"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.

Stroke-Related Visual Impairment; is There an Association with Atrial Fibrillation?

BACKGROUND/OBJECTIVES: Stroke-related visual impairment and atrial fibrillation are both common following stroke. This study explores whether presence of visual impairment following stroke is associated with presence of atrial fibrillation (AF). SUBJECTS/METHODS: The Impact of Visual Impairment after Stroke (IVIS) study is a multi-centre, acute stroke unit, prospective epidemiology study. Standardised visual assessments included visual acuity, reading, visual fields, eye movements and visual perception. AF and blood pressure (BP) were measured on admission. Further data capture included stroke type, age, gender, stroke severity. Analysis included descriptive statistics, independent samples analysis and multivariate analysis for comparison of AF and visual impairment against covariates. RESULTS: 1500 stroke admissions were recruited of which 1204 stroke survivors had visual assessment. New onset stroke-related visual impairment (n = 703) was significantly associated with older age and stoke severity. AF and BP data were available for 889 stroke survivors. AF was present on admission for 258 stroke survivors and significantly associated with older age, stroke severity and discharge destination. A significant association was found for presence of AF and presence of visual impairment. However, stroke severity was a contributing factor for this association. High systolic BP (>140 mmHg) was present in 62% and high diastolic BP (>90 mmHg) in 29%, but not associated with presence of visual impairment. CONCLUSIONS: AF and visual impairment, independently, occur commonly in stroke. Although our results show an association between AF and visual impairment, this appears to be independently influenced by stroke severity. AF was not associated with type of visual impairment or extent of visual recovery. It remains unknown if AF causes more severe visual impairment.

Interventions for eye movement disorders due to acquired brain injury.

BACKGROUND: Acquired brain injury can cause eye movement disorders which may include: strabismus, gaze deficits and nystagmus, causing visual symptoms of double, blurred or 'juddery' vision and reading difficulties. A wide range of interventions exist that have potential to alleviate or ameliorate these symptoms. There is a need to evaluate the effectiveness of these interventions and the timing of their implementation. OBJECTIVES: We aimed to assess the effectiveness of any intervention and determine the effect of timing of intervention in the treatment of strabismus, gaze deficits and nystagmus due to acquired brain injury. We considered restitutive, substitutive, compensatory or pharmacological interventions separately and compared them to control, placebo, alternative treatment or no treatment for improving ocular alignment or motility (or both). SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (containing the Cochrane Eyes and Vision Trials Register) (2017, Issue 5), MEDLINE Ovid, Embase Ovid, CINAHL EBSCO, AMED Ovid, PsycINFO Ovid, Dissertations & Theses (PQDT) database, PsycBITE (Psychological Database for Brain Impairment Treatment Efficacy), ISRCTN registry, ClinicalTrials.gov, Health Services Research Projects in Progress (HSRProj), National Eye Institute Clinical Studies Database and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP). The databases were last searched on 26 June 2017. No date or language restrictions were used in the electronic searches for trials. We manually searched the Australian Orthoptic Journal, British and Irish Orthoptic Journal, and ESA, ISA and IOA conference proceedings. We contacted researchers active in this field for information about further published or unpublished studies. SELECTION CRITERIA: We included randomised controlled trials (RCTs) of any intervention for ocular alignment or motility deficits (or both) due to acquired brain injury. DATA COLLECTION AND ANALYSIS: Two review authors independently selected studies and extracted data. We used standard methods expected by Cochrane. We employed the GRADE approach to interpret findings and assess the quality of the evidence. MAIN RESULTS: We found five RCTs (116 participants) that were eligible for inclusion. These trials included conditions of acquired nystagmus, sixth cranial nerve palsy and traumatic brain injury-induced ocular motility defects. We did not identify any relevant studies of restitutive interventions.We identified one UK-based trial of a substitutive intervention, in which botulinum toxin was compared with observation in 47 people with acute sixth nerve palsy. At four months after entry into the trial, people given botulinum toxin were more likely to make a full recovery (reduction in angle of deviation within 10 prism dioptres), compared with observation (risk ratio 1.19, 95% CI 0.96 to 1.48; low-certainty evidence). These same participants also achieved binocular single vision. In the injection group only, there were 2 cases of transient ptosis out of 22 participants (9%), and 4 participants out of 22 (18%) with transient vertical deviation; a total complication rate of 24% per injection and 27% per participant. All adverse events recovered. We judged the certainty of evidence as low, downgrading for risk of bias and imprecision. It was not possible to mask investigators or participants to allocation, and the follow-up between groups varied.We identified one USA-based cross-over trial of a compensatory intervention. Oculomotor rehabilitation was compared with sham training in 12 people with mild traumatic brain injury, at least one year after the injury. We judged the evidence from this study to be very low-certainty. The study was small, data for the sham training group were not fully reported, and it was unclear if a cross-over study design was appropriate as this is an intervention with potential to have a permanent effect.We identified three cross-over studies of pharmacological interventions for acquired nystagmus, which took place in Germany and the USA. These studies investigated two classes of pharmacological interventions: GABAergic drugs (gabapentin, baclofen) and aminopyridines (4-aminopyridines (AP), 3,4-diaminopyridine (DAP)). We judged the evidence from all three studies as very low-certainty because of small numbers of participants (which led to imprecision) and risk of bias (they were cross-over studies which did not report data in a way that permitted estimation of effect size).One study compared gabapentin (up to 900 mg/day) with baclofen (up to 30 mg/day) in 21 people with pendular and jerk nystagmus. The follow-up period was two weeks. This study provides very low-certainty evidence that gabapentin may work better than baclofen in improving ocular motility and reducing participant-reported symptoms (oscillopsia). These effects may be different in pendular and jerk nystagmus, but without formal subgroup analysis it is unclear if the difference between the two types of nystagmus was chance finding. Quality of life was not reported. Ten participants with pendular nystagmus chose to continue treatment with gabapentin, and one with baclofen. Two participants with jerk nystagmus chose to continue treatment with gabapentin, and one with baclofen. Drug intolerance was reported in one person receiving gabapentin and in four participants receiving baclofen. Increased ataxia was reported in three participants receiving gabapentin and two participants receiving baclofen.One study compared a single dose of 3,4-DAP (20 mg) with placebo in 17 people with downbeat nystagmus. Assessments were made 30 minutes after taking the drug. This study provides very low-certainty evidence that 3,4-DAP may reduce the mean peak slow-phase velocity, with less oscillopsia, in people with downbeat nystagmus. Three participants reported transient side effects of minor perioral/distal paraesthesia.One study compared a single dose of 4-AP with a single dose of 3,4-DAP (both 10 mg doses) in eight people with downbeat nystagmus. Assessments were made 45 and 90 minutes after drug administration. This study provides very low-certainty evidence that both 3,4-DAP and 4-AP may reduce the mean slow-phase velocity in people with downbeat nystagmus. This effect may be stronger with 4-AP. AUTHORS' CONCLUSIONS: The included studies provide insufficient evidence to inform decisions about treatments specifically for eye movement disorders that occur following acquired brain injury. No information was obtained on the cost of treatment or measures of participant satisfaction relating to treatment options and effectiveness. It was possible to describe the outcome of treatment in each trial and ascertain the occurrence of adverse events.

A Randomised Controlled Trial of Treatment for Post-Stroke Homonymous Hemianopia: Screening and Recruitment.

The authors report the screening process and recruitment figures for the VISION (Visual Impairment in Stroke; Intervention Or Not) trial. This is a prospective, randomised, single-blinded, three-arm controlled trial in 14 UK acute hospital stroke units. Stroke teams identified stroke survivors suspected as having homonymous hemianopia. Interventions included Fresnel prisms versus visual search training versus standard care (information only). Primary outcome was change in visual field assessment from baseline to 26 weeks. Secondary measures included change in quality-of-life questionnaires. Recruitment opened in May 2011. A total of 1171 patients were screened by the local principal investigators. Of 1171 patients, 178 (15.2%) were eligible for recruitment: 87 patients (7.4%) provided consent and were recruited; 91 patients (7.8%) did not provide consent, and 993 of 1171 patients (84.8%) failed to meet the eligibility criteria. Almost half were excluded due to complete/partial recovery of hemianopia (43.6%; n = 511). The most common ineligibility reason was recovery of hemianopia. When designing future trials in this area, changes in eligibility criteria/outcome selection to allow more patients to be recruited should be considered, e.g., less stringent levels of visual acuity/refractive error. Alternative outcomes measurable in the home environment, rather than requiring hospital attendance for follow-up, could facilitate increased recruitment.

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.

Detection of Visual Field Loss in Pituitary Disease: Peripheral Kinetic Versus Central Static.

Visual field assessment is an important clinical evaluation for eye disease and neurological injury. We evaluated Octopus semi-automated kinetic peripheral perimetry (SKP) and Humphrey static automated central perimetry for detection of neurological visual field loss in patients with pituitary disease. We carried out a prospective cross-sectional diagnostic accuracy study comparing Humphrey central 30-2 SITA threshold programme with a screening protocol for SKP on Octopus perimetry. Humphrey 24-2 data were extracted from 30-2 results. Results were independently graded for presence/absence of field defect plus severity of defect. Fifty patients (100 eyes) were recruited (25 males and 25 females), with mean age of 52.4 years (SD = 15.7). Order of perimeter assessment (Humphrey/Octopus first) and order of eye tested (right/left first) were randomised. The 30-2 programme detected visual field loss in 85%, the 24-2 programme in 80%, and the Octopus combined kinetic/static strategy in 100% of eyes. Peripheral visual field loss was missed by central threshold assessment. Qualitative comparison of type of visual field defect demonstrated a match between Humphrey and Octopus results in 58%, with a match for severity of defect in 50%. Tests duration was 9.34 minutes (SD = 2.02) for Humphrey 30-2 versus 10.79 minutes (SD = 4.06) for Octopus perimetry. Octopus semi-automated kinetic perimetry was found to be superior to central static testing for detection of pituitary disease-related visual field loss. Where reliant on Humphrey central static perimetry, the 30-2 programme is recommended over the 24-2 programme. Where kinetic perimetry is available, this is preferable to central static programmes for increased detection of peripheral visual field loss.

Medication management in patients with dysphagia: a service evaluation.

The administration of medicines to patients with dysphagia presents substantial challenges to patient safety. Within stroke services, where up to half of patients may experience dysphagia, ensuring safe medication management is particularly challenging. This article describes how best practice within one stroke unit is being achieved by means of a knowledge-to-action service improvement project, ongoing education and training, and the input of a specialist dysphagia practitioner.

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.

Negative beliefs about breathlessness increases panic for patients with chronic respiratory disease.

Breathlessness is a multidimensional symptom of respiratory disease and is associated with the experience of panic. Patients with panic disorder have increased mortality, morbidity and healthcare utilisation that is unrelated to their disease severity. Our qualitative study aimed to appraise respiratory patients' experiences of breathlessness and whether their cognitions were associated with panic aetiology. The self-regulatory theory was utilised to develop the framework for the semi-structured interview schedule. Twelve individuals with respiratory disease at a U.K. cardiothoracic centre participated and their data were analysed using interpretative phenomenological analysis. Perceived control over the disease, symptoms and panic emerged as the core theme with three related belief systems; (1) Perceived consequences of panic and disease; (2) Illness and symptom coherence; and (3) Emotional adaptation. Panic symptoms were most prevalent in participants with low perceived control over symptoms and the disease, negative beliefs about the life-limiting consequences of unpredictable breathless attacks and by those using emotional coping strategies such as denial and avoidance. The experience of panic for respiratory patients can be explained through the cognitive-behavioural model of anxiety, which highlights the contributory role of catastrophic beliefs about the control and consequences of symptoms and disease as a significant contributory factor for the prevalence and maintenance of panic. The mortality and morbidity of respiratory patients is significantly affected by a co-morbid diagnosis of panic disorder and so it is critical to patients' long-term healthcare that their psychological experiences are assessed. Healthcare services must enhance patients' understanding about their disease to improve their confidence to control symptoms. Recent evidence suggests that cognitive-behavioural interventions that increase problem-solving coping will reduce catastrophic misinterpretations about the perceived consequences of breathlessness and improve emotional adaption to respiratory disease.

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.

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.

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.

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.

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.

Classification of Left Atrial Diseased Tissue Burden Determined by Automated Voltage Analysis Predicts Outcomes after Ablation for Atrial Fibrillation.

BACKGROUND: The burden and persistence of atrial fibrillation (AF) have been associated with the presence and extent of left atrial (LA) fibrosis. Recent reports have implicated an association between the extent of LA fibrosis and the outcome of pulmonary vein isolation (PVI). We aimed to analyse the value of an automated scar quantification method in the prediction of success following PVI. METHODS: One hundred and nine consecutive patients undergoing PVI for paroxysmal or persistent AF were included in our observational study with a 2-year follow-up. Prior to PVI, patients underwent high-definition LA electroanatomical mapping, and scar burden was quantified by automated software (Voltage Histogram Analysis, CARTO 3, Biosense Webster), then classified into 4 subgroups (Dublin Classes I-IV). Recurrence rates were analysed on and off antiarrhythmic drug therapy (AAD), respectively. RESULTS: The overall success rate was 74% and 67% off AAD at 1- and 2-year follow-up, respectively. Patients with Dublin Class IV had significantly lower success rates (p = 0.008, off AAD). Dublin Class IV (OR = 2.27, p = 0.022, off AAD) and the presence of arrhythmia in the blanking period (OR = 3.28, p = 0.001, off AAD) were the only significant predictors of recurrence. The use of AAD did not affect these results. CONCLUSIONS: We propose a classification of low voltage areas based on automated quantification by software during 3D mapping prior to PVI. Patients with high burden of low voltage areas (>31% of <0.5 mV, Dublin Class IV) have a higher risk of recurrence following PVI. Information gathered during electroanatomical mapping may have important prognostic value.

The effectiveness of a group cognitive-behavioural breathlessness intervention on health status, mood and hospital admissions in elderly patients with chronic obstructive pulmonary disease.

Non-pharmacological breathlessness interventions in lung cancer have proven beneficial. Breathlessness is also a major symptom in chronic obstructive pulmonary disease (COPD). This study measured the effectiveness of a non-exercise-based four-week cognitive-behavioural breathlessness intervention, delivered in a group setting for elderly patients with severe COPD. The results of the one-year feasibility study are presented. Patients with COPD were asked to complete the St. George's Respiratory Questionnaire and Hospital Anxiety and Depression Scale six weeks before the intervention, at the start and end of the intervention and at six weeks follow-up. The multidisciplinary intervention used a cognitive-behavioural format to address understanding of COPD and medication, anxiety, panic and depression, activity pacing, relaxation, breathing retraining and goal-setting. Retrospective data on accident & emergency (A&E) attendances and length of hospital stay was collected six months before and six months after the intervention and the data compared to a matched waiting list control group. The results showed significant improvements in depression and health status. There was a non-significant improvement in anxiety. There was a significant reduction in A&E attendance and a non-significant reduction in length of hospital stay in the intervention group, compared to comparative increases in the control group, highlighting the cost-effectiveness of the intervention.

Orthoptic Services in the UK and Ireland During the COVID-19 Pandemic.

AIM: COVID-19 has widely impacted hospital services. The purpose of this study was to determine the impact of COVID-19 on Orthoptists and their clinical practice in the UK, Ireland, and Channel Islands. METHODS: 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. 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. RESULTS: The survey response rate was 79%. The survey was completed by orthoptic departments, on average 10 days post lockdown. Many orthoptic services were cancelled/paused with remaining services largely reserved for emergency cases and urgent care. A substantial rise in tele-consultations was reported by 94%, which largely consisted of telephone and video calls and which was regarded generally as working well. Barriers to tele-consultations were mainly IT related but with concerns also raised regarding ethical and confidentiality issues. Shortage of personal protective equipment (PPE) was reported by one third of departments along with issues relating to conflicting information about the use of PPE. CONCLUSIONS: We have reported information on the changing face of orthoptic clinical practice during the COVID-19 pandemic. The survey has highlighted emerging tele-consultation practice and the importance of centralised profession-specific guidelines.

The Value of Voltage Histogram Analysis Derived Right Atrial Scar Burden in the Prediction of Left Atrial Scar Burden.

INTRODUCTION: Growing evidence suggests that fibrotic changes can be observed in atrial fibrillation (AF) in both atria. Quantification of the scar burden during electroanatomical mapping might have important therapeutic and prognostic consequences. However, as the current invasive treatment of AF is focused on the left atrium (LA), the role of the right atrium (RA) is less well understood. We aimed to characterize the clinical determinates of the RA low-voltage burden and its relation to the LA scaring. METHODS: We have included 36 patients who underwent catheter ablation for AF in a prospective observational study. In addition to LA mapping and ablation, high-density RA bipolar voltage maps (HD-EAM) were also reconstructed. The extent of the diseased RA tissue (≤0.5 mV) was quantified using the voltage histogram analysis tool (CARTO®3, Biosense Webster). RESULTS: The percentage of RA diseased tissue burden was significantly higher in patients with a CHA2DS2-VASc score ≥ 2 (p = 0.0305), higher indexed LA volume on the CTA scan and on the HD-EAM (p = 0.0223 and p = 0.0064, respectively), or higher indexed RA volume on the HD-EAM (p = 0.0026). High RA diseased tissue burden predicted the presence of high LA diseased tissue burden (OR = 7.1, CI (95%): 1.3-38.9, p = 0.0145), and there was a significant correlation of the same (r = 0.6461, p < 0.0001). CONCLUSIONS: Determining the extent of the right atrial low-voltage burden might give useful clinical information. According to our results, the diseased tissue burden correlates well between the two atria: the right atrium mirrors the left atrium.

Vision Screening Assessment (VISA) tool: diagnostic accuracy validation of a novel screening tool in detecting visual impairment among stroke survivors.

PURPOSE: Screening for visual problems in stroke survivors is not standardised. Visual problems that remain undetected or poorly identified can create unmet needs for stroke survivors. We report the validation of a new Vision Impairment Screening Assessment (VISA) tool intended for use by the stroke team to improve identification of visual impairment in stroke survivors. METHODS: We conducted a prospective case cohort comparative study in four centres to validate the VISA tool against a specialist reference vision assessment. VISA is available in print or as an app (Medicines and Healthcare products Regulatory Agency regulatory approved); these were used equally for two groups. Both VISA and the comprehensive reference vision assessment measured case history, visual acuity, eye alignment, eye movements, visual field and visual inattention. The primary outcome measure was the presence or absence of visual impairment. RESULTS: Two hundred and twenty-one stroke survivors were screened. Specialist reference vision assessment was by experienced orthoptists. Full completion of screening and reference vision assessment was achieved for 201 stroke survivors. VISA print was completed for 101 stroke survivors; VISA app was completed for 100. Sensitivity and specificity of VISA print was 97.67% and 66.67%, respectively. Overall agreement was substantial; K=0.648. Sensitivity and specificity of VISA app was 88.31% and 86.96%, respectively. Overall agreement was substantial; K=0.690. Lowest agreement was found for screening of eye movement and near visual acuity. CONCLUSIONS: This validation study indicates acceptability of VISA for screening of potential visual impairment in stroke survivors. Sensitivity and specificity were high indicating the accuracy of this screening tool. VISA is available in print or as an app allowing versatile uptake across multiple stroke settings.