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Stroke Study Day 30.11.05
Stroke Study Day 30.11.05

The Role of the Orthoptist in visual defects

after a Stroke

by Fanny Freeman

Orthoptist

Worcestershire Royal Hospital

Stroke Study Day 30.11.05 The Role of the Orthoptist in visual defects after a Stroke by
Eye Care Staff
Eye Care Staff

Optometrist (Optician) checks for glasses and screens for eye conditions

Ophthalmologist (Eye Doctor) treats Eye Conditions

Ophthalmic nurses Orthoptist

Eye Care Staff • Optometrist (Optician) checks for glasses and screens for eye conditions • Ophthalmologist
Orthoptist
Orthoptist

Diagnose and treat Squints and Eye Movement problems

Diagnose and Treat Lazy Eyes Diagnose and relieve Double Vision Visual Field Testing Low Vision Aids

Screening for ocular defects in children and adults

Orthoptist • Diagnose and treat Squints and Eye Movement problems • Diagnose and Treat Lazy Eyes
How to become an Orthoptist
How to become an Orthoptist

3 year degree course Sheffield or Liverpool University

Work along side an Ophthalmologist either in the community or hospital based

How to become an Orthoptist • 3 year degree course • Sheffield or Liverpool University •
My role as an Orthoptist
My role as an Orthoptist

Worcestershire Royal Hospital, stroke patients referred if visual problems

Evesham Stroke Rehab. Ward, all patients

Advise on ocular defects and manage if required

Advise on previous ocular conditions

Screen for unknown previous ocular conditions

My role as an Orthoptist • Worcestershire Royal Hospital, stroke patients referred if visual problems •
My role as an Orthoptist • Worcestershire Royal Hospital, stroke patients referred if visual problems •
My role as an Orthoptist • Worcestershire Royal Hospital, stroke patients referred if visual problems •
My role as an Orthoptist • Worcestershire Royal Hospital, stroke patients referred if visual problems •

Advise on glasses

My role as an Orthoptist • Worcestershire Royal Hospital, stroke patients referred if visual problems •
My role as an Orthoptist • Worcestershire Royal Hospital, stroke patients referred if visual problems •
My role as an Orthoptist • Worcestershire Royal Hospital, stroke patients referred if visual problems •
Why did I get started
Why did I get started

When working at Cheltenham General Hospital 20 years

ago found 2 patients who had double vision who had not

been referred for many months Orthoptists wondered how many more patients were

missing out on treatment which could help the rehab

programme

Audit of 247 stroke patients showed 15% recorded diplopia or ocular movement problems by doctor

Audit of 26 (56 excluded) consecutive stroke patients by

Orthoptist 46% recorded diplopia or ocular movement

problems

Why did I get started • When working at Cheltenham General Hospital 20 years ago found
What is vision
What is vision

Form =Visual Acuity = reading=TV

What is vision • Form =Visual Acuity = reading=TV • Movement = Visual Field = peripheral

Movement = Visual Field = peripheral vision=mobility

Colour Vision Contrast Sensitivity = brightness Binocular Vision = 3D vision

What is vision • Form =Visual Acuity = reading=TV • Movement = Visual Field = peripheral
Visual System
Visual System

Eyes Visual Pathways Control of Eye Muscles Visual Perception

Visual System • Eyes • Visual Pathways • Control of Eye Muscles • Visual Perception
The Eye
The Eye

Lids and tear production Cornea Lens / Accommodation Retina Focussing image on the fovea

The Eye • Lids and tear production • Cornea • Lens / Accommodation • Retina •
Focussing the image
Focussing the image

Clear pathway through to retina Correct Glasses Myopia, Hypermetropia and Astigmatism Accommodation defects Presbyopia aging

Types of Glasses, single lenses, bifocals and varifocals

Focussing the image • Clear pathway through to retina • Correct Glasses • Myopia, Hypermetropia and
Glasses
Glasses

Important to have correct up-to-date glasses Make sure glasses are clean Make sure glasses fit well Glasses for reading or long and short sight Type of glasses, single lens, bifocal or varifocals

Glasses • Important to have correct up-to-date glasses • Make sure glasses are clean • Make
Visual Pathways
Visual Pathways

Complete Homonymous Hemianopia (HH) Left HH may get Visual Inattention

Right HH problems with reading and visual recognition

Parietal Loop Inferior lose the ground Temporal Loop Superior lose the sky Bilateral HH registration as blind

Visual Pathways • Complete Homonymous Hemianopia (HH) • Left HH may get Visual Inattention • Right
Control of Eye Movements
Control of Eye Movements

Complex Saccades change the line of sight Smooth Pursuit keep image focussed on fovea when image moves Vestibular keep image focussed on fovea while head moves Cerebellum smoothes out movement

Control of Eye Movements • Complex • Saccades change the line of sight • Smooth Pursuit
Midbrain Control of Eye Movements
Midbrain Control of Eye
Movements

Horizontal Gaze Centres to Right and Left Vertical Gaze Centres for Up and Down Convergence centre Motor nerve nuclei III, IV and VI

Midbrain Control of Eye Movements • Horizontal Gaze Centres to Right and Left • Vertical Gaze
Eye Muscles and Nerve Supply
Eye Muscles and Nerve Supply

III Inferior Rectus, Medial Rectus, Superior

Rectus, Inferior Oblique, Lid and pupil and

accommodation. Eye turns out and pupil may be dilated, lid closed IV Superior Oblique Vertical double image

VI Lateral Rectus Horiz double image :affected eye turns in

Eye Muscles and Nerve Supply • III Inferior Rectus, Medial Rectus, Superior Rectus, Inferior Oblique, Lid
Pre-existing Ocular Conditions
Pre-existing Ocular Conditions

Check previous history (from notes)

Monitor any current treatment i.e. eye drops for glaucoma

Explain findings to MDT visual limits and affect on rehab

Give advice to patient/carers/MDT team

Pre-existing Ocular Conditions • Check previous history (from notes) • Monitor any current treatment i.e. eye
Common Eye Conditions
Common Eye Conditions

Cataract, easily treated with replacement lens

Glaucoma needs drops for life to preserve sight

Diabetic retinopathy screening programme

Age Related macular degeneration less likely if non smoking

Common Eye Conditions • Cataract, easily treated with replacement lens • Glaucoma needs drops for life
Eye Signs suggesting Cerebrovascular Disease
Eye Signs suggesting
Cerebrovascular Disease

Amaurosis fugax, transient monocular

blindness need to investigate carotid

artery

TIA with homonymous hemianopia or quadrantanopia

Ipsilateral cranial nerve palsy with contralateral motor and/or sensory deficit

Disorders of eye gaze Retinal ischaemia

Eye Signs suggesting Cerebrovascular Disease • Amaurosis fugax, transient monocular blindness need to investigate carotid artery
Circle of Willis
Circle of Willis
Circle of Willis
Posterior Circulation Syndrome POCI
Posterior Circulation Syndrome
POCI

Thrombosis of posterior cerebral artery Cerebellar and brain stem signs Cranial nerve defects Facial weakness opposite to hemiparesis Inability to control tongue movements Vertigo Weakness of both arms and legs

Posterior Circulation Syndrome POCI • Thrombosis of posterior cerebral artery • Cerebellar and brain stem signs
Posterior Circulation Syndrome Ocular Conditions • Gaze Palsy Diplopia due to III, IV and VI palsy

Posterior Circulation Syndrome Ocular Conditions

Posterior Circulation Syndrome Ocular Conditions • Gaze Palsy Diplopia due to III, IV and VI palsy

Gaze Palsy Diplopia due to III, IV and VI palsy

Internuclear Ophthalmolplegia Convergence and Accommodation Defects Occipital Lobe = Visual Field Loss

Posterior Circulation Syndrome Ocular Conditions • Gaze Palsy Diplopia due to III, IV and VI palsy
Posterior cerebral artery infarct
Posterior cerebral artery infarct
Guidelines for Referral
Guidelines for Referral

c/o double vision, visual field defect, blurred vision Consistent closure of one eye Obvious squint / deviation of gaze Ptosis (lid droop) Indication of visual field defect

Guidelines for Referral • c/o double vision, visual field defect, blurred vision • Consistent closure of
Place of Examination
Place of Examination

In-patient (bedside if necessary) refer direct to Orthoptist Out patient refer to Ophthalmologist

Place of Examination • In-patient (bedside if necessary) refer direct to Orthoptist • Out patient refer
Orthoptic Examination
Orthoptic Examination

History Observations Visual Acuity Distance and Reading Cover Test Ocular Movements / Saccades Convergence Frisby

Orthoptic Examination • History • Observations • Visual Acuity Distance and Reading • Cover Test •
Observations
Observations

Side of hemiparesis

Side of facial palsy

Head Posture Ocular Posture Ocular Appendages Pupils Glasses, Strength, Type and Fit

Closing one eye

Observations • Side of hemiparesis • Side of facial palsy • Head Posture • Ocular Posture
Visual Inattention
Visual Inattention

Reading

Vision 2 pen Test

Albert’s Test Line bisection Test

Visual Inattention • Reading • Vision 2 pen Test • • Albert’s Test • Line bisection
Management
Management

Referral to Ophthamologists/ Opticians/ rehabilitation officers (social services)

Facial Palsy-failure to close eye lid-good advice, treatment, lubrication required

Orthoptic follow-up Advice and counselling

Management • Referral to Ophthamologists/ Opticians/ rehabilitation officers (social services) • Facial Palsy-failure to close eye
Reduced Vision
Reduced Vision

Plot progress Refer to Optician Refer to Ophthalmologist Low Visual Aid Clinic

Reduced Vision • Plot progress • Refer to Optician • Refer to Ophthalmologist • Low Visual
Ocular Motility Disorders
Ocular Motility Disorders

Supranuclear = gaze palsy Internuclear Infranuclear = nerve palsy III ;IV ; VI Skew deviation Manifest Squint Convergence / Accomm. Insufficiency Nystagmus

Ocular Motility Disorders • Supranuclear = gaze palsy • Internuclear • Infranuclear = nerve palsy III
Double Vision
Double Vision

Fresnel Prisms to join double vision Occlusion (Patching) Abnormal Head Posture Orthoptic Treatment Surgery Botulinum Toxin to eye muscles Plot progress

Double Vision • Fresnel Prisms to join double vision • Occlusion (Patching) • Abnormal Head Posture
Hemianopia
Hemianopia

Explain defect Help with reading Markers, Typoscopes Use of eye movements Prisms Advise re driving requirements

Hemianopia • Explain defect • Help with reading Markers, Typoscopes • Use of eye movements •
Registration
Registration

Certificate of visual impairment (CVI) Can be completed if any visual problems Sight impaired (partially sighted) Homonymous hemianopia Severely sight impaired (blind) Bilateral homonymous hemianopia

Registration • Certificate of visual impairment (CVI) • Can be completed if any visual problems •
Lid defects with stroke
Lid defects with stroke

Lid problems can give rise to infection Ptosis due to third nerve palsy

Inability to close eye due to Facial nerve palsy

Weeping eye due to lower lid palsy Lid retraction due to brain stem defect

Lid defects with stroke • Lid problems can give rise to infection • Ptosis due to
Advice for driving
Advice for driving

Relay information re Vision and Visual Field Defects to rehab team Vision must be able to read number plate Visual field requirements 120 degrees so if Homonymous Hemianopia unable to drive Unable to drive with double vision

Advice for driving • Relay information re Vision and Visual Field Defects to rehab team •
Visual Defects of 100 CVA
Visual Defects of 100 CVA
60 50 40 30 20 10 0 Sy VF VA NVA x2 VI NAD
60
50
40
30
20
10
0
Sy
VF
VA
NVA
x2
VI
NAD
Visual defects with Strokes
Visual defects with Strokes

58% of patients with strokes complain of some visual symptom

Loss of visual field : Homonymous Hemianopia = loss of one half of vision in each eye

Blurred Vision Problems with reading

Visual defects with Strokes • 58% of patients with strokes complain of some visual symptom •
Detection of visual defects
Detection of visual defects

Symptoms: double vision (diplopia),

blurred vision, loss of vision maybe to one

side, problems reading

Signs: closing one eye, knocking over things, ignoring one side usually left side, poor eye contact, eyes deviated to one side.

Previous ocular history, check medication

Detection of visual defects • Symptoms: double vision (diplopia), blurred vision, loss of vision maybe to
Practical Tips
Practical Tips

Introduce yourself with speech when approaching someone with a sight

problem

Giving drinks, food etc check they can find it or explain where you have put it

If known Homonymous Hemianopia care with position on ward, seeing side to ward

Clear water jug with clear plastic glass impossible to see if sight problems, use

Practical Tips • Introduce yourself with speech when approaching someone with a sight problem • Giving
Practical Tips • Introduce yourself with speech when approaching someone with a sight problem • Giving
Practical Tips • Introduce yourself with speech when approaching someone with a sight problem • Giving
Practical Tips • Introduce yourself with speech when approaching someone with a sight problem • Giving

colour jug or squash

Practical Tips • Introduce yourself with speech when approaching someone with a sight problem • Giving
Demonstration Glasses
Demonstration Glasses

Cataract / Macular Degeneration Visual Field loss Double vision

(Glaucoma = tunnel vision)

Demonstration Glasses • Cataract / Macular Degeneration • Visual Field loss • Double vision • (Glaucoma
Normal View
Normal View
Out of focus/ no glasses
Out of focus/ no glasses
Left homonymous hemianopia

Left homonymous hemianopia

Left homonymous hemianopia
Bilateral homonymous hemianopia
Bilateral homonymous hemianopia
Diabetic Retinopathy
Diabetic Retinopathy
Double Vision (Diplopia)
Double Vision (Diplopia)
Double Vision (Diplopia)
Double Vision (Diplopia)
Cataract
Cataract
What to do if visual defect suspected
What to do if visual defect
suspected

Listen to the person’s visual problems Observation may give an indication Check had recent eye test with Optician Refer to GP/Consultant with recommendation referral to Eye Dept

What to do if visual defect suspected • Listen to the person’s visual problems • Observation
Orthoptist’s Role in CVA Patients undergoing rehabilitation
Orthoptist’s Role in CVA
Patients undergoing
rehabilitation

Cost Effective, saves time and goal setting should be within visual capacity

Prevents loss of confidence Explanation of Visual Defects to patient, carers and to other medical personnel Orthoptists are used to non-verbal tests

Orthoptist’s Role in CVA Patients undergoing rehabilitation • Cost Effective, saves time and goal setting should
References
References

Lockerly, A. ‘Correctable visual impairment in stroke rehab.’ Patients. Age and Aging,29,221- 222 (2000)

Freeman C. & Rudge N ‘The Orthoptic Role in the Management of stroke patients’ 6

th

International Orthoptic Conference (1987)

MacIntosh C Stroke revisited: ‘Visual problems following stroke’ British Orthoptic Journal (2003)

Gilhotra J et al ‘Homonymous Visual Field Defects and Stroke in an Older Population’

Stroke 33:2417-2420 (2002)

References • Lockerly, A. ‘Correctable visual impairment in stroke rehab.’ Patients. Age and Aging,29,221 - 222