Stroke Study Day 30.11.05

1. Stroke Study Day 30.11.05 The Role of the Orthoptist in visual defects after a Stroke by Fanny Freeman Orthoptist Worcestershire Royal Hospital

2. Eye Care Staff • Optometrist (Optician) checks for glasses and screens for eye conditions • Ophthalmologist (Eye Doctor) treats Eye Conditions • Ophthalmic nurses • Orthoptist

3. 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

4. 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

5. 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 • Advise on glasses

6. 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

7. What is vision • Form =Visual Acuity = reading=TV • Movement = Visual Field = peripheral vision=mobility • Colour Vision • Contrast Sensitivity = brightness • Binocular Vision = 3D vision

8. Visual System • Eyes • Visual Pathways • Control of Eye Muscles • Visual Perception

10. The Eye • Lids and tear production • Cornea • Lens / Accommodation • Retina • Focussing image on the fovea

11. 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

12. 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

14. 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

15. 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

16. 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

18. 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

19. 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

20. 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

21. 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

22. Circle of Willis

23. 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

24. Posterior Circulation Syndrome Ocular Conditions • Gaze Palsy • Diplopia due to III, IV and VI palsy • Internuclear Ophthalmolplegia • Convergence and Accommodation Defects • Occipital Lobe = Visual Field Loss

25. Posterior cerebral artery infarct

26. 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

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

28. Orthoptic Examination • History • Observations • Visual Acuity Distance and Reading • Cover Test • Ocular Movements / Saccades • Convergence • Frisby

29. Observations • Side of hemiparesis • Side of facial palsy • Head Posture • Ocular Posture • Ocular Appendages • Pupils • Glasses, Strength, Type and Fit • Closing one eye

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

32. 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

33. Reduced Vision • Plot progress • Refer to Optician • Refer to Ophthalmologist • Low Visual Aid Clinic

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

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

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

37. 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

38. 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

39. 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

40. Visual Defects of 100 CVA

41. 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

42. 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

43. 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 colour jug or squash

44. Demonstration Glasses • Cataract / Macular Degeneration • Visual Field loss • Double vision • (Glaucoma = tunnel vision)

45. Normal View

46. Out of focus/ no glasses

47. Left homonymous hemianopia

48. Bilateral homonymous hemianopia

49. Diabetic Retinopathy

50. Double Vision (Diplopia)