Vision assessments for stroke survivors need to go beyond standard checks and involve neuro-orthoptists, says Dr Michelle Courtney-Harris.
Vision impairment can be a debilitating consequence of stroke.1-3 If you couple that with pre-existing ocular conditions with pathological changes contributing to vision impairment, then standard rehabilitation programs need modifications to ensure optimum patient responses and outcomes without hinderance.
During the acute inpatient phase of the stroke journey an inclusive vision assessment by an eyecare practitioner, such as an orthoptist, is key for information dissemination among the stroke care team.
Research indicates that many stroke survivors do not receive timely or adequate assessment of their visual function following stroke, resulting in vision impairments that are often unrecognised, untreated or managed too late. 3,4
Comprehensive vision assessment in stroke survivors should extend beyond functional deficits such as visual field (VF) loss or neglect. It must also include evaluation of visual acuity, refractive error, and pre-existing ocular conditions to inform clinical decisions regarding overall visual status, the need for ongoing treatment and the urgency for referral.
Furthermore, communication and mobility challenges common among stroke survivors can complicate the examination process, necessitating a modified and patient-centred approach to visual assessment.
Neuro-orthoptists apply their specialised expertise to assess and diagnose complex visual disturbances in patients with acquired brain injuries, such as stroke.
In non-verbal patients, objective measures of visual acuity can be obtained using resolution or grating tests in conjunction with matching plates. Careful observation of head posture, eye movements, and integration of other sensory pathways provide insight into functional impact of ocular motility abnormalities.
Notably, patients may not report diplopia, particularly if their vision is poor, if the double images are widely separated, or if they fall within a visual field defect.
Comprehensive assessment of both central and peripheral vison is essential to determine the extent and distribution of preserved visual function.
Additionally, the use of an ophthalmoscope to assess red reflexes can assist in identification of refractive errors, certain types of cataracts, and signs of severe retinal atrophy.
A bedside assessment can limit the tools at the examiner’s disposal. Orthoptists undertaking this role are often required to modify their methods to gain results.
KEY TESTING TIPS:
• Question the patient about pre-existing and previously treated eye conditions.
Vision Assessment
• For non-verbal or cognitive impaired patients, use resolution or grating tests (e.g. LEA paddles, Teller, Cardiff or OKN drum).
• Use a 3m chart when possible, with or without matching board. Sheridan Gardiner single letters are a suitable option.
• Test vision with known glasses; patients over 45 may require near correction even if they don’t wear distance glasses.
Visual Function Testing:
• Use colour vision tests and Amsler chart for central function.
• Performing confrontation visual field (VF) is a useful initial screen but ensure proper technique.
• For peripheral function, use manual quantitative tests like Bjerrum or Goldmann where possible. Bjerrum’s VF also helps educate patients and families on spatial impact of field loss.
• With computerised perimetry, slower response settings may be needed and include one test that explores greater than 30 degrees of VF.
• An ophthalmoscope (even without dilation) can help detect refractive error, cataract and retinal disease – best performed in a darkened room and requires skill.
Ocular Motility
• Observe eye alignment and use light reflex to detect abnormalities.
• If an abnormal head posture (AHP) is present, test with and without it and note any change to the eye pattern and or presence of diplopia. If the patient has already compensated for ocular motility issues this should be acknowledged and supported during rehabilitation.
• Engage the vestibular-ocular pathway to assess and potentially enhance eye movement range for rehabilitation.
• Remember, motion, action and recognition pathways linked to vision are complex and include frontal, parietal and temporal lobes and the brainstem.
About the Author: Dr Michelle Courtney-Harris is a clinical orthoptist and early career researcher at UTS, whose work spans neurological visual deficits, ocular pathology, and interdisciplinary reflective practice, with a strong focus on patient-centred care and contributions to the Australian Stroke Foundation’s Living Guidelines. Acknowledging the contribution of Ms Kate Thompson, a senior clinical orthoptist with special interests in stroke, brain injury and neuro-orthoptics.
References
- Hepworth L, Rowe FJ. Visual impairment following stroke–the impact on quality of life: a systematic review. Ophthalmology Research: an international journal. 2016.
- Rowe FJ. Vision In Stroke cohort: Profile overview of visual impairment. Brain and Behavior. 2017.
- Rowe FJ. Stroke survivors’ views and experiences on impact of visual impairment. Brain and behavior. 2017.
- Sorbello S, Rose K, French A, Rowe F, Lau S. Meeting the need for post-stroke vision care in Australia: a scoping narrative review of current practice. Disability and rehabilitation. 2024.
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