All patients with a new or suspected stroke or TIA should have a visual screening as part of their initial examination. This should include screening for reduced vision, visual field loss, eye movement disorders and double vision. Any changes in vision should be recorded in the patient’s notes. Referral on for specialist input should be considered. This may be to Occupational Therapy, Ophthalmology or Orthoptics. Inter-unit referrals should be filled in and sent to the appropriate department.
Stroke Visual Pathway for Assessment and Referral
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This pathway and referral process has been developed to meet the needs of those with vision changes post-stroke. Visual problems that go undetected can interfere with a person’s rehabilitation, cause difficulties in their daily activities and increase their risk of falls.
Visual changes post-stroke
Changes in vision frequently occur following a stroke. These may take the form of low vision, change in eye movement, visual field impairment and /or perceptual deficits. They can be distressing and delay rehabilitation and it is important that vision assessment is carried out promptly.
RCP Stroke Guideline (2016) Section 4.17 recommends;
People with stroke should be: ‒ assessed for visual acuity whilst wearing the appropriate glasses to check their ability to read newspaper text and see distant objects clearly; ‒ examined for the presence of visual field deficit (e.g. hemianopia) and eye movement 87 disorders (e.g. strabismus and motility deficit).
People with altered vision, visual field defects or eye movement disorders after stroke should receive information, support and advice from an orthoptist and/or an ophthalmologist.
BEST Practice Statement for Vision
- Occupational Therapists: provide interventions to improve visual attention, search and speed and efficiency in visual processing. They can teach strategies to compensate for deficits in acuity and visual fields and eye movements to complete ADLS safely and effectively
- Orthoptics: can assess and treat a range of eye problems but in particular eye movement disorders. Treatment may involve occlusion (eye patching), eye exercises, and prisms (special lenses on glasses). They will also provide patient specific information, advice and support including web-based therapy to improve scanning
- Ophthalmologists: are doctors treating a range of eye diseases. Treatment can include eye surgery, eye treatments. Only ophthalmologists can certify people as partially sighted or blind on the register.
Inter-unit referral forms should be completed for all services.
BIOS- have a referral form for Orthoptics which can provide more information and guidance for staff
All staff carrying initial assessment of visual loss should be familiar with the Standardised visual and eye mobility assessment.
Information leaflets on Visual Problems after a Stroke are available from CHSS. Other charities, eg The Stroke Association also have information that can be printed or viewed online.
Understanding visual loss can be complex and it can be difficult for patients and family to grasp. Consideration of using glasses that mimic visual loss and apps that can illustrate this can be useful tools for families and carers.
Patients, their families and carers can be directed to the Stroke4Carers and SelfHelp4Stroke websites to aid understanding.
'Contacts and useful information sources', Chest Heart and Stroke Scotland – www.chss.org.uk. This website contains stroke information and signposts to other useful sites:
Royal National Institute for the Blind – https://www.rnib.org.uk/
SelfHelp4Stroke – http://selfhelp4stroke.org/
Sight Action Highland – http://www.sightaction.org.uk/
Patients can be referred to Sight Action for aids and adaptation to help their vision in their own home. Referral forms should be completed and sent.
Reablement and community Occupational Therapy can assess and work with patients in their own home to improve confidence and independence. A tailored visual rehabilitation programme will be completed with the patient’s goals.
Patients can be supported in their visual programmes by CHSS Rehabilitation Service.