1. Sonia MacDiarmid Advanced Orthoptist sonia.macdiarmid@whh.nhs.uk

2.  Research  Visual complications following stroke  Impact of visual impairment  Treatment and therapeutic options available

3.  VIS Study (Vision in stroke) – Multicentre observational study  VISION (Visual impairment in stroke intervention or not) – RCT  IVIS study (Incidence/Impact of Visual Impairment after Stroke) – Multicentre observational study

4. Stroke Consultants Advanced Stroke Practitioners NursesPhysio SALTOT Orthoptist Social workers Dietician

5.  Stroke Rehabilitation June 2013 1. Screen for visual defects 2. Referral to Orthoptics 3. Treatment for diplopia and visual field loss

6.  Stroke survivors continue to have unmet need in relation to vision problems  Across the UK there is inequality in care provision for stroke survivors who have visual problems (Thomas Pocklington Trust)

8.  Visual impairment occurs in approximately 60% of strokes  Complications can occur in isolation or in combination  Subtle disorders can be difficult to identify without accurate screening  15% of those in VIS study reported no visual symptoms but had a measured visual impairment when assessed.  Screening for visual impairment is vital post stroke

9.  Homonymous hemianopia  Quadrantanopia  Scotomas  Macular sparing hemianopia  Cortical Blindness

11.  Incidence - 52% (VIS)  Recovery (if occurs expected within 4 – 6/52)  45% recovered (7% full recovery, 38% partial – VIS study)  Predictor of functional status on discharge (Jones 2006) Associated with worse outcome (Shen et al 2006)

12. Visual stimuli contralateral to the lesion site is ignored i.e. right sided stroke = left visual neglect Sensory (perceptual) or motor (movement of limbs) Personal space Peripersonal space Extra personal space

13.  Incidence 14% (VIS study)  Adversely affects functional recovery and negatively affects rehabilitation (Jones 2006)  Longer hospitalisation, poorer prognosis  Little or no insight into disability

14. Perceptual defects  Perception is the process by which we detect and make sense of information from the outside world  Perceptual deficits accounted for 18% of visual impairment in VIS Study  Largest group of patients with left sided visual inattention/neglect (14%)  Small number had visual hallucinations (2.5%) and object agnosia (2.2%)

15. Agnosia – inability to identify previous familiar objects Achromatopsia – Loss of colour perception Alexia – Loss of reading ability Graphesthesia – Inability to recognise writing

16. Visual perceptual defects Visual hallucinations – Appreciates images that do not exist Simultagnosia – Unable to recognise all the elements of a certain scene Propasagnosia – unable to recognise previous familiar faces or learn to recognise new ones

18.  Incidence 16.5% (Rowe et al 2009)  Exotropia the most common deviation (Rowe et al 2009)

19. Gaze dysfunctionCranial nerve palsiesSupranuclear palsies Convergence weakness Nystagmus

20.  Incidence of low vision for near 26.5% (<0.3) and 25% distance (Rowe et al)  Incidence of uncorrected refractive error in 65> is 17% (Reidy et al 1998)  Study of 93 patients, 46% had improvement of vision with new glasses (Park et al 2005)  Study of 77 patients (Lotery et al 2000) 26% visual impairment 25% did not have glasses in hospital 27% Dirty, scratched or damaged

21.  Retinal artery occlusion  Complete or partial sudden loss of monocular vision  Medical emergency  BRAO  CRVO

22.  Assess visual acuity  Preserve cornea  Prevent exposure keratitis  Treatment  Viscotears ¾ x day  Ortolux eye patch  Lacrilube at night  Eyelid taped closed at night

23. Affects are more debilitating when age related ocular defects are combined with neurological defects

24.  Failure to respond to one side  Bumping into objects/door frames  Walking/veering to one side  Fail to recognise limbs  Leaving half food on plate  Poor hand eye co-ordination  Poor balance  Abnormal AHP  Inability to close one eye/unequal blink reflex  Closing of one eye  Obvious squint  Poor or unexplained lack of improvement in rehabilitation  Failure to respond to one side  Bumping into objects/door frames  Walking/veering to one side  Fail to recognise limbs  Leaving half food on plate  Poor hand eye co-ordination  Poor balance  Abnormal AHP  Inability to close one eye/unequal blink reflex  Closing of one eye  Obvious squint  Poor or unexplained lack of improvement in rehabilitation

25.  Asymptomatic  Blurred vision/diplopia  Loss of vision to one side/one eye (blind in one eye)  Difficulty in reading, finding beginning or end of the line, missing their place, words jumbling up  Objects moving  Hallucinations  Lack of confidence in mobility/balance  Asymptomatic  Blurred vision/diplopia  Loss of vision to one side/one eye (blind in one eye)  Difficulty in reading, finding beginning or end of the line, missing their place, words jumbling up  Objects moving  Hallucinations  Lack of confidence in mobility/balance

26.  Visual complications following stroke are concealed disabilities  Unlike physical disabilities  Limits quality of life  Increased depression  Poor functional ability  Increase in falls

27. Failure to recognise own limbsWash and dress one side of bodyArm of glasses over one earMiss half of the food on plateHousekeepingShoppingPreparing meals

28. Limit opportunities for social and economic participation and inclusion Reduces self esteem Restricts access to public services, transport and leisure activities Limit the ability to retain or gain employment (RNIB)

29. TreatmentTherapyRehabilitation

30. Treat any symptoms Advice for the patient/family Communication to the Stoke Team Further investigations/onward referral Monitor

31. Restitution SubstitutionCompensatory

32. visual search strategies Typoscopes and red markers for reading, reading vertically Online therapy Apps Word search/dot to dot Exaggerated eye and head movements Patients learn to direct their gaze towards the affected side

33.  Training voluntary attentional shifts to improve awareness  Use of general visual stimulation: objects, relatives on neglected side, family photos, games, puzzles  Patients may do well on clinical tests but fail in activities of daily living. Difficulty in transferring skills

34.  Einstein brain trainer – vision section  Neuro sudoko  Vision therappy  Nintendo DS sight package  Visual fields easy  Spotthedifference.com  Free run/action fish/angry birds

35.  Vision Tap vision therapy / therAppy

36. Reading exercises Right sided field loss – red marker to the right side of the page Left sided field loss – red marker to the left side of the page

37. Typoscopes  The text visible to the patient is reduced to help with visual overload  Patients can track and scan easier with limited text on view

38.  Free therapy which can help improve reading speeds in patients with hemianopic alexia (difficulty reading due to field defect)  Practising reading moving text has been shown to improve reading speeds on normal text

39.  www.eyesearch.ucl.ac.uk www.eyesearch.ucl.ac.uk  Free online therapy for patients with visual search problems caused by brain injury  Designed to improve patients speed and accuracy when finding objects

40.  Patients have a diplopic image from the blind side into the seeing side  Make eye and head movements to the blind side to view image

41. Use of prisms with hemianopia

42.  Visual restorative therapy  Computer packages  Flicker stimulation of blind field  Some reports of improved navigation, reading and sensitivity but no permanent reduction in field loss Henning Mast, Novavision Dr Arash Sahraie sightscience

43. Treatment options that are viable in clinical setting Scanning exercises, reading/copying exercises, word searches, dot to dot Integrating this into rehab programme Reading exercises with markers and typoscopes

44. Fresnel prisms/occlusionExercises

45. Large print books/magazines White stick Improve lighting – natural light lamps, increase contrast De clutter the home Position objects to the non affected side

46.  This forms a large part of the therapy  Patients and carers given targeted advice  Members of the IDT given specific visual function information  Information leaflets and written instructions  Local information leafelts  Stroke association  BIOS

47.  Arrange for refraction either with hospital Optometrist or outside agency  Many local optometrists will do domiciliary visits or national compnaies  Public Health - Raise awareness of free yearly eye tests and importance of maintaining good ocular health

48.  Referral to the ECLO and low vision services  Registration of certificate of visual impairment (CVI)  Sight impaired/severly sight impaired  Financial and social benefits of registration  Referral to social services for further rehabilitation and support  Develop links with rehabilitation officers and work closely with them.

49.  Incidence of stroke survivors returning back to driving: 30% ( Fisk 2002 ) 36.5% ( Hawley 2001 )  90% of all information used in driving is visual.

50.  Homonymous hemianopia or quadrantanopia will automatically exclude persons from driving  Must have no areas of field defect within the 120 degrees horizontal and 20 degrees vertical  Referral to driving mobility centres  Patients with stable visual fields for 12 months following stroke may apply for their licence

51.  Evidence of visual complications following stroke  Importance of screening patients for visual defects  Overview of the therapeutic options available to maximise rehabilitation potential

52.  Thank you for listening  Sonia.macdiarmid@whh.nhs.uk Sonia.macdiarmid@whh.nhs.uk