Developing a stroke-vision care pathway: a consensus study.

PURPOSE: We aimed to develop a stroke-vision care pathway for stroke survivors with visual impairment. METHODS: A literature review searched key electronic bibliographic databases for care pathways related to stroke/vision. Two focus group meetings using semi-structured/nominal group technique reached consensus on items relevant for inclusion in a stroke-vision care pathway. Following the development of the pathway, we obtained feedback through consultation with patient and professional groups. RESULTS: The literature review identified two care pathways relevant to acute stroke and generic vision disorders. Outputs from focus groups related to how stroke survivors present with vision problems; the time points at which stroke survivors present with vision symptoms; the relevance of different types of visual condition to different vision services; the importance of support services supplementary to hospital services and; the importance of key resources to promote awareness of vision problems in stroke survivors. Refinement of the pathway considered time duration from stroke onset, reporting of symptoms to services, and signposting/referrals required dependent on visual condition type. CONCLUSIONS: This new stroke-vision care pathway is a process pathway describing potential options for stroke survivors with visual impairment to access health care and obtain appropriate referral(s) to vision services relevant to their specific vision problem(s).IMPLICATIONS FOR REHABILITATIONVisual impairment is a common consequence of stroke.It is imperative that those who care for stroke survivors are aware of the visual consequences of stroke and make the appropriate referrals for vision and support services.The stroke-vision care pathway is a process pathway that describes the potential options for stroke survivors with visual impairment to access health care and obtain the appropriate referral(s) to vision services relevant to their specific vision problem(s).The stroke-vision care pathway is available (free to download) from the VISION research unit (www.vision-research.co.uk) website and available as supplemental information with this publication.

Impact of visual impairment following stroke (IVIS study): a prospective clinical profile of central and peripheral visual deficits, eye movement abnormalities and visual perceptual deficits.

AIM: This study evaluates the spectrum of visual impairment in stroke survivors. METHODS: The Impact of Visual Impairment after Stroke (IVIS) study is a multi-centre, acute stroke unit, prospective epidemiology study. Comprehensive visual examination was offered to all stroke survivors. RESULTS: 1500 stroke admissions were recruited. 1204 stroke survivors had visual assessment. Reduced central vision was documented in 529, visual field loss in 308, ocular motility abnormalities in 533 stroke survivors, visual perception deficits in 59 stroke survivors and visual inattention in 315 stroke survivors. About half, regardless of visual impairment type, were visually asymptomatic. Recovery, whether full or partial, was best for central vision, ocular motility abnormalities and visual perception deficits (about 70% improvement) occurring over a mean follow-up period of 2-3 months. CONCLUSIONS: Incidence of impaired central vision, visual field loss, ocular motility disorders and visual inattention was 29.4%, 24.8%, 39.3% and 26.2% respectively. Visual impairment was more likely to occur in more severe stroke and older stroke survivors. Asymptomatic cases raise concerns for acute stroke units where robust specialist vision screening is not routine. Those with partial/no recovery require specialist follow-up and management whilst the wide range of abnormalities highlight the need for specialist visual assessment acutely.Implications for rehabilitationVisual impairment is a common consequence of stroke.Incidence of visual impairment is about 60%.Significant numbers of stroke survivors are visually asymptomatic, highlighting the need for standardised vision assessments.Many stroke survivors have persistent long-term visual impairment, necessitating referral and access to specialist eye care services.

"Eye" Don't See: An Analysis of Visual Symptom Reporting by Stroke Survivors from a Large Epidemiology Study.

AIM: The purpose was to explore the reported symptoms of post-stroke visual impairment from a large multi-centre prospective epidemiology study. METHODS: Visual assessment, including a case history, visual acuity, ocular alignment, ocular motility, visual fields, visual inattention and visual perception, was attempted for all stroke admissions to three acute stroke units. RESULTS: Of 1500 stroke admissions, 1204 received a visual assessment, of which 867 had one or more visual impairments. Of those identified with visual impairment 44.4% reported visual symptoms. The most common visual symptoms were blurred/altered vision (22.1%), field loss (12.6%), diplopia (9.9%) and reading difficulties (9.7%). 703 were identified to have a new visual impairment, 47.1% reported visual symptoms. No visual symptoms were reported by 38.4% and 14.5% were unable to report symptoms. Visual symptoms were first reported at a median of 3 days (IQR2-8) and mean of 16.0 days (SD39.8) from stroke onset. Those that reported symptoms were younger (p<0.001) and more independent (p<0.001) than those who were asymptomatic or unable to report. No significant difference was found between likelihood of reporting visual symptoms or not based on severity of reduced central vision, visual field loss or visual inattention. Stroke survivors with a manifest squint and cranial nerve palsies were significantly more likely to report symptoms. CONCLUSIONS: Almost 40% of stroke survivors with new onset visual impairment do not or cannot report visual symptoms. This highlights the importance of objective screening to ensure stroke survivors receive appropriate and timely referral to specialist services to access necessary treatment.

Accuracy of kinetic perimetry assessment with the Humphrey 850; an exploratory comparative study.

AIM: To compare kinetic perimetry on the Humphrey 850 and Octopus 900 perimeters for assessment of visual fields, uniocular rotations and fields of binocular single vision. METHODS: Prospective cross section study comparing Humphrey 850 kinetic perimetry to kinetic perimetry using the Octopus 900. Results were compared for both perimeters for the measurement of visual field boundaries, uniocular rotations and fields of binocular single vision in subjects with normal visual function, with comparisons of mean vector extremity values and duration of testing. A visual field boundary overlay was used to assess detection potential of Humphrey 850 kinetic perimetry using I4e and I2e targets in results of known abnormal visual fields. RESULTS: Fifteen subjects (30 eyes) with normal parameters of visual function underwent dual perimetry assessment. Mean visual field boundaries and ocular rotation extremity values were similar for Humphrey and Octopus kinetic perimetry along horizontal meridians. Measurements for Humphrey perimetry were significantly smaller for superior and inferior visual field and rotations with ceiling effects at approximately 40 and 50 degrees, respectively. Use of visual field boundary overlays for 140 patient results showed high detection of the known abnormal visual field results by the Humphrey 850 perimeter (91.4% with I4e target; 95% with I2e target) but with notable exceptions for peripheral superior visual field defects. CONCLUSIONS: The Humphrey perimeter's aspheric bowl introduces a ceiling effect for measurements in the superior and inferior visual field at approximately 40 and 50 degrees respectively. This results in potential diagnostic accuracy issues when measuring uniocular rotations, fields of binocular single and visual field boundaries in conditions that specifically impair superior and/or inferior ocular motility (e.g., thyroid eye disease) or visual fields (e.g., chiasmal compression).

High incidence and prevalence of visual problems after acute stroke: An epidemiology study with implications for service delivery.

BACKGROUND: Visual problems are an under-reported sequela following stroke. The aim of this study is to report annual incidence and point prevalence of visual problems in an acute adult stroke population and to explore feasibility of early timing of visual assessment. METHODS AND FINDINGS: Multi-centre acute stroke unit, prospective, epidemiology study (1st July 2014 to 30th June 2015). Orthoptists reviewed all patients with assessment of visual acuity, visual fields, ocular alignment, ocular motility, visual inattention and visual perception. 1033 patients underwent visual screening at a median of 3 days (IQR 2) and full visual assessment at a median of 4 days (IQR 7) after the incident stroke: 52% men, 48% women, mean age 73 years and 87% ischaemic strokes. Excluding pre-existent eye problems, the incidence of new onset visual sequelae was 48% for all stroke admissions and 60% in stroke survivors. Three quarters 752/1033 (73%) had visual problems (point prevalence): 56% with impaired central vision, 40% eye movement abnormalities, 28% visual field loss, 27% visual inattention, 5% visual perceptual disorders. 281/1033 (27%) had normal eye exams. CONCLUSIONS: Incidence and point prevalence of visual problems in acute stroke is alarmingly high, affecting over half the survivors. For most, visual screening and full visual assessment was achieved within about 5 days of stroke onset. Crucial information can thus be provided on visual status and its functional significance to the stroke team, patients and carers, enabling early intervention.

Visual Impairment Screening Assessment (VISA) tool: pilot validation.

OBJECTIVE: To report and evaluate a new Vision Impairment Screening Assessment (VISA) tool intended for use by the stroke team to improve identification of visual impairment in stroke survivors. DESIGN: Prospective case cohort comparative study. SETTING: Stroke units at two secondary care hospitals and one tertiary centre. PARTICIPANTS: 116 stroke survivors were screened, 62 by naïve and 54 by non-naïve screeners. MAIN OUTCOME MEASURES: Both the VISA screening tool and the comprehensive specialist vision assessment measured case history, visual acuity, eye alignment, eye movements, visual field and visual inattention. RESULTS: Full completion of VISA tool and specialist vision assessment was achieved for 89 stroke survivors. Missing data for one or more sections typically related to patient's inability to complete the assessment. Sensitivity and specificity of the VISA screening tool were 90.24% and 85.29%, respectively; the positive and negative predictive values were 93.67% and 78.36%, respectively. Overall agreement was significant; k=0.736. Lowest agreement was found for screening of eye movement and visual inattention deficits. CONCLUSIONS: This early validation of the VISA screening tool shows promise in improving detection accuracy for clinicians involved in stroke care who are not specialists in vision problems and lack formal eye training, with potential to lead to more prompt referral with fewer false positives and negatives. Pilot validation indicates acceptability of the VISA tool for screening of visual impairment in stroke survivors. Sensitivity and specificity were high indicating the potential accuracy of the VISA tool for screening purposes. Results of this study have guided the revision of the VISA screening tool ahead of full clinical validation.