Feature, Orthoptics Australia

Caring for stroke or brain injury patients

Orthoptists are uniquely positioned to assess and manage the visual needs of acquired brain injury and rehabilitation patients, writes orthoptist and academic MICHELLE COURTNEY-HARRIS.

Visual problems in patients admitted to hospital for acute care, such as an acquired brain injury (ABI), including stroke, often go unrecognised (1). Deficits to sensory and motor functions because of an ABI can vary from subtle to debilitating with the most reported defect being that of disruption to one’s peripheral field of view (2, 3).

Michelle Courtney-Harris.

It is also important to remember that while a larger proportion of hospital and rehabilitation admissions are of older people (4), the likelihood of pre-existing ocular conditions co-existing with any newly acquired visual problems will be greater (5), with up to 73% of stroke survivors noted to have some form of visual impairment (6).

Changes to a patient’s level of visual function can add a level of complication to patient care, individual mobility and interfere with prescribed rehabilitation tasks.

With our specialist training in ocular motility, ocular pathology and low vision, orthoptists are in the unique position of being able to triage, assess and manage individual visual needs of stroke or brain injury survivors.

Assessment performed by an orthoptist may be while the patient is an admitted inpatient or once discharged. In addition, orthoptists provide feedback and guidance to other health professionals for the adaptation of their services based again on the individual visual needs of the patient.

The role of the orthoptist in the care of stroke or brain injury survivors includes the identification and management of pre-existing pathology and newly acquired ocular misalignments, which may include gaze or nerve palsies. Patients may experience disturbances to vision and contrast, diplopia or loss of their peripheral vision that can affect simple tasks such as reading, feeding, dressing and safe navigation for general mobility in non-familiar environments.

When looking after stroke or brain injury survivors a typical day for the orthoptist may consist firstly around triaging patients within hospital stroke and rehabilitation units and assessing those most likely to have a visual deficit.

Further assessment involves ocular motor orthoptic and ocular neurological examination including visual field and visual neglect testing. On identification of a visual deficit, the orthoptist will determine if the ocular condition is pre- existing or newly acquired secondary to stroke or brain injury.

Orthoptic treatment provided includes fitting of Fresnel prisms for diplopia, training in adapting to a visual field loss and/or visual neglect and orthoptic exercises.

The orthoptist has a strong educational role, including liaising with hospital staff, the patient’s family, and the provision of counselling regarding their visual deficit and any impact it may have on their activities of daily living.

Recommendations made may involve review with an ophthalmologist, optometrist, or an assessment at a low vision clinic such as Vision Australia or Guide Dogs Australia. All patients discharged from stroke and rehabilitation units receive follow-up, particularly in relation to their ability to meet visual driving requirements.

Orthoptic assessment of these patients is instrumental to prompt application of appropriate intervention and management strategies.

While not all hospitals or rehabilitation units currently have direct access to orthoptic services, in the absence of this service, the Vision Defect in Stroke Screening Tool (S-ViST) and the accompanying online Vision Defect in Stroke Education Module is available to all NSW Health-employed professionals.

The Vision Defect in Stroke Screening tool is a clinically validated compact document that targets a patient’s eye health history, prompts for simple observations and assessment of ocular misalignment and tests vision. The online case-based education module is a simple interactive platform with the purpose of improving knowledge on both common age-related ocular conditions and visual problems caused by stroke. Both resources provide non-eyecare health professionals with the ability to, at the very least, identify and refer on patients who are experiencing visual changes (7).

Access to both resources by those outside of NSW Health, especially for the screening tool itself, can be made by contacting the Agency for Clinical Innovation (ACI) Ophthalmology Network directly or via the ACI website (online education module).

ABOUT THE AUTHOR: Michelle Courtney-Harris is an experienced orthoptist, lecturer at the Discipline of Orthoptics, UTS and PhD candidate under examination. Contributions were also made by Kathryn Thomson and Susanne Brunner, both experienced orthoptists in the assessment and management of stroke survivors.

References 

  1. Jolly N, Thompson K, Macfarlane A. The Orthoptist and the management of visual problems in inpatients with stroke: A pilot study to compare existing models of care. 2008.
  2. Rowe FJ. Vision In Stroke cohort: Profile overview of visual impairment. Brain and Behavior. 2017;7(11):e00771.
  3. Rowe FJ. Stroke survivors’ views and experiences on impact of visual impairment. Brain and behavior. 2017;7(9):e00778.
  4. Australian Institute of Health and Welfare. Reports and data-hospitals-admitted patients [Available from: https://www.aihw.gov.au/reports-data/myhospitals/sectors/admitted-patients.
  5. Australian Institute of Health Welfare. A Guide to Australian Eye Health Data: Australian Institute of Health and Welfare; 2019 [Available from: https://www.aihw.gov.au/reports/australias-health/guide-australian-eye-health-data/contents/table-of-contents; https://www.aihw.gov.au/reports/eye-health/eye-health/contents/how-common-is-visual-impairment.
  6. Rowe FJ, Hepworth LR, Howard C, Hanna KL, Cheyne CP, Currie JJPo. High incidence and prevalence of visual problems after acute stroke: An epidemiology study with implications for service delivery. 2019;14(3):e0213035.
  7. Agency for Clinical Innovation. Ophthalmology Network Resources, Available from: https://aci.health.nsw.gov.au/resources/ophthalmology.

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