UK exceptional case driving application outcomes in post-stroke homonymous hemianopia: results from a clinical study.

PURPOSE: We report results in relation to returning to driving in the UK under the exceptional cases rule for visual field loss. METHODS: The Hemianopia Adaptation Study is a prospective clinical study recruiting adult stroke survivors with new onset homonymous hemianopia. The mobility assessment course (MAC) was used to measure navigational scanning. Car drivers were offered a 1-year post-stroke assessment to consider referral for driving assessment. RESULTS: Of 144 participants, 51 were eligible for driving assessment, with 13 (25.4%) accepting appointment for UK Driving and Vehicle Licensing Agency (DVLA) referral. A statistically significant difference in gender and baseline Barthel (stroke severity) scores was found between those requesting referral and those declining (p = 0.046; p < 0.001). MAC outcomes were significantly different, with those referred having a lower percentage of target omissions (9.0%) and faster mean course completion time (46.0 s), than those not referred (28.3%/72.5 s) (p = 0.006/p < 0.001). Twelve of the 13 referred were offered a driving assessment by the DVLA. All 12 passed and returned to driving. CONCLUSIONS: It is possible for individuals with post-stroke homonymous hemianopia to return to driving, where exceptional cases criteria are met. There is evidence to support use of the MAC as a clinical measurement of adaptation.IMPLICATIONS FOR REHABILITATIONIndividuals with post-stroke homonymous hemianopia should be fully informed regarding driving regulations that can differ between countries and sometimes different states within a country, as well as provided with the support and opportunity to consider a return to driving if appropriate.Professionals providing care within the stroke multi-disciplinary team should be aware that it is possible for patients with homonymous hemianopia to return to driving, when exceptional cases criteria are met.The mobility assessment course (MAC) should be considered as a clinical measurement of adaptation in homonymous hemianopia.A cut-off score of ≤25% omissions on MAC could be employed to determine those likely to adapt to hemianopia long-term and potentially return to driving.

The Impact of Visual Impairment on Completion of Cognitive Screening Assessments: A Post-Hoc Analysis from the IVIS Study.

Aim: The aim of this study was to evaluate completed cognitive screens in stroke survivors with and without visual impairment to explore whether the presence of visual impairment impacts on completion of cognitive screening. Materials and methods: Cognitive screening assessment was undertaken using the Oxford Cognitive Screen (OCS). Data from visual function assessments (inclusive of visual acuity, visual fields, eye movements and visual perception evaluation) were analysed to determine whether presence and/or type of visual impairment impacted on cognitive screening scores achieved. Covariates, including glasses use, gender, age at stroke onset and stroke type, were used to assess confounding impacts on scores attained during cognitive screening. Results: 1500 stroke admissions were recruited. One hundred ninety-seven who completed the OCS, were identified from the IVIS study database. Those who reported visual symptoms performed worse statistically on all cognitive tasks except the recall recognition (p = 0.232) and executive tasks (p = 0.967). Visual symptoms did not prevent participants from completing every section of the OCS (p = 0.095). In certain tasks, those not wearing their required glasses performed worse, including the executive function (p = 0.012), broken hearts and sentence reading tasks. Conclusions: Many tasks within cognitive screening assessment are impacted by presence of visual deficits, and adjustments, where possible (e.g. good lighting, large print) should be used to facilitate completion of cognitive screening. It is important to ensure required reading correction is worn during screening.

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.

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.

Delivery of high quality stroke and vision care: experiences of UK services.

PURPOSE: We sought to identify exemplars of high quality care provision from established stroke vision services. METHODS: We identified areas of high quality services across the UK, judged as having integrated stroke/vision care provision for stroke survivors. Healthcare professionals were selected to participate in 1:1 interviews or focus groups. A strengths-weaknesses-opportunities-threats (SWOT) framework was used to lead the discussion in a semi-structured format. Thematic analysis was undertaken. RESULTS: Interviewees (n = 24) from 14 NHS Trusts included eye clinic managers, nurses, orthoptists, occupational therapists and physiotherapists. Identified strengths of their services included established communication, training provision for stroke team staff, "open access" for referrals, use of standardised screening/referral forms, provision of lay summaries and information sheets, patients assessed on the stroke unit with continued follow-up and initial visual assessments made within 1 week of stroke onset. Weaknesses included lack of funding, insufficient orthoptic cover, and time consuming retraining of stroke staff because of staff rotation and changes. Opportunities included increasing the number (or length) of orthoptic sessions and training of stroke staff. Perceived threats related to funding and increased appointment waiting times. CONCLUSIONS: Practical elements for improved stroke and vision care provision are highlighted which can be implemented with relatively little financial inputs. Implications for Rehabilitation Integrated vision services within stroke units can improve the detection of visual problems in stroke survivors leading to earlier visual rehabilitation. Orthoptists within core stroke teams are beneficial to the delivery of a high quality service. This study illustrates clear practical elements to support the provision of high quality integrated stroke and vision services. Relatively little financial inputs are required to fund such services but with larger potential to improve patient care.

Care provision for poststroke visual impairment.

BACKGROUND: We sought to explore the care provision for poststroke visual impairment and variations in this in the United Kingdom. METHODS: Survey questions were developed and piloted with clinicians, academics, and users. Questions addressed types of visual problems; how these were identified, treated, and followed up; care pathways in use; links with other professions; and referral options. The survey was accessed via a Weblink, which was circulated through UK professional organizations to multiprofessional members of ophthalmic and stroke teams. RESULTS: A total of 548 completed electronic surveys were obtained. In all, 49.5% of respondents represented stroke teams, 42.5% eye teams, and 8% from other teams, for example, emergency care. Many respondents (41%) saw patients within 1 week of stroke. Nineteen percent did not personally test vision: 11% had a visiting clinician to test vision, and 22% used screening tools. Validated tests were used for the assessment of visual acuity (39.5%), visual field (57.5%), eye movement (48.5%), and visual function (58.5%). Visual problems suspected by family or professionals were high (88.5%). Typical overall follow-up period of vision care was less than 3 months. In all, 46% of respondents used designated care pathways for stroke survivors with visual problems; 33.5% of respondents did not provide visual information leaflets. CONCLUSIONS: Significant inequality exists in care for stroke survivors who experience visual problems. There is great variability in how vision screening is undertaken, which vision tests are used, methods of referral to eye care services, how visual problems are managed, and what vision information is provided to stroke survivors/carers. Further work is required to ensure equality and effective care.

An NGO approach for addressing the nutrition dilemma: Pohnpei focuses on awareness, food analysis, conservation, and food processing.

The establishment of the Island Food Community of Pohnpei, a non-governmental organization (NGO) based in Pohnpei, Federated States of Micronesia, presents a new approach for promoting Pacific Island food for its health and many other benefits. Its vision is holistic, stressing the importance of island food for sustainable development, economic benefits, self-reliance, improved health, cultural preservation, and human dignity, at the same time protecting the natural resources. A major reason for the establishment of this NGO is the emergence of an epidemic of nutrition-related health problems, including diabetes, heart disease, cancer, vitamin A deficiency, and anemia. Although health is at the cornerstone of the establishment of this NGO and health officers are integrally involved, the project is closely associated with the agriculture sector. The Island Food Community of Pohnpei works via an ethnographic participatory inter-agency approach, and its activities include the identification and promotion of nutrient-rich varieties of the traditional staple foods, incorporating the 'Yellow Varieties Message'. There are also activities to conserve rare varieties and to develop small-scale food processing.