1. Sight and Stroke Educational Presentation Pack on Visual Defects Associated with Stroke Produced by the Scottish AHP Practice Development Network-Orthoptics

2. Presentation Aims & Objectives To educate health professionals about the range of visual defects that affect patients following a stroke This presentation will help health professionals identify those patients suspected of having orthoptic and/or visual field defects Raise awareness within the stroke MDT of identified defects and how these contribute to a patients rehabilitation Increase awareness of the range of assessments and treatments used by Orthoptists if someone has visual difficulties associated with stroke

3. Role of the Orthoptist Specialise in assessment of visual function Monitor visual development Assess, diagnose and treat ocular muscle defects (congenital/acquired) Assess visual fields Work closely with Ophthalmologists Hospital based but also work in community and school settings

4. Guidelines British and Irish Orthoptic Society- Standards of Proficiency 2006 SIGN guidelines- recommend visual assessment NICE -National clinical guidelines for stroke do not mention the assessment of vision

5. Sight and Stroke Facts Many patients suffer from visual difficulties following stroke (70% SIGN) Strong link between visual problems and outcomes of rehabilitation (Rowe 2003) Early diagnosis, treatment and visual rehabilitation is important (Rowe 2003) Benefits of orthoptic treatment well recognised (Rowe 2003) Evidence suggests that persistent visual difficulties related to attention may continue even though rehabilitation is considered complete. These may not be detected by standard tests (Cunningham et al 2004) Orthoptic services are currently provided throughout Scotland

6. Common Symptoms of Visual Difficulties in Stroke Reduced vision and loss of vision Ghosting of images Hallucinations Visual Agnosia (visual neglect) Eye movement defects Eye strain Frontal Headache Diplopia Oscillopsia (apparent movement of objects)

7. Common Signs of Visual Difficulties in Stroke Loss of awareness of people and objects especially on one side Poor orientation Patients closing one eye Apparent visual discomfort Eye-hand co-ordination difficulties Clumsiness Spatial awareness difficulties Compensatory head or body posture Nystagmus

8. Visual Field Defects Variable in nature/severity In the literature the incidence of visual field defects ranges from 50% - 72% (Freeman 2002, MacIntosh 2003, Clisby 1995, Freeman and Rudge 1988). The most common condition is homonymous hemianopia with an incidence of 30% Very slight visual field restoration can occur naturally. Recovery is often within the first month after onset Few therapeutic approaches exist

9. Why identify visual defects? Important for rehabilitation Ward position may aid resolution Driving standards Blind/partial sighted registration

10. Visual Pathway

12. Prism Therapy for Hemianopia Fresnel prisms placed on patients glasses Creates a visual displacement of peripheral field on the “blind” side “extends” patients functioning visual field

13. Homonymous Hemianopia Handy Hints Clear explanation of defect important for patient safety Improved communication can be achieved by addressing the patient on sighted side Typoscope/bright targets aid reading activities Steady eye strategy can help reading activities Prism therapy can enhance use of existing visual field

14. Diplopia (Double Vision) Diplopia can occur following stroke in the presence of cranial nerve palsies, supranuclear and infranuclear ocular motility defects Disruption of vascular supply to ocular nerve or muscles can result in diplopia Abducens (VIth Cranial Nerve) Oculomotor (IIIrd Cranial Nerve) Trochlear (IVth Cranial Nerve) Diplopia often results following transient ischemic attack (TIA) Diplopia may be intermittent or constant Diplopia may be horizontal, vertical or tilted and may be distant dependent

15. VIth nerve palsy/Lateral Rectus Palsy Most common nerve paresis Often more troublesome for distance viewing Often more troublesome for distance viewing Eye horizontally misaligned Eye horizontally misaligned Horizontal diplopia- an example can be seen above Horizontal diplopia- an example can be seen above

16. IIIrd Nerve Paresis Multiple muscle involvement Possible ptosis- diplopia not complained of if lid covers eye Dilated pupil possible however pupillary involvement less common with vascular aetiology Eye position= out and down Combined horizontal and vertical diplopia

17. IVth Nerve Palsy Torsional diplopia often troublesome for patient and difficult to treat Particular problems for close work Difficulty negotiating stairs or uneven surfaces

18. Vertical and Horizontal Diplopia May also be caused by conditions other than nerve paresis Thorough investigation is recommended Prompt assessment and treatment are beneficial to rehabilitation and prognosis

19. Orthoptic Management of Diplopia Prisms Teaching Head Posture Bangerter Foils/ Occlusion Education of patient Monitoring of recovery Botulinum Toxin

20. Importance of Glasses The stronger a patients glasses are the more dependant they will be on them Carers should try to determine: If a patient has glasses? What activities the glasses would normally be used for? If the patient has more than one pair of glasses, e.g. reading glasses, glasses for distance use.

21. Appropriate Referrals Suspected -Diplopia -Visual field defects -Visual neglect -Bilateral visual acuity defects - Nystagmus - Spatial awareness problems

22. Inappropriate Referrals Ocular pain/discomfort Suspected infection Uniocularly reduced visual acuity All of the above and any ocular emergencies must be referred via medical staff to an ophthalmologist

23. To improve patients quality of care following a stroke and assist in their rehabilitation.

24. Thanks go to all who helped to develop this presentation. In particular we would like to thank the Practice Development Team at NHS QIS, the Practice Development Representatives, Darren Brand and Sonia McGuinness. Remember to download our leaflet and poster which accompany this presentation at www.nhshealthquality.org/ahpwww.nhshealthquality.org/ahp

25. References Rowe, F, (2003) Supranuclear and internuclear control of eye movements: a review, British Orthoptic Journal 60 Freeman CF, Rudge NB. (1988) Cerebrovascular accident and the Orthoptist. British Orthoptic Journal. 45: 8-18 Freeman CF. (2003) Collaborative working on a stroke- rehabilitation ward. Parallel Vision (British and Irish Orthoptic Society). 56: 3 MacIntosh C. (2003) Stroke re-visited: visual problems following stroke and their effect on rehabilitation. British Orthoptic Journal. 60: 10-14 Fowler MS, Wade DT, Rochardson AJ, Stein JE. (1996) Squints and diplopia seen after brain damage. Journal of Neurology. 243: 86-90 Clisby, C: Visual Assessment Of Patients With Cerebrovascual Accident On The Elderly Care Wards. British Orthoptic Journal 1995;52:38 I. Cunningham; F.J.Rowe; P.C. Knox; A.C. Fisher and C.Jack.(2004) Attentional visual field analysis amongst stroke survivors, British Orthoptic Journal 61