lateral Rectus Palsy

Most common nerve paresis Most common nerve paresis Often more troublesome for distance viewingOften more troublesome for distance viewingEye horizontally misalignedEye horizontally misalignedHorizontal diplopia- an example can be seen aboveHorizontal diplopia- an example can be seen above

IIIrd Nerve Paresis

• Multiple muscle involvement• Possible ptosis- diplopia not

complained of if lid covers eye• Dilated pupil possible however

pupillary involvement less common with vascular aetiology

• Eye position= out and down• Combined horizontal and vertical

diplopia

IVth Nerve Palsy

• Torsional diplopia often troublesome for patient and difficult to treat

• Particular problems for close work• Difficulty negotiating stairs or uneven surfaces

Vertical and Horizontal Diplopia

• May also be caused by conditions other than nerve paresis

• Thorough investigation is recommended

• Prompt assessment and treatment are beneficial to rehabilitation and prognosis

Orthoptic Management of Diplopia

• Prisms• Teaching Head Posture• Bangerter Foils/ Occlusion• Education of patient• Monitoring of recovery• Botulinum Toxin

Importance of Glasses

The stronger a patients glasses are the more dependant they will be on them

Carers should try to determine: If a patient has glasses? What activities the glasses would normally

be used for? If the patient has more than one pair of

glasses, e.g. reading glasses, glasses for distance use.

Appropriate Referrals

• Suspected - Diplopia- Visual field defects- Visual neglect- Bilateral visual acuity defects- Nystagmus- Spatial awareness problems

Inappropriate Referrals

• Ocular pain/discomfort• Suspected infection• Uniocularly reduced visual acuity

• All of the above and any ocular emergencies must be referred via medical staff to an ophthalmologist

To improve patients quality of care following a stroke and assist in their rehabilitation.

• Thanks go to all who helped to develop this presentation. In particular we would like to thank the Practice Development Team at NHS QIS, the Practice Development Representatives, Darren Brand and Sonia McGuinness.

• Remember to download our leaflet and poster which accompany this presentation at www.nhshealthquality.org/ahp

References

• Rowe, F, (2003) Supranuclear and internuclear control of eye movements: a review, British Orthoptic Journal 60

• Freeman CF, Rudge NB. (1988) Cerebrovascular accident and the Orthoptist. British Orthoptic Journal. 45: 8-18

• Freeman CF. (2003) Collaborative working on a stroke-rehabilitation ward. Parallel Vision (British and Irish Orthoptic Society). 56: 3

• MacIntosh C. (2003) Stroke re-visited: visual problems following stroke and their effect on rehabilitation. British Orthoptic Journal. 60: 10-14

• Fowler MS, Wade DT, Rochardson AJ, Stein JE. (1996) Squints and diplopia seen after brain damage. Journal of Neurology. 243: 86-90

• Clisby, C: Visual Assessment Of Patients With Cerebrovascual Accident On The Elderly Care Wards. British Orthoptic Journal 1995;52:38

• I. Cunningham; F.J.Rowe; P.C. Knox; A.C. Fisher and C.Jack.(2004) Attentional visual field analysis amongst stroke survivors, British Orthoptic Journal 61