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Do Stroke Patients Require Vision Assessment? Age and Ageing 2009; 38: 188–193 C The Author 2008. Published by Oxford University Press on behalf of the British Geriatrics Society. doi: 10.1093/ageing/afn230 All rights reserved. For Permissions, please email: [email protected] Published electronically 21 November 2008 Visual impairment following stroke: do stroke patients require vision assessment? FIONA ROWE1,DARREN BRAND2,CAROLE A. JACKSON2,ALISON PRICE3,LINDA WALKER4, SHIRLEY HARRISON5,CARLA ECCLESTON6,CLAIRE SCOTT7,NICOLA AKERMAN8, CAROLINE DODRIDGE9,CLAIRE HOWARD10,TRACEY SHIPMAN11,UNA SPERRING12, SONIA MACDIARMID13,CICELY FREEMAN14 1 Directorate of Orthoptics and Vision Science, University of Liverpool, Thompson Yates Building, Brownlow Hill, Liverpool L69 Downloaded from https://academic.oup.com/ageing/article/38/2/188/16402 by guest on 29 September 2021 3GB, UK 2Department of Orthoptics, Royal United Hospitals NHS Trust, Combe Park, Bath BA1 3NG, UK 3Department of Orthoptics, Sandwell and West Birmingham NHS Trust, City Hospital, Birmingham B18 7QH, UK 4Department of Orthoptics, East Lancashire Hospitals NHS Trust, Royal Blackburn Hospital, Lancashire, BB2 3HH, UK 5Department of Orthoptics, Bury PCT, Bury, Lancashire BL9 0EN, UK 6Department of Orthoptics, Derby Hospitals NHS Foundation Trust, Derby City General Hospital, Derby, Derbyshire, DE22 3NE, UK 7Department of Orthoptics, Ipswich Hospital NHS Trust, Ipswich, Suffolk IP4 5PD, UK 8Department of Orthoptics, University Hospitals NHS Trust, Southampton, Hampshire SO16 6YD, UK 9Department of Orthoptics, Oxford Radcliffe Hospitals NHS Trust, Headley Way Headington, Oxford OX3 9DU, UK 10Department of Orthoptics, Salford Primary Care Trust, Pendleton Way, Salford M6 5FW, UK 11Department of Orthoptics, Sheffield Teaching Hospitals Foundation Trust, Glossop Road, Sheffield S10 2JF, UK 12Department of Orthoptics, Swindon and Marlborough NHS Trust, Marlborough Road, Swindon SN3 6BB, UK 13Department of Orthoptics, Wrightington, Wigan and Leigh NHS Trust, Wigan Lane, Wigan WN1 2NN, UK 14Department of Orthoptics, Worcestershire Acute Hospitals NHS Trust, Charles Hasting Way, Worcester WR5 1DD, UK Address correspondence to: F. Rowe. Tel: (+44) 0151 7945732; Fax: (+44) 0151 7945781. Email: [email protected] Abstract Background: the types of visual impairment followings stroke are wide ranging and encompass low vision, eye movement and visual field abnormalities, and visual perceptual difficuilties. Objective: the purpose of this paper is to present a 1-year data set and identify the types of visual impairment occurring following stroke and their prevalence. Methods: a multi-centre prospective observation study was undertaken in 14 acute trust hospitals. Stroke survivors with a suspected visual difficulty were recruited. Standardised screening/referral and investigation forms were employed to document data on visual impairment specifically assessment of visual acuity, ocular pathology, eye alignment and movement, visual perception (including inattention) and visual field defects. Results: three hundred and twenty-three patients were recruited with a mean age of 69 years [standard deviation (SD) 15]. Sixty-eight per cent had eye alignment/movement impairment, 49% had visual field impairment, 26.5% had low vision and 20.5% had perceptual difficulties. Conclusions: of patients referred with a suspected visual difficulty, only 8% had normal vision status confirmed on exam- ination. Ninety-two per cent had visual impairment of some form confirmed which is considerably higher than previous publications and probably relates to the prospective, standardised investigation offered by specialist orthoptists. However, under-ascertainment of visual problems cannot be ruled out. Keywords: visual impairment, stroke, ocular motility, visual field, visual perception, elderly Introduction Low vision can relate to associated vascular pathology or to other co-existent ocular abnormalities [10]. Visual field Every year, an estimated 110,000 people in the UK have loss commonly will involve a homonymous hemianopia or a stroke [1]. The visual sequelae of stroke are many [2–9]. quadrantanopia [3, 4, 7, 12]. Ocular motility disorders can be 188 Visual impairment following stroke divided into cortical deficits of eye movements and brain stem signs, investigation of visual field, ocular motility and percep- defects. Visual perception difficulties are wide ranging [13]. tual aspects. Visual fields are assessed by confrontation if the The most commonly recognised is visual inattention/neglect patient is seen on the ward or rehabilitation unit. When seen [8, 9]. in clinic, quantitative measures of visual field are undertaken Visual problems such as complete hemianopia or large by Humphrey automated perimeter and Goldmann manual strabismus can be spotted easily. Subtle disorders such as perimeter. Complete homonymous hemianopia was defined impaired fast eye movements and gaze defects can be diffi- as loss of visual field to one side from central fixation and the cult to identify without correct evaluation of the visual sys- vertical meridian of the field outwards. Partial homonymous tem. A significant proportion of patients in stroke units have hemianopia was defined as loss of visual field to one side that unrecognised visual problems resulting in little or no advice was incomplete with some residual vision on the affected side or management [2, 14]. The eye-care team can address many near the vertical meridian of the field. of these issues directly along with timely feedback of such Assessment of ocular alignment and motility consists information to other health professionals involved in the care of cover test, evaluation of saccadic, smooth pursuit and Downloaded from https://academic.oup.com/ageing/article/38/2/188/16402 by guest on 29 September 2021 of these patients [11]. vergence eye movements, retinal correspondence (Bagolini The impact of visual impairment can be wide ranging. glasses), fusional vergence (20D or fusional range), stereopsis The impact on functional performance can include general (Frisby near test), prism cover test and lid and pupil function. mobility, ability to judge distances due to diplopia or impaired Perceptual deficits are recorded after questioning of the stereo vision, reading impairment due to cortical or ocular patient and/or carers and relatives. Inattention is assessed dysfunction and visual hallucinations. Impact to quality of by means of a combination of assessments including line life includes changes to independent living, ability to drive, bisection, Albert’s test, cancellation tests, memory tests using loss of confidence and links to depression [16–20]. verbal description and drawing. Although it is recognised that many patients will suffer Visual acuity was assessed at near and distance fixation visual disability as a result of stroke, data are lacking as to the with Snellen or logMAR acuity tests. Low visual acuity was prevalence of disability, extent and recovery. There are little considered in two categories. The first defined low visual data with respect to strabismus and ocular motility disorders acuity as less than best corrected 6/12 Snellens acuity or following stroke [3–5, 21]. 0.3 logMAR in accordance with UK driving standards [22]. In May 2006, a prospective multi-centre trial commenced The second defined low visual acuity as <6/18 Snellens acuity in the UK. The primary aim is to evaluate the effect of or 0.5 logMAR and equal to or better than 3/60 Snellens stroke on vision: specifically ocular perception, alignment acuity as per World Health Organisation (WHO) guidelines and movement, how these impact on quality of life and the [23]. Additionally, WHO define low vision as a corresponding information that is required from visual assessment for the visual field loss to <20 degrees in the best corrected eye. multidisciplinary team. The purpose of this paper is to high- WHO define blindness as a visual acuity of <3/60 Snellens light the extent of visual impairment occurring within this acuity or a corresponding visual field loss to <10 degrees in stroke population. the best corrected eye. Stroke details are recorded from patient notes accounting for stroke laterality, type and area involved. Ocular treatment Methods and materials details are recorded along with outcome. Results were inputted to the statistical package SPSS The design is a prospective multi-centre observational case version 15. cohort trial with ethical approval. The vision in stroke (VIS) group consists of local investigators responsible for assess- ing stroke patients and collecting patient data. The data are Results collated centrally at the University of Liverpool. The study is being undertaken in accordance with the Tenets of Helsinki. Data are presented from a 1-year data set: 1 May 2006 to The target population was stroke patients suspected of 30 April 2007. Five hundred and one patients were referred having a visual difficulty. Referrals could be made from for visual assessment. One hundred and seventy-eight pa- inpatient wards, rehabilitation units, community services or tients were excluded (49% male, 51% female: Table 1). Pa- outpatient clinics. Patients were given an information sheet tients were not excluded because of the type or severity of and recruited after informed, written consent. The patients were excluded if they were unable to consent, unwilling to Table 1. Reasons for exclusion consent, if their diagnosis was that of transient ischaemic attack or if they were discharged without vision assessment. Inability to consent (cognitive
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