Perceptions of vision care following neurological impairment: a qualitative study.

BACKGROUND: Visual impairment is a common consequence of neurological impairments, and can impact a person's ability to undertake everyday tasks, affecting their confidence and mental health. Previous qualitative research in the UK has shown inequalities to exist where patients are accessing vision care after stroke, but little is known around the experiences of accessing vision care following other neurological impairments, and a lack of national guidelines prevent standardised care planning. The aim of this qualitative study is to explore the perceptions of vision care after neurological impairment, and to identify possible inequalities and support mechanisms, where it has been possible to access vision care. METHODS: University ethical approval was obtained, and adults with a visual impairment as a result of a neurological impairment were offered an in-depth interview to explore their vision care experiences. Data were collected between April and November 2021 and analysed using iterative, thematic analysis (TA), informed by a social constructionist ideology. RESULTS: Seventeen participants were recruited. Three overarching themes were conceptualised in relation to the participants' perception of vision care: Making sense of the visual impairment; The responsibility of vision care; and Influential factors in care quality perception. CONCLUSION: Inequalities were noted by participants, with most reporting a lack of suitable vision care offered as part of their neurological rehabilitation. Participants were thus burdened with the task of seeking their own support online, and encountered inaccurate and worrying information in the process. Participants noted changes in their identity, and the identity of their family carers, as they adjusted to their vision loss. The findings from this research highlight a need for clinicians to consider the long-term impact of vision loss after neurological impairment, and ensure patients are provided with adequate support and information, and appropriate referral pathways, alleviating this patient burden.

Enhancing learning outcomes through multisensory integration: A fMRI study of audio-visual training in virtual reality.

The integration of information from different sensory modalities is a fundamental process that enhances perception and performance in real and virtual environments (VR). Understanding these mechanisms, especially during learning tasks that exploit novel multisensory cue combinations provides opportunities for the development of new rehabilitative interventions. This study aimed to investigate how functional brain changes support behavioural performance improvements during an audio-visual (AV) learning task. Twenty healthy participants underwent a 30 min daily VR training for four weeks. The task was an AV adaptation of a 'scanning training' paradigm that is commonly used in hemianopia rehabilitation. Functional magnetic resonance imaging (fMRI) and performance data were collected at baseline, after two and four weeks of training, and four weeks post-training. We show that behavioural performance, operationalised as mean reaction time reduction in VR, significantly improves. In separate tests in a controlled laboratory environment, we showed that the behavioural performance gains in the VR training environment transferred to a significant mean RT reduction for the trained AV voluntary task on a computer screen. Enhancements were observed in both the visual-only and AV conditions, with the latter demonstrating a faster response time supported by the presence of audio cues. The behavioural learning effect also transfers to two additional tasks that were tested: a visual search task and an involuntary visual task. Our fMRI results reveal an increase in functional activation (BOLD signal) in multisensory brain regions involved in early-stage AV processing: the thalamus, the caudal inferior parietal lobe and cerebellum. These functional changes were only observed for the trained, multisensory, task and not for unimodal visual stimulation. Functional activation changes in the thalamus were significantly correlated to behavioural performance improvements. This study demonstrates that incorporating spatial auditory cues to voluntary visual training in VR leads to augmented brain activation changes in multisensory integration, resulting in measurable performance gains across tasks. The findings highlight the potential of VR-based multisensory training as an effective method for enhancing cognitive function and as a potentially valuable tool in rehabilitative programmes.

Meeting the need for post-stroke vision care in Australia: a scoping narrative review of current practice.

PURPOSE: Determine current vision care pathways and practices for stroke survivors in Australia and internationally, focusing on identifying reoccurring gaps in these pathways and unmet care needs. METHOD: A scoping narrative review was conducted to identify literature related to post-stroke vision care practices and perspectives of patients and health professionals. RESULTS: A total of 16193 articles were retrieved and 28 deemed eligible for inclusion. Six were Australian, 14 from the UK, four from the USA, and four from within Europe. Post-stroke vision care is largely unstandardized, with substantial inconsistency in the use of vision care protocols, who executes them and at what point in post-stroke care they are utilised. Health professionals and stroke survivors expressed that unmet care needs were primarily a result of lack of education and awareness regarding post-stroke eye problems. Other gaps in care pathways related to the timing of vision assessment, provision of ongoing support, and the integration of eye-care specialists into the stroke team. CONCLUSION: Further research is needed into current Australian post-stroke vision care to accurately assess whether the needs of stroke survivors are being met. Available evidence indicates that in Australia, there is a requirement for well-defined protocols for vision screening, education, management, and referral of stroke survivors.Implications for RehabilitationPost-stroke vision care in Australia is unstandardised, which may cause inequities in vision care provision to Australian stroke survivors in different regions and/or care facilities.Education and training pertaining to stroke-related vision conditions for stroke healthcare professionals and the inclusion of eye-care professionals in stroke care teams is likely to improve gaps in care practice/pathways identified in the current evidence base.Management of stroke-related visual conditions should be inclusive of detailed information provision that is specific to the patients condition(s) and circumstances, as well as ongoing, long-term management strategies/support services to better aid stroke survivor"s reintegration into the community.

Botulinum toxin for the treatment of strabismus.

BACKGROUND: The use of botulinum toxin as an investigative and treatment modality for strabismus is well reported in the medical literature. However, it is unclear how effective it is in comparison with other treatment options for strabismus. OBJECTIVES: The primary objective was to examine the efficacy of botulinum toxin therapy in the treatment of strabismus compared with alternative conservative or surgical treatment options. This review sought to ascertain those types of strabismus that particularly benefit from the use of botulinum toxin as a treatment option (such as small angle strabismus or strabismus with binocular potential, i.e. the potential to use both eyes together as a pair). The secondary objectives were to investigate the dose effect and complication rates associated with botulinum toxin. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, LILACS and three trials registers on 6 July 2022, together with reference checking to identify additional studies. We did not use any date or language restrictions in the electronic searches for trials. SELECTION CRITERIA: We planned to include randomized controlled trials (RCTs) comparing botulinum toxin with strabismus surgery, botulinum toxin alternatives (i.e. bupivacaine) and conservative therapy such as orthoptic exercises, prisms, or lens therapy for people of any age with strabismus. All relevant RCTs identified in this update compared botulinum toxin with strabismus surgery. DATA COLLECTION AND ANALYSIS: We used standard methods expected by Cochrane and assessed the certainty of the body of evidence using GRADE. MAIN RESULTS: We included four RCTs with 242 participants that enrolled adults with esotropia or exotropia, children with acquired esotropia, and children with infantile esotropia. The follow-up period ranged from six to 36 months. Two studies were conducted in Spain, and one each in Canada and South Africa. We judged the included studies to have a mixture of low, unclear and high risk of bias. We did not consider any of the included studies to be at low risk of bias for all domains. All four studies reported the proportion of participants who improved or corrected strabismus, defined as ≤ 10 prism diopters (PD) at six months (two studies) or ≤ 8 PD at one year (two studies). Low-certainty evidence suggested that participants treated with the surgery may be more likely to improve or correct strabismus compared with those who treated with botulinum toxin (risk ratio (RR) 0.72, 95% confidence interval (CI) 0.53 to 0.99; I² = 50%; 4 studies, 242 participants; low-certainty evidence). One study, which enrolled 110 children with infantile esotropia, suggested that surgery may reduce the incidence of additional surgical intervention required, but the evidence was very uncertain (RR 3.05, 95% CI 1.34 to 6.91; 1 study, 101 participants; very low-certainty evidence). Two studies conducted in Spain compared botulinum toxin with surgery in children who required retreatment for acquired or infantile esotropia. These two studies provided low-certainty evidence that botulinum toxin may have little to no effect on achieving sensory fusion (RR 0.88, 95% CI 0.63 to 1.23; I² = 0%; 2 studies, 102 participants) and stereopsis (RR 0.86, 95% CI 0.59 to 1.25; I² = 0%; 2 studies, 102 participants) compared with surgery. Three studies reported non-serious adverse events. Partial transient ptosis (range 16.7% to 37.0%) and transient vertical deviation (range 5.6% to 18.5%) were observed among participants treated with botulinum toxin in three studies. In one study, 44.7% participants in the surgery group experienced discomfort. No studies reported serious adverse events or postintervention quality of life. AUTHORS' CONCLUSIONS: It remains unclear whether botulinum toxin may be an alternative to strabismus surgery as an independent treatment modality among certain types of strabismus because we found only low and very low-certainty evidence in this review update. Low-certainty evidence suggests that strabismus surgery may be preferable to botulinum toxin injection to improve or correct strabismus when types of strabismus and different age groups are combined. We found low-certainty evidence suggesting botulinum toxin may have little to no effect on achievement of binocular single vision compared with surgery in children with acquired or infantile esotropia. We did not find sufficient evidence to draw any meaningful conclusions with respect to need for additional surgery, quality of life, and serious adverse events. We identified three ongoing trials comparing botulinum toxin with conventional surgeries in the varying types of strabismus, whose results will provide relevant evidence for our stated objectives. Future trials should be rigorously designed, and investigators should analyze outcome data appropriately and report adequate information to provide evidence of high certainty. Quality of life and cost-effectiveness should be examined in addition to clinical and safety outcomes.

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.

Measurement of Saccade Parameters in Relation to Adaptation to Homonymous Hemianopia.

Purpose: To report saccade parameters in participants during adaptation to post-stroke homonymous hemianopia. Methods: In a prospective observational case cohort study, adult stroke survivors with new onset homonymous hemianopia were recruited. Using quantitative measurement, saccade parameters were measured and compared between the hemianopic and non-hemianopic sides. Two participants with longitudinal measurements were compared with age-matched controls. Results: Of 144 clinical study participants, quantitative saccade measurements were only possible in 14 due to an inability to visualise targets on the hemianopic side in the majority. In 9 of the 14 participants, at four weeks post-stroke, mean (±SD) saccade latency was significantly longer to the hemianopic (328.4 ± 105.9 ms) compared to the non-hemianopic side (234.7 ± SD53.6 ms; t = 4.2, df = 8, p = 0.003). The number of correct saccadic responses out of 50 was significantly lower to the hemianopic side (36.6 ± SD14.1) in comparison to the non-hemianopic side (44.4 ± SD7.5; t = -3.1, df = 8, p = 0.014). In two participants studied over an eight-week time period, saccadic differences to the hemianopic side persisted despite apparent recovery of visual field. Conclusion: As participants with residual visual field loss were unable to perform quantitative assessments, the widespread use of this approach in this setting is limited. However, in those whom measurements were possible, there were statistically significant differences in saccade parameters between hemianopic and non-hemianopic sides that persisted post-visual recovery. Exploration of saccades in relation to adaptation to hemianopia and response to saccadic scanning/search training requires further examination.

Validation of a vision-screening tool for use by nurses and other non-eye care health practitioners on stroke survivors.

Purpose: To validate a vision-screening tool for use by nurses and other non-eye care health practitioners (NECHP) to aid identification of visual deficits and ocular conditions in stroke survivors.Material and Methods: Stroke survivors were recruited from two metropolitan Sydney public hospitals who had no access to on-site eye care professionals. Those admitted for 3 days and who were able to provide clear responses were randomly allocated into two groups. All were assessed by a NECHP using a purposely designed bedside vision-screening tool to assess their visual function. In Group 1, the orthoptist repeated the assessment with the same vision-screening tool, in Group 2 they performed a comprehensive orthoptic assessment. Levels of agreement and sensitivity and specificity for key outcomes were assessed.Findings: Levels of agreement for most items analyzed for Group 1 reached 80%. Comparison of the screening tool to a comprehensive orthoptist assessment (Group 2), demonstrated high (88.57-91.12%) sensitivity and specificity for detecting pre-existing and acquired visual problems.Conclusion: The vision-screening tool is a valid instrument for use by NECHP, for the detection of vision defects in stroke survivors. Improved detection of eye conditions may facilitate timely identification and management of visual conditions in stroke survivors, potentially improving patient care and rehabilitation outcomes.

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.

National application of the European visual field standards for driving: a survey study.

Aims: To provide an overview of how the European visual field standards for driving (specified in Commission Directive 2009/113/EC) are applied and determine whether individuals with visual field defects are treated equally across Europe. Methods: One ophthalmic expert from each of 32 European countries was invited to participate in an electronic survey. They were presented with threshold and Esterman perimetry results of 15 cases of visual field defects and asked to classify each case as either passed or failed in reference to their national standards. The results were compared with the European Driving Test Group 1 (EDT1), which is a new perimetry algorithm that adheres to the recommendations by the Eyesight Working Group. Fleiss' kappa was used to determine the inter-rater agreement. Results: Twenty-five countries responded. Three of 15 cases were passed by all. Full agreement on a failed case was not reached. Denmark graded most leniently and passed 12 cases. Bulgaria, Romania and Slovakia graded most strictly and passed five cases. The Fleiss' kappa score was 0.52 (95% CI 0.49 to 0.55). Only Slovenia was in full agreement with the EDT1. Fifteen countries endorsed specific perimetric tests for assessing fitness to drive. Five of these also defined pass/fail criteria. Conclusion: The directive fails to establish a uniform approach to the visual field requirements, as evident by moderate pass/fail agreement between the national experts. Because the visual standards for driving are enforced differently, identical visual field loss can result in either revocation or approval of a driving license.

Development of core outcome sets and core outcome measures for central visual impairment, visual field loss and ocular motility disorders due to stroke: a Delphi and consensus study.

OBJECTIVES: Reporting of research for stroke-related visual impairment is inconsistent. The aim of this study was to define three core outcome sets (COS) and related core outcome measurements (COM) for central visual impairment, visual field loss and ocular motility disorders in stroke research. DESIGN: The consensus process consisted of an online three-round Delphi survey followed by a consensus meeting of key stakeholders. SETTING: UK-wide survey. PARTICIPANTS: Stakeholders included orthoptists, occupational therapists, ophthalmologists, stroke survivors and COS users such as researchers, journal editors and guideline developers. OUTCOME MEASURES: For COS development, a list of potentially relevant visual outcomes was created after review of the literature and further grouped into outcome domains. For COM development, a list of potential instruments was created after review of the literature and quality appraised for reliability and validity. RESULTS: COS-119 potential outcomes extracted from published literature. Similar assessment outcomes were grouped into 24 outcome domains. Delphi process included 123 participants in round 1, 65 round 2, 51 round 3. Twelve participants attended the consensus meeting with recommended outcome domains for central visual impairment (visual acuity, functional vision, quality of life), visual field loss (visual fields, functional vision, quality of life) and ocular motility disorders (eye alignment, eye movements, functional vision, quality of life). COM-52 test options extracted from the COS outcomes and grouped into 16 domains. Thirteen participants attended the COM consensus meeting. Recommended instruments for measurement of these outcomes include; Logarithm of the Minimal Angle of Resolution visual acuity, cover test, cardinal position eye movement assessments, peripheral visual field perimetry, Visual Function Questionnaire-25. CONCLUSIONS: COS and COM are defined for vision research for stroke survivors. Their use has potential to reduce heterogeneity in routine clinical practice and improve standardisation and accuracy of vision assessment. Future research is required to evaluate the use of these COS and COM.

Audio-visual stimulation for visual compensatory functions in stroke survivors with visual field defect: a systematic review.

BACKGROUND: Hemianopia is a complete or partial blindness in the visual fields of both eyes, commonly caused by cerebral infarction. It has been hypothesized that systematic audio-visual (AV) stimulation of the blind hemifield can improve accuracy and search times, probably due to the stimulation of bimodal representations in the superior colliculus (SC), an important multisensory structure involved in both the initiation and execution of saccades. METHODS: A narrative synthesis of the findings is presented to highlight how AV rehabilitation impacts on patients with hemianopia including visual oculomotor function, functional ability in activities of daily living, hemianopic dyslexia, visual scanning and searching tasks, maintaining of functional ability post training and the effect on brain multisensory integration by using neuroimaging. RESULTS: Sixteen studies were included (fourteen articles (188 participants) and two literature reviews). Results were grouped into AV training of hemianopia in adults and in children and then further grouped according to the AV task type: tasks measuring the training effects by comparing visual stimulation training to audio-visual training, localization abilities in homonymous hemianopia (HH) and AV integration in patients with HH. CONCLUSION: Systematic AV training may improve the processing of visual information by recruiting subcortical pathways, and because most of the patients with visual cortex damage have an intact SC, it might be useful to use the bimodal AV training to activate retinotectal functions. Nevertheless, the underlying mechanisms supporting the reported positive effects are not currently understood. Systematic functional and/or structural imaging studies may help in understanding the underlying mechanism and inform the design of optimal training paradigms.

Adaptation to post-stroke homonymous hemianopia - a prospective longitudinal cohort study to identify predictive factors of the adaptation process.

PURPOSE: To determine any factors that predict how an individual will adapt to post-stroke hemianopic visual field loss, with close monitoring of the adaptation process from an early stage. MATERIALS AND METHODS: The Hemianopia Adaptation Study (HAST) is a prospective observational longitudinal cohort clinical study. Adult stroke survivors (n = 144) with new onset homonymous hemianopia were monitored using standardised mobility assessment course (MAC) as the primary outcome measure of adaptation. RESULTS: Several baseline variables were found to be good predictors of adaptation. Three variables were associated with adaptation status at 12-weeks post-stroke: inferior % visual field, % total MAC omissions, and MAC completion time (seconds). Baseline measurements of these variables can predict the adaptation at 12 weeks with moderate to high accuracy (area under ROC curve, 0.82, 95% CI 0.74-0.90). A cut-off score of ≤25% target omissions is suggested to predict which individuals are likely to adapt by 12-weeks post-stroke following gold standard care. CONCLUSIONS: Adaptation to hemianopia is a personal journey with several factors being important for prediction of its presence, including MAC outcomes and extent of inferior visual field loss. A clinical recommendation is made for inclusion of the MAC as part of a functional assessment for hemianopia.Implications for rehabilitationThe mobility assessment course (MAC) should be considered as an assessment of mobility/scanning in the rehabilitation of patients with homonymous hemianopia.A cut-off score of ≤25% omissions on MAC could be employed to determine those likely to adapt to hemianopia long-term.Targeted support and therapy for patients with significant visual loss in the inferior visual field area should be considered.

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.

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.

The Use of the Saccadometer to Identify Saccadic Characteristics in Myasthenia Gravis: A Pilot Study.

BACKGROUND: Myasthenia gravis (MG) often presents with ocular signs that mimic other forms of ocular defects, such as isolated cranial nerve palsy. Normal velocity or even hyperfast saccadic eye movements in the presence of deficits of smooth pursuit have been well described in the literature in myasthenic patients. The reason for these paradoxical clinical findings has been reported to be due to increased postsynaptic folding of the fast-twitch fibers responsible for the execution of a saccade which is absent in those fibers responsible for slower, smooth eye movement. Saccadic characteristics therefore offer a point of differential diagnosis between patients suspected of having ocular motility deficits as a result of MG and those caused by other neuropathies. The advent of portable quantitative saccadic assessment means that previously laboratory-based assessments that require specialist equipment and training may now be undertaken clinically, providing a noninvasive test that can aid the differential diagnosis of the condition. The aim of this pilot study was to investigate the feasibility of the saccadometer (Ober Consulting, Poznan, Poland) in detecting the saccadic characteristics associated with myasthenia, specifically normal peak velocity (PV) in a group of patients confirmed with myasthenia. METHODS: A group of 5 patients with a confirmed diagnosis of MG were recruited from a single site into the study along with 5 age-matched healthy volunteers. All myasthenic patients had ocular signs such as underaction or limitations of motility confirmed through ocular clinical examination. Healthy volunteers were screened for any underlying ocular motility or neurological defects before inclusion within the study. All participants undertook 100 trials of both 10 and 20° amplitude saccades, and mean PV, amplitude, and latency were recorded using the saccadometer for each individual. Overall, mean PV, amplitude, and latency were collated for both myasthenic and healthy control groups for each saccade size and compared. RESULTS: The mean PV was significantly greater (481 ± 103.5 deg/seconds) for myasthenic patients compared with healthy controls (384 ± 42.8 deg/seconds) (P < 0.05) in 10° saccades. PV was also greater in myasthenics for 20° saccades; however, this difference did not reach statistical significance for patients with MG (547 ± 89.8 deg/seconds vs 477 ± 104.5 deg/seconds) (P = 0.14). The latency of participants with MG was not significantly different from those of age-matched healthy participants in 10° saccades but was significantly different for 20° saccades. There was no difference in amplitude measured between the groups. CONCLUSIONS: PV for both 10 and 20° saccades was greater in myasthenic patients compared with healthy controls. All myasthenic patients produced normal velocity saccades in the presence of deficits of smooth ocular motility. The results from this small pilot study demonstrate the potential use of the saccadometer in a clinical setting to provide a noninvasive aid in the diagnosis of patients suspected with myasthenia.

Orthoptic service survey in the UK and Ireland during the interim recovery period (summer 2020) of the COVID-19 pandemic.

COVID-19 extended through 2020 with impact on all hospital services. The purpose of this study was to determine the extent of orthoptic service provision during the initial recovery period from July to September 2020 in the UK, Ireland and Channel Islands. We conducted a prospective survey-based cross-sectional study using an online survey aiming for coverage of orthoptic departments across the UK, Ireland and Channel Islands. The survey sought to gather data on orthoptic practice during the COVID-19 pandemic period between the first and second waves in the UK. Questions included within the survey asked about the impact on services paused or reduced during the pandemic, the reinstatement of services, backlog of appointments, changes to arrangement and conduct of appointments, changes to working practice, impact to lives of orthoptists, and access by orthoptists to professional support and guidelines. We circulated the online survey through the British and Irish Orthoptic Society that reaches over 95% of UK and Irish orthoptic services and through social media and orthoptic research networks. This survey was open from July 1st to September 30th 2020 and achieved a response rate from orthoptic departments of 85%. A high rate (92%) of teleconsultations continued with 50% of departments using a proforma to guide the teleconsultation and with added use of risk assessment for patient appointments. To enable reopening of clinics, multiple changes were made for patient and staff flow through clinic areas. Reduced clinical capacity was confirmed by 76.5% of departments. Appointments averaged 15-20 minutes and there was routine use of PPE and cleaning and adoption of staggered appointments with added evening/weekend clinics. There was increased use of information resources/leaflets for patients and dependence on professional and health care guidance documents. The average backlog for patient appointments had increased to 26 weeks. The initial UK and Irish recovery phase in summer 2020 allowed a glimpse at adjustments needed to reopen orthoptic clinics for in-person appointments. Teleconsultation remained in frequent use but with greater risk assessment and triage to identify those requiring in-person appointments.

Standard automated perimetry using size III and size V stimuli in advanced stage glaucoma: an observational cross-sectional comparative study.

OBJECTIVES: In this study, we sought to evaluate the extent of further visual field that could be assessed when using stimulus size V in standard automated perimetry compared with size III in advanced stage glaucoma and whether cut-off values could be determined for when to switch from size III to size V. DESIGN: Prospective cross-sectional study. SETTING: Single-centre outpatient eye clinic in India (New Delhi). PARTICIPANTS: Advanced stage glaucoma defined as stages 3-4. INTERVENTION: Central static perimetry with Octopus 900 G programme (size III stimulus dynamic strategy) and low vision central programme (size V stimulus dynamic strategy). PRIMARY AND SECONDARY OUTCOME MEASURES: Visual field assessment for right and left eyes with both sizes III and V were undertaken within one clinic visit. RESULTS: We recruited 126 patients (170 eyes). Mean patient age at assessment was 55.86 years (SD 15.15). Means (SD) for size III versus size V, respectively, were 6.94 dB (5.58) and 12.98 dB (7.77) for mean sensitivity, 20.02 dB (5.67) and 19.22 dB (7.74) for mean deviation, 5.89 dB (2.29) and 7.69 dB (2.78) for standard loss variance and 3.32 min (1.07) and 6.40 min (1.43) for test duration. All except mean deviation were significantly different between size III and V tests. CONCLUSION: Useful visual field information was obtained with size V stimuli which allowed continued monitoring of these patients that was not possible with size III. Increased test duration, standard loss variance and mean sensitivity were found with size V, as expected, given that more visual responses were obtained with the increased target size. A switch from size III to V may be considered when mean sensitivity reaches 10 dB and/or mean deviation reaches 18 dB.

The Impact of Visual Impairment in Stroke (IVIS) Study - Evidence of Reproducibility.

Reporting generalisable data across stroke populations is important. We aimed to evaluate the Impact of Visual Impairment after Stroke (IVIS) visual assessment protocol in a different UK geographical area. This was a single-centre acute stroke unit, prospective study (IVIS-extension (IVIS-e) study) with comparison to a multi-centre acute stroke cohort (IVIS study). Orthoptists reviewed all stroke survivors with a standardised assessment of visual acuity, visual fields, ocular alignment, ocular motility, visual inattention and visual perception including a standardised follow-up strategy. 123 stroke survivors underwent visual screening: 42% women, 58% men, mean age 63.6 years and 86% ischaemic strokes. Ethnicity consisted of 68.3% white British and 28.5% being Pakistani, Indian, Caribbean, Bangladeshi, Black and Chinese. Two died and 28 could not be assessed. Of the 93 remaining, 10 stroke survivors (10.8%) had a normal visual assessment and 83 (89.2%) had visual impairments detected. Fifty-seven stroke survivors were assessed at their first orthoptic visit within 3 days of stroke onset; the remainder being assessed at subsequent orthoptic visits to the stroke unit. The visual profile was similar across the IVIS-e and original IVIS cohorts for most types of visual impairment although, overall, more visual impairment was detected in IVIS-e. Differences between the cohorts were primarily related to lower age and smaller white British ethnicity in the IVIS-e cohort. This likely relates to the differing population demographics for the two cohort geographical areas. Further roll-out of the IVIS assessment protocol to other regions and countries would improve detection of post-stroke visual impairment.

Identifying priority review questions for Cochrane Eyes and Vision: protocol for a priority setting exercise.

INTRODUCTION: Cochrane Eyes and Vision (CEV) is an international network of individuals working to prepare, maintain and promote access to systematic reviews of interventions to treat, prevent or diagnose eye diseases or vision impairment. CEV plans to undertake a priority setting exercise to identify systematically research questions relevant to our scope, and to formally incorporate input from a wide range of stakeholders to set priorities for new and updated reviews. METHODS AND ANALYSIS: The scope of CEV is broad and our reviews include conditions that are common and have a high global disease burden, for example, cataract and dry eye disease, and conditions that are rare but have a high impact on quality of life and high individual cost such as eye cancer. We plan to focus on conditions prioritised by WHO during the development of the Package of Eye Care Interventions. These conditions were selected based on a combination of data on disease magnitude, healthcare use and expert opinion. We will identify priority review questions systematically by summarising relevant data on research in Eyes and Vision from a range of sources, and compiling a list of 10-15 potential review questions (new and/or updates) for each condition group. We will seek the views of external and internal stakeholders on this list by conducting an online survey. Equity will be a specific consideration. ETHICS AND DISSEMINATION: The study has been approved by the ethics committee of the London School of Hygiene & Tropical Medicine. We will disseminate the findings through Cochrane channels and prepare a summary of the work for publication in a peer-reviewed journal.

Core outcome set for three ophthalmic conditions: a healthcare professional and patient consensus on core outcome sets for amblyopia, ocular motility and strabismus (COSAMS Study).

OBJECTIVES: Amblyopia, strabismus and ocular motility disorders are common conditions with significant impact on visual function, appearance and quality of life. We aimed to establish a core set of outcomes for each of the three conditions for use in clinical trials and routine clinical practice. DESIGN: A comprehensive databank of outcomes was developed from a systematic review of the literature and a series of focus groups with healthcare professionals, researchers, patients and carers. The databank of outcomes was scored in a two-round Delphi Survey completed by two stakeholder groups: healthcare professionals/researchers and patients/carers. Results of the online Delphi were discussed at a face-to-face consensus meeting where the core outcome sets were finalised. SETTING: UK-wide consultation. PARTICIPANTS: Researchers, clinicians, patients and carers. OUTCOME MEASURES: Core outcome sets. RESULTS: For amblyopia, strabismus and ocular motility, 40/42/33 participants contributed to both rounds of the Delphi; six/nine/seven members attended consensus meetings, respectively. Consensus was reached on ten core outcomes for both amblyopia and ocular motility and nine for strabismus. All three conditions shared the core outcomes: adverse events, cost, vision-related quality of life and ocular alignment. The strabismus and ocular motility disorder core sets included, in addition, measuring the deviation, binocular vision, ocular movement, patient satisfaction and symptoms. The amblyopia set, distinct from the sets for the other two conditions, included best corrected distance and near visual acuity, spherical and cylindrical refraction, compliance and treatment-related and functionality/long-term impacts. CONCLUSIONS: The study used robust consensus methods to develop a core outcome set for three ophthalmic conditions. Implementation of these core outcome sets in clinical trials and routine clinical practice will ensure that the outcomes being measured and reported are relevant to all stakeholders. This will enhance the relevance of study findings and enable comparison of results from different studies.