Orthoptists are not typically part of the core stroke multi-disciplinary team in Australia – but they should be, argues SHANELLE SORBELLO.
While the Stroke Foundation’s Australian Clinical Guidelines for Stroke Management1 strives to improve stroke care practices across the country, there remains an alarming gap in current guidelines with respect to eye-related rehabilitation.
“Stroke survivors reported issues such as significant delays in initial vision assessment and diagnosis.”
Lack of guidance in eye-related stroke care in Australia indicates its provision is not standardised and unlikely to attract the resources and attention given to other stroke related deficits.
Recommendations from the Stroke Foundation Acute Stroke Services Framework2 omits mention of eyecare specialists in the multidisciplinary stroke team and their presence in stroke or rehabilitation facilities is undocumented.
The 2017 Orthoptics Australia Workforce Survey3 found 21 orthoptists working in a rehabilitation setting, while 38 identified clinical neuro-ophthalmology as their main area of employment.
In 2020, NSW Health reported that 37 orthoptists were employed in 9 out of 15 local health districts.4 This suggests that unlike other countries with locally trained orthoptists, such as those within the UK, orthoptists are not typically part of the core stroke multi-disciplinary team in Australia.
In addition, few NSW public hospitals having on-site ophthalmic services (6%).5 With only two hospital eye clinics outside Sydney, this indicates that patients with stroke-related eye deficits in rural and remote regions are likely at even greater disadvantage.
As part of the Pathway Research for Eye Care in Stroke (PRECiS) study, I conducted a scoping review of current post-stroke vision care in Australia.6 This revealed limited Australian research, with no published protocols or pathways to support provision of eyecare for stroke survivors in Australia.
Most evidence is from the UK and Europe. In 2019, a UK study showed that 85% of stroke health professionals utilised post-stroke vision care protocols.7 This is the likely result of a growing UK evidence-base, inclusion of eye specific information in stroke guidelines8 and naming orthoptists as necessary members of the stroke team, with orthoptic assessment considered the gold-standard and proving to address gaps in provision of vision rehabilitation.9,10,11
Utilisation of evidence-based vision screening tools for stroke survivors administered by non-eyecare professionals, also facilitates prompt identification of eye conditions.9,12,13,14
The PRECiS study used surveys and interviews with stroke survivors and stroke health professionals to capture their experience of current vision care practices.
The overwhelming majority of health professionals reported that they did not have protocols or care plans for eye problems following stroke.
Stroke survivors reported issues such as significant delays in initial vision assessment and diagnosis, poor provision of information on eye conditions and available support services, with a generalised lack of short-term management and onward referral.
The PRECiS study consequently developed the NSW Post-stroke Vision Care Framework (NSW-PVCF) consisting of 43 best practice statements and a diagrammatic care pathway, in agreement with stakeholders.
The NSW-PVCF is a considerable expansion to the current eye-related Australian national and state-based stroke guidelines.1,15,16 Stroke clinical care pathways have previously shown improvement in multidisciplinary care provision, reduced length of hospital stays, and health costs17 highlighting potential benefit to the health system and stroke survivors.
The NSW-PCVF was developed in consideration of the unique characteristics and challenges presented within the context of Australian healthcare. However, the strategies employed in this framework may be transferrable to other countries looking to overcome challenges in delivering equitable, high-quality healthcare in regions where there are sparse populations,18 geographically diverse communities, and proportionately to countries in UK and Europe, relatively small, ageing and stroke affected populations.19
Acknowledgements: The PRECiS study was undertaken as a doctoral project by Shanelle Sorbello at the University of Technology Sydney under the supervision of Professor Kathryn Rose (Primary Supervisor), Dr Amanda French and Professor Fiona Rowe.
About the Author: Shanelle Sorbello holds a PhD in Orthoptics at the University of Technology Sydney and is currently managing the Australian Eye and Ear Health Survey at The Westmead Institute for Medical Research which aims to investigate the prevalence of eye disease and hearing loss across Australia.
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References
1. Stroke Foundation (2021). Clinical Guidelines for Stroke Management. Melbourne, Australia.
2. Stroke Foundation. National Stroke Audit – Acute Stroke Services Framework 2019. Melbourne, Australia.
3. Jolly N, Kelly J, Silveira S, Giribaldi M. Orthoptics Australia workforce survey 2017. Australian Orthoptic Journal. 2019;51:25-30.
4. Horizons Scanning and Scenario Generation Project, Health Connect Consulting. NSW Health Orthoptist Workforce. https://www.health.nsw.gov.au/workforce/alliedhealth/Documents/orthoptist-horizons-scanning-report.pdf. Published 2020. Accessed May 11, 2021.
5. Agency for Clinical Innovation (ACI). NSW Public Ophthalmology Clinics Information. https://aci.health.nsw.gov.au/networks/ophthalmology/clinics. Accessed December 20, 2021.
6. Sorbello, S., Rose, K., French, A., Rowe, F., & Lau, S. (2023). Meeting the need for post-stroke vision care in Australia: a scoping narrative review of current practice. Disability and Rehabilitation, ahead-of-print(ahead-of-print), 1–8. https://doi.org/10.1080/09638288.2023.2214743
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18. Australian Bureau of Statistics (ABO). Regional Population. 2019-20. https://www.abs.gov.au/statistics/people/population/regional-population/2019-20#data-download. Accessed December 20, 2021.
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