"Invisible" visual impairments. A qualitative study of stroke survivors` experience of vision symptoms, health services and impact of visual impairments

Perceptions of vision care following neurological impairment: a qualitative study

BACKGROUND

Visual impairment is a common consequence of neurological impairments, and can impact a person's ability to undertake everyday tasks, affecting their confidence and mental health. Previous qualitative research in the UK has shown inequalities to exist where patients are accessing vision care after stroke, but little is known around the experiences of accessing vision care following other neurological impairments, and a lack of national guidelines prevent standardised care planning. The aim of this qualitative study is to explore the perceptions of vision care after neurological impairment, and to identify possible inequalities and support mechanisms, where it has been possible to access vision care.

METHODS

University ethical approval was obtained, and adults with a visual impairment as a result of a neurological impairment were offered an in-depth interview to explore their vision care experiences. Data were collected between April and November 2021 and analysed using iterative, thematic analysis (TA), informed by a social constructionist ideology.

RESULTS

Seventeen participants were recruited. Three overarching themes were conceptualised in relation to the participants' perception of vision care: Making sense of the visual impairment; The responsibility of vision care; and Influential factors in care quality perception.

CONCLUSION

Inequalities were noted by participants, with most reporting a lack of suitable vision care offered as part of their neurological rehabilitation. Participants were thus burdened with the task of seeking their own support online, and encountered inaccurate and worrying information in the process. Participants noted changes in their identity, and the identity of their family carers, as they adjusted to their vision loss. The findings from this research highlight a need for clinicians to consider the long-term impact of vision loss after neurological impairment, and ensure patients are provided with adequate support and information, and appropriate referral pathways, alleviating this patient burden.

Assessment of visual problems after acquired brain injury: a survey of current practice in Danish hospitals

OBJECTIVES

To explore current hospital practice in relation to the assessment of vision problems in patients with acquired brain injury.

DESIGN

A survey study.

SUBJECTS

A total of 143 respondents from hospital settings, with background in occupational therapy and physical therapy, participated in the survey.

METHODS

The survey questionnaire, developed collaboratively by Danish and Norwegian research groups, encompassed 22 items categorically covering "Background information", "Clinical experience and current practice", "Vision assessment tools and protocols", and "Assessment barriers". It was sent out online, to 29 different hospital departments and 18 separate units for occupational therapists and physiotherapists treating patients with acquired brain injury.

RESULTS

Most respondents worked in acute or subacute hospital settings. Few departments had an interdisciplinary vision team, and very few therapists had formal education in visual problems after acquired brain injury. Visual assessment practices varied, and there was limited use of standardized tests. Barriers to identifying visual problems included patient-related challenges, knowledge gaps, and resource limitations.

CONCLUSION

The study emphasized the need for enhanced interdisciplinary collaboration, formal education, and standardized assessments to address visual problems after acquired brain injury. Overcoming these challenges may improve identification and management, ultimately contributing to better patient care and outcomes in the future.

Symptoms at stroke onset as described by patients: a qualitative study

BACKGROUND

Stroke is a common and severe disease that requires prompt care. Symptom expressions as one-sided weakness and speech difficulties are common and included in public stroke campaigns. For some patients stroke can present with subtle and less common symptoms, difficult to interpret. The symptom severity assessed by the National Institutes of Health Stroke Scale has decreased, and symptoms at onset may have changed. Therefore, we aimed to investigate how patients describe their symptoms at the onset of a first-time stroke.

METHODS

The study used a qualitative descriptive design and conventional content analysis. Data were collected through recorded interviews with 27 patients aged 18 years and older hospitalised with a first-time stroke between October 2018 and April 2020. Data were analysed on a manifest level.

RESULTS

Symptoms at stroke onset were presented in two themes: Altered Reality and Discomfort and Changed Body Functions and described in five categories. Various types of symptoms were found. All symptoms were perceived as sudden, persistent, and never experienced before and this appear as a "red thread" in the result. Regardless of symptom expressions, no specific symptom was described as more severe than another.

CONCLUSIONS

Stroke symptoms were described with a variety of expressions. Many described complex symptoms not typical of stroke, which can make it difficult to recognise the symptoms as a stroke and delay medical care. Public stroke campaigns should emphasize the importance of seeking medical care at the slightest suspicion of stroke and could be designed to help achieve this.

Meeting the need for post-stroke vision care in Australia: a scoping narrative review of current practice

PURPOSE

Determine current vision care pathways and practices for stroke survivors in Australia and internationally, focusing on identifying reoccurring gaps in these pathways and unmet care needs.

METHOD

A scoping narrative review was conducted to identify literature related to post-stroke vision care practices and perspectives of patients and health professionals.

RESULTS

A total of 16193 articles were retrieved and 28 deemed eligible for inclusion. Six were Australian, 14 from the UK, four from the USA, and four from within Europe. Post-stroke vision care is largely unstandardized, with substantial inconsistency in the use of vision care protocols, who executes them and at what point in post-stroke care they are utilised. Health professionals and stroke survivors expressed that unmet care needs were primarily a result of lack of education and awareness regarding post-stroke eye problems. Other gaps in care pathways related to the timing of vision assessment, provision of ongoing support, and the integration of eye-care specialists into the stroke team.

CONCLUSION

Further research is needed into current Australian post-stroke vision care to accurately assess whether the needs of stroke survivors are being met. Available evidence indicates that in Australia, there is a requirement for well-defined protocols for vision screening, education, management, and referral of stroke survivors.

Reading Difficulties in Individuals with Homonymous Visual Field Defects: A Systematic Review of Reported Interventions

Reading difficulties are amongst the most commonly reported problems in individuals with homonymous visual field defects (HVFDs). To be able to provide guidance for healthcare professionals considering offering reading training, researchers in this field and interested individuals with HVFDs, this systematic review aims to (1) provide an overview of the contextual and intervention characteristics of all published HVFD interventions and (2) generate insights into the different reading outcome measures that these studies adopted. A search on PsycINFO, MEDLINE and Web of Science was conducted up to February 2, 2023. All intervention studies for HVFD in which reading was measured were included. Data was collected about the intervention type, session duration, number of sessions, the intensity, duration, circumstance of the interventions, country in which the intervention was studied and reading measures. Sixty records are included, describing 70 interventions in total of which 21 are specifically reading interventions. Overall, adjusted saccadic behaviour interventions occur most in the literature. A wide range within all intervention characteristics was observed. Forty-nine records reported task-performance reading measures, and 33 records reported self-reported reading measures. The majority of task-performance measures are based on self-developed paragraph reading tasks with a time-based outcome measure (e.g. words per minute). Future research could benefit from making use of validated reading tests, approaching the measurement of reading mixed-methods and providing participants the possibility to supply outcomes relevant to them.

Individualized goals expressed by patients undergoing stroke rehabilitation: an observational study

OBJECTIVES

To explore the rehabilitation goals measured with the Patient-Specific Functional Scale (PSFS) in patients undergoing acute and subacute stroke rehabilitation. In addition, to assess whether PSFS goals corresponded to impairments and activity limitations, as identified by standardized measures.

DESIGN

Observational study.

PARTICIPANTS

A total of 71 participants undergoing inpatient stroke rehabilitation.

METHODS

The PSFS goals were linked to second-level categories in the International Classification of Functioning, Disability and Health (ICF), using established linking rules. Frequencies of the linked ICF categories were calculated. Frequencies of participants with limitations in walking, activities of daily living (ADL), vision, language, and cognition, were calculated, along with goals in corresponding areas of functioning.

RESULTS

The participants' goals were linked to 50 second-level ICF categories, comprising areas such as walking and moving, ADL, language, vision, and cognition. The most frequent ICF categories were "Moving around in different locations" (n = 24), "Walking" (n = 23), "Toileting" (n = 16), "Hand and arm use (n = 12) and "Fine hand use (n = 12)". Of participants with limitations in walking, cognition, and vision, 85%, 10%, and 16%, respectively, had goals in these areas.

CONCLUSION

Participants' goals included walking, ADL, language, vision, and cognition. Few with impairments in cognition or vision had goals in these corresponding areas on the PSFS.

Intrarater and interrater reliability of the dynamic gait index in post stroke patients with eye movement disorders

BACKGROUND

The Dynamic Gait Index (DGI) is a useful tool that has been evaluated for its reliability in patients with vestibular disorders, elderly people and, in chronic stroke population. Present study was aimed to evaluate the intrarater and interrater reliability of the DGI to measure dynamic balance and gait performance in stroke patients with eye movement disorders.

METHODS

A sample of 30 stroke patients suffering from eye movement disorders were recruited. Two Physical therapists assessed the intrarater and interrater reliability of the DGI in two testing sessions three days apart. In the later session, two raters assessed the patients' performance simultaneously on the DGI. The reliability was calculated using the intra-class correlation coefficient (ICC2, 1). Standard error of measurement (SEM) and minimal detectable change (MDC95) at 95% confidence interval were also calculated. A significance level was set at p-value <0.05.

RESULTS

The (ICC2, 1) for intrarater and interrater reliability of total DGI scores was 0.86 and 0.91 respectively. While (ICC2, 1) for intrarater and interrater reliability of individual items ranged from 0.73 to 0.91 to 0.73-0.93, respectively. The (SEM) and (MDC95) for intrarater reliability of total DGI scores were 0.76 and 2.10, respectively. Corresponding values for interrater reliability were 0.62 and 1.71, respectively.

CONCLUSIONS

The DGI is a reliable tool for evaluating the dynamic balance and gait performance in stroke patients with eye movement disorders. This tool showed good to excellent intrarater and interrater reliability of total DGI scores and moderate to good intrarater and interrater reliability of individual items of the DGI.

NIHSS is deficient in acute stroke presenting with cortical deafness; clinical skills remain the backbone: a case report

Background

National institutes of health stroke scale (NIHSS) is used, since its appearance in analysis of stroke in any national or international single center or multicenter study. It is also the golden standard assessment scale for stroke patients whether by emergency medical services on the way to hospital or by emergency room staff and by neurologists whether juniors or senior consultants. Yet, it is not capable of identifying all stroke cases. Along the current case report a relatively rare case of cortical deafness is presented highlighting its rarity and its vascular mechanism as well as how defective is NIHSS in recognizing it.

Case presentation

72-year-old female patient presented with sudden episodic less than 60 min duration of bilateral deafness; initial imaging showed right hemispheric encephalomalacia of old stroke. Patient was initially managed as psychogenic case especially that her NIHSS was zero. On returning again to emergency room she was administered thrombolysis and regained full hearing power. Follow-up imaging revealed a new ischemic stroke along her left auditory cortex explaining her cortical deafness.

Conclusion

Cortical deafness might be missed especially that NIHSS does not detect it. NIHSS role as the only golden standard scale for diagnosing and following up stroke cases ought to be revised.

Time-frequency analysis of brain activity in response to directional and non-directional visual stimuli: an event related spectral perturbations (ERSP) study

Objective.A large part of the cerebral cortex is dedicated to the processing of visual stimuli and there is still much to understand about such processing modalities and hierarchies. The main aim of the present study is to investigate the differences between directional visual stimuli (DS) and non-directional visual stimuli (n-DS) processing by time-frequency analysis of brain electroencephalographic activity during a visuo-motor task. Electroencephalography (EEG) data were divided into four regions of interest (ROIs) (frontal, central, parietal, occipital).Approach.The analysis of the visual stimuli processing was based on the combination of electroencephalographic recordings and time-frequency analysis. Event related spectral perturbations (ERSPs) were computed with spectrum analysis that allow to obtain the average time course of relative changes induced by the stimulus presentation in spontaneous EEG amplitude spectrum.Main results.Visual stimuli processing enhanced the same pattern of spectral modulation in all investigated ROIs with differences in amplitudes and timing. Additionally, statistically significant differences in occipital ROI between the DS and n-DS visual stimuli processing in theta, alpha and beta bands were found.Significance.These evidences suggest that ERSPs could be a useful tool to investigate the encoding of visual information in different brain regions. Because of their simplicity and their capability in the representation of brain activity, the ERSPs might be used as biomarkers of functional recovery for example in the rehabilitation of visual dysfunction and motor impairment following a stroke, as well as diagnostic tool of anomalies in brain functions in neurological diseases tailored to personalized treatments in clinical environment.

Interventions for perceptual disorders following stroke

BACKGROUND

Perception is the ability to understand information from our senses. It allows us to experience and meaningfully interact with our environment. A stroke may impair perception in up to 70% of stroke survivors, leading to distress, increased dependence on others, and poorer quality of life. Interventions to address perceptual disorders may include assessment and screening, rehabilitation, non-invasive brain stimulation, pharmacological and surgical approaches.

OBJECTIVES

To assess the effectiveness of interventions aimed at perceptual disorders after stroke compared to no intervention or control (placebo, standard care, attention control), on measures of performance in activities of daily living.  SEARCH METHODS: We searched the trials registers of the Cochrane Stroke Group, CENTRAL, MEDLINE, Embase, and three other databases to August 2021. We also searched trials and research registers, reference lists of studies, handsearched journals, and contacted authors.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of adult stroke survivors with perceptual disorders. We defined perception as the specific mental functions of recognising and interpreting sensory stimuli and included hearing, taste, touch, smell, somatosensation, and vision. Our definition of perception excluded visual field deficits, neglect/inattention, and pain.

DATA COLLECTION AND ANALYSIS

One review author assessed titles, with two review authors independently screening abstracts and full-text articles for eligibility. One review author extracted, appraised, and entered data, which were checked by a second author. We assessed risk of bias (ROB) using the ROB-1 tool, and quality of evidence using GRADE.  A stakeholder group, comprising stroke survivors, carers, and healthcare professionals, was involved in this review update.

MAIN RESULTS

We identified 18 eligible RCTs involving 541 participants. The trials addressed touch (three trials, 70 participants), somatosensory (seven trials, 196 participants) and visual perception disorders (seven trials, 225 participants), with one (50 participants) exploring mixed touch-somatosensory disorders. None addressed stroke-related hearing, taste, or smell perception disorders. All but one examined the effectiveness of rehabilitation interventions; the exception evaluated non-invasive brain stimulation. For our main comparison of active intervention versus no treatment or control, one trial reported our primary outcome of performance in activities of daily living (ADL):  Somatosensory disorders: one trial (24 participants) compared an intervention with a control intervention and reported an ADL measure.  Touch perception disorder: no trials measuring ADL compared an intervention with no treatment or with a control intervention.  Visual perception disorders: no trials measuring ADL compared an intervention with no treatment or control.  In addition, six trials reported ADL outcomes in a comparison of active intervention versus active intervention, relating to somatosensation (three trials), touch (one trial) and vision (two trials).   AUTHORS' CONCLUSIONS: Following a detailed, systematic search, we identified limited RCT evidence of the effectiveness of interventions for perceptual disorders following stroke. There is insufficient evidence to support or refute the suggestion that perceptual interventions are effective. More high-quality trials of interventions for perceptual disorders in stroke are needed. They should recruit sufficient participant numbers, include a 'usual care' comparison, and measure longer-term functional outcomes, at time points beyond the initial intervention period. People with impaired perception following a stroke should continue to receive neurorehabilitation according to clinical guidelines.

Effects of visual scanning exercises in addition to task specific approach on balance and activities of daily livings in post stroke patients with eye movement disorders: a randomized controlled trial

Background

Impaired vision is one of the commonest and most disabling consequence following stroke. Among all visual impairments, eye movement disorders are found in 70% of stroke patients which include nystagmus, strabismus, gaze palsies, disconjugate eye movements and cranial nerve palsies. They have a wide ranging impact on balance and activities of daily livings by creating difficulties in maintaining normal alignment and appropriate movement of eyes. The purpose of this study was to examine the effects of visual scanning exercises in addition to task specific approach on balance and activities of daily livings in post stroke patients with eye movement disorders.

Methods

This study is a randomized controlled trial and was conducted in the University of Lahore Teaching Hospital from May 2019 to October 2020. A sample of 64 patients was recruited and randomly allocated into experimental and control group. 32 patients in experimental group were treated with visual scanning exercises along with task specific approach and 32 patients in control group were treated with task specific approach alone. Pre and post assessment of balance and activities of daily livings was assessed on BERG BALANCE SCALE and BARTHEL INDEX SCALE at baseline and at 4^th week.

Results

Intra-group analysis of BERG BALANCE SCALE in experimental group showed statistically significant result (p < 0.05) in all items except in items 4, 13 and 14 respectively. Intra-group analysis of BERG BALANCE SCALE in control group showed statistically significant result (p < 0.05) in items 3, 5, 8 and 12 respectively, whereas remaining all items showed statistically insignificant result. Intra-group analysis of BARTHEL INDEX SCALE in experimental group showed statistically significant result in all items (p < 0.05) except in items 9 and 10 respectively. Intra-group analysis of BARTHEL INDEX in control group showed statistically significant result (p < 0.05) in items 1, 3, 4 and 8 respectively whereas remaining all items showed statistically insignificant result. Inter-group analysis showed statistically significant result in total scores of BERG BALANCE SCALE (p = 0.000) and BARTHEL INEX SCALE (p = 0.033).

Conclusion

Visual scanning exercises along with task specific approach were found to be more effective in comparison to task specific approach alone.

Trial registration

Trial registration number: [IRCT20190717044237N1], trial registration date: 10/11/2019,

Supplementary Information

The online version contains supplementary material available at 10.1186/s12883-022-02843-7.

'If we don't assess the patient's vision, we risk starting at the wrong end': a qualitative evaluation of a stroke service knowledge translation project

Background

Visual impairments (VIs) affect 60% of stroke survivors and have negative consequences for rehabilitation and quality of life poststroke. Symptoms of VIs post stroke are difficult to identify for stroke survivors and health care professionals without using a structured vision assessment. In this study, we qualitatively evaluate the implementation outcomes after implementing a structured visual assessment with the Competence, Rehabilitation of Sight after Stroke Vision (KROSS) assessment tool in stroke care services.

Methods

This is a qualitative study comprising four focus group interviews. The health care personnel (HCP) involved in the implementation or with experience using the KROSS assessment tool in practice were invited to participate. We used Proctor et al.’s definitions of implementation outcomes as a framework, which informed the interview guide and analysis. We used a deductive - inductive content analysis, as described by Elo and Kyngäs.

Results

The participants found the structured vision assessment with the KROSS tool as being acceptable; they expressed a motivation and intention to use the new routine in practice. They believed it was important to assess their patient’s visual function because it influenced other rehabilitation activities and activities of daily living. Most of the participants reported having adopted the vision assessment in their practice, except for those participants from the home care services who experienced that they have few stroke survivors to follow up on. The assessment was believed to be more appropriate to perform within the rehabilitation services where there is more of a focus on functional assessments. Although vision assessment was new to all the participants, they felt that they improved their vision assessment skills by regularly using the assessment tool. Together with sufficient instructions and supervision, they believed that vison assessment was feasible for their practise. Including the vison assessment in the existing routines and systems was important to promote sustainable implementation.

Conclusion

Implementing a structured vision assessment with the KROSS tool in health care services was experienced as acceptable and feasible. The new routine led to increased attention towards poststroke VIs and increased collaboration with vision experts. Tailoring the routine to each practice and how they organise their work can support the integration of a vision assessment in their routines. To promote better vision care poststroke vision assessment and follow up should be included in the stroke care pathways.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07732-w.

Rehabilitation of visual perception in cortical blindness

Blindness is a common sequela after stroke affecting the primary visual cortex, presenting as a contralesional, homonymous, visual field cut. This can occur unilaterally or, less commonly, bilaterally. While it has been widely assumed that after a brief period of spontaneous improvement, vision loss becomes stable and permanent, accumulating data show that visual training can recover some of the vision loss, even long after the stroke. Here, we review the different approaches to rehabilitation employed in adult-onset cortical blindness (CB), focusing on visual restoration methods. Most of this work was conducted in chronic stroke patients, partially restoring visual discrimination and luminance detection. However, to achieve this, patients had to train for extended periods (usually many months), and the vision restored was not entirely normal. Several adjuvants to training such as noninvasive, transcranial brain stimulation, and pharmacology are starting to be investigated for their potential to increase the efficacy of training in CB patients. However, these approaches are still exploratory and require considerably more research before being adopted. Nonetheless, having established that the adult visual system retains the capacity for restorative plasticity, attention recently turned toward the subacute poststroke period. Drawing inspiration from sensorimotor stroke rehabilitation, visual training was recently attempted for the first time in subacute poststroke patients. It improved vision faster, over larger portions of the blind field, and for a larger number of visual discrimination abilities than identical training initiated more than 6 months poststroke (i.e., in the chronic period). In conclusion, evidence now suggests that visual neuroplasticity after occipital stroke can be reliably recruited by a range of visual training approaches. In addition, it appears that poststroke visual plasticity is dynamic, with a critical window of opportunity in the early postdamage period to attain more rapid, more extensive recovery of a larger set of visual perceptual abilities.

User engagement in the development of a home-based virtual multidisciplinary stroke care clinic for stroke survivors and caregivers: a qualitative descriptive study

PURPOSE

To understand the user expectations and the facilitators and barriers of using a virtual multidisciplinary stroke care clinic ("virtual clinic").

METHODS

A qualitative descriptive study involving two rounds of face-to-face semi-structured interviews per participant was conducted. We purposively recruited ten participants in Hong Kong who were receiving traditional stroke rehabilitation. The first interview was conducted to explore participants' expectations. The second interview was conducted after a 4-week trial of the virtual clinic. Both interviews were analysed using thematic analysis. The findings were translated from Cantonese into English.

RESULTS

Before using the virtual clinic, the participants perceived a need for (i) information communication technology guidance and support, (ii) familiar hardware and applications, and (iii) services to meet psychosocial needs. Facilitators identified by the participants included (i) feeling safe and supported, (ii) willingness to learn, adapt to, and use the new service, and (iii) ease of use with a flexible schedule. Issues relating to (i) internet connectivity, (ii) hardware, and (iii) interface and design were perceived barriers to the use of the clinic.

CONCLUSION

This study provides findings of users' expectations of using telehealth services. Their perspectives on facilitators and barriers may increase the adoption of the newly developed telehealth service.Implications for rehabilitationTo implement telehealth as part of post-stroke care, it is important to ensure that stroke survivors and caregivers have the necessary information and communication technology support and infrastructure to engage in two-way interactions.Stroke survivors and caregivers may be inclined to use telehealth services due to ease of use, having flexibility in scheduling consultation sessions, do not need to travel to the clinic, useful online content, and remote blood pressure monitoring.Addressing the barriers of using telehealth services (e.g., hardware issues, internet connectivity issues, and user interface to facilitate the reading of information on the website) can improve the usability and acceptance to ensure the successful adoption of telehealth as part of post-stroke recovery.

Barriers and facilitators to the implementation of a structured visual assessment after stroke in municipal health care services

Background

Stroke is a leading cause of disability worldwide. Visual impairments (VIs) affect 60% of stroke survivors, and have negative consequences for rehabilitation and post-stroke life. VIs after stroke are often overlooked and undertreated due to lack of structured routines for visual care after stroke. This study aims to identify and assess barriers and facilitators to the implementation of structured visual assessment after stroke in municipal health care services. The study is part of a larger knowledge translation project.

Methods

Eleven leaders and municipal interdisciplinary health care professionals participated in qualitative interviews. During two workshops, results from the interviews were discussed with 26 participants from municipal health care services and user representatives. Data from interviews and workshops were collected before the intervention was implemented and analyzed using content analysis.

Results

The analysis identified individual and contextual barriers and facilitators. The individual barriers were related to the participants' experiences of having low competence of visual functions and vision assessment skills. They considered themselves as generalists, not stroke experts, and some were reluctant of change because of previous experiences of unsuccessful implementation projects. Individual facilitators were strong beliefs that including vision in stroke care would improve health care services. If experienced as useful and evidence based, the new vision routine would implement easier. Contextual barriers were experiences of unclear responsibility for vision care, lack of structured interdisciplinary collaboration and lack of formal stroke routines. Time constraints and practical difficulties with including the vision tool in current medical records were also expressed barriers. Contextual facilitators were leader support and acknowledgement, in addition to having a flexible work schedule.

Conclusions

This study shows that improving competence about VIs after stroke and skills in assessing visual functions are particularly important to consider when planning implementation of new vision routines in municipal health care services. Increased knowledge about the consequences of living with VIs after stroke, and the motivation to provide best possible care, were individual facilitators for changing clinical practice. Involving knowledge users, solutions for integrating new knowledge in existing routines, along with easily accessible supervision in own practise, are essential facilitators for promoting a successful implementation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06467-4.

"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.

Rehabilitation of cortically induced visual field loss

PURPOSE OF REVIEW

Homonymous visual field defects are a common sequela of stroke, and are assumed to be permanent within a few weeks of the event. Because consensus about the efficacy of rehabilitation is lacking, visual therapy is rarely prescribed. Here, we review current rehabilitation options and strategies in the translational pipeline that could change these perspectives.

RECENT FINDINGS

The mainstays of available therapy for homonymous visual defects are compensation training and substitution, which allow patients to better use their spared vision. However, early clinical studies suggest that vision can partially recover following intensive training inside the blind field. Research into the relative efficacy of different restorative approaches continues, providing insights into neurophysiologic substrates of recovery and its limitations. This, in turn, has led to new work examining the possible benefits of earlier intervention, advanced training procedures, noninvasive brain stimulation, and pharmacological adjuvants, all of which remain to be vetted through properly powered, randomized, clinical trials.

SUMMARY

Research has uncovered substantial visual plasticity after occipital strokes, suggesting that rehabilitative strategies for this condition should be more aggressive. For maximal benefit, poststroke vision-restorative interventions should begin early, and in parallel with strategies that optimize everyday use of an expanding field of view.