INTRODUCTION problems experienced by stroke survivors and how



Stroke is a
serious life-threatening medical condition caused due to the impairment of
blood supply to the brain. The National Institute of Health and Clinical
Excellence (NICE ) in its 2008 guideline explained stroke as a preventable and
treatable disease. The International classification of diseases ,however, in
its 11th revision  defined
stroke as an ‘acute focal neurological dysfunction’1; the
cause for which could be a focal infarction, hemorrhage or a cause not
identified by advanced neuroimaging techniques. Patients after a stroke suffer
from physical problems such as movement and balance, visual disturbance,
swallowing, continence issues2, to name a few and these
problems could affect the overall quality of a stroke survivors life, 2
however, understanding of stroke as a disease process  has expanded over the years and this has
contributed to significantly better outcome among patients 3.
In this essay I decided to emphasize on the visual problems experienced by
stroke survivors and how focused rehabilitation could improve their quality of
life.I would also discuss anatomy and physiology of eye as a part of visual system
.I intend to discuss stroke, types,risk factors , management and
recommendations focused specifically on visual field defects due to stroke

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The theory and literature I use in this essay
will be supported by a case study, adhering to ‘ respect to the people’s right
to privacy and confidentiality’ 4. Gibbs´s Reflective Model
(Gibbs, 1988)11 is used in this assignment to structure the
content of this essay because this model is very clear and precise, allowing
for description, analysis and evaluation of the experience and helps a person
to look into the existing practice and develop an action plan to bring out
recommendations which would be beneficial in the future.

                     BODY 1- STATISTICS AND

‘Make vision count’. This was the World sight
day ‘call to action for world’ theme for the year 2017, which shows us that the
sense of sight, through which we perceive 80 per cent of all  impressions , is by far the most important of
all senses. The world stroke organization in its report explained that stroke
as a non communicable disease has attained epidemic proportions and  1 in 6 people worldwide will have a stroke in
their lifetime and according to their statistics released as a report in 201614
,worldwide 17 million people suffer a stroke every year and  6.5 million people die from it and also there
are 26 million stroke survivors . Valery et al (2014)12
projects that the burden of stroke due to illness, disability and early death
it causes is set to double worldwide within the next 15 years.

Stroke devastates lives
around the world 13 and it claims a life every 6 seconds.
Stroke is considered to be the  second
leading cause of death for people over the age of 60, and the fifth leading
cause in people aged 15 to 5914. It also affects children
as well as both men and women. Stroke is responsible for more deaths annually
than AIDS, tuberculosis and malaria combined14

statistics 15 released by the United Kingdom Stroke
Association in January 2017 showed that of the 1.2 million stroke survivors in
the UK, 60 per cent have vision problems immediately after their stroke and
this reduces to about 20% by three months after a stroke. Alex Pollock et al.,
2012 in his study10 pointed out that an estimated 20% to
57% of people suffer from visual field defects after stroke, which affects
their function, quality of life, ability to participate in rehabilitation,
depression, anxiety, and social isolation.


Vision related
problems occur due to the damage stroke cause to the brain and depending on the
part of the brain affected, the severity of the problems varies. For instance
Gall et al( 2010)5 conducted a prospective study
to evaluate vision-related and health-related quality of life in first stroke
patients with homonymous visual field defects (VFD) with respect to the extent
of the lesion pointed out that, Homonymous visual field defects (VFD) are among
the most common disorders after posterior-parietal strokes.The study which
spanned for nine years from 1998 to 2007 found out that patients who suffered
visual field defects due to stroke had a severely reduced vision-related and
health-related quality of life even after 2.5 years and  stroke-related impairment level is
significantly exacerbated by Visual field defects.  In an article written by David C Broadway 6  he pointed out that patients who already have
other co-morbidities like glaucoma might see a poor prognosis when their vision
is affected by means of a stroke6.

Mrs,A, a 86
year old female patient was brought  to
the Accident and Emergency department 
following  a fall and  onset of right sided weakness. Assessment was
done using NIHSS scale7 and a CT scan was done which showed
a left sided partial anterior circulation infarct but patient was found to be
not a suitable candidate20
for thrombolysis as the time onset of the stroke was not known. Patient was
brought in to the stroke unit and on subsequent assessment she was found to
have left homonymous hemianopsia by which her field of vision was limited to
only left side of both eyes.

The World Heath Organization defined that stroke
is caused by8″ the interruption of the blood supply to
the brain, usually because a blood vessel bursts or is blocked by a clot
which  cuts off the supply of oxygen and
nutrients, causing damage to the brain tissue”.

American Stroke Association classified stroke
9 based on the pathophysiology. Obstruction in the blood vessels
supplying blood to the brain by means of a thrombus or embolus  constitutes more than 85% of strokes, 15% of
strokes are hemorrhagic in nature and occurs when a and hemorrhagic stroke,
which occurs when a  blood vessel
ruptures . Two types of weakened blood vessels usually cause hemorrhagic
stroke: aneurysms and arteriovenous malformations (AVM) are the two types of
weakened blood vessels which cause hemorrhagic stroke.

According to the National institute of Heart
,Lung and Blood institute16 Certain traits, conditions, and habits increases
a persons  risk of having a stroke or
transient ischemic attack (TIA) and such traits, conditions, and habits are
known as risk factors. Increased number of risk factors put a person on an
increased risk of stroke. Some of the risk factors are modifiable which include
hypertension and smoking, obesity, sedentary lifestyle, alcoholism and some are
non- modifiable which include age, gender and family history(Australian Stroke
Association 2015)

Vision problems occurring due to a stroke can be
largely classified under four headings which include (a) central vision loss-
which could lead to a near total vison loss 
(b) visual field loss- where loss of sight happens to one part of visual
field (c) eye movement problems-  (d)
visual processing problems which include visual neglect, where brain is
impaired of information from one side

To clearly
understand how stroke affects the visual pathways a knowledge on how the visual
system work is important. The human eye is one of the most valuable and
sensitive sense organs which enables us to see the what is around us. The18
human eye is like a camera and its lens system forms an image on the retina.
Light enters the eye through  cornea and
most of the refraction for the light rays entering the eye occurs at the outer
surface of the cornea. The crystalline lens merely provides the finer
adjustment of focal length required to focus objects at different distances on
the retina. We find a structure called iris behind the cornea. Iris is a dark
muscular diaphragm that controls the size of the pupil. The pupil regulates and
controls the amount of light Figure . The eye lens forms an inverted real image
of the object on the retina and  the
light-sensitive cells get activated upon illumination and generate electrical
signals and these signals are sent to the brain via the optic nerves. The brain
interprets these signals, and finally, processes the information so that we
perceive objects as they are. 18A damage  to any part of the visual system can lead to
significant loss of visual functioning. For instance , if any of the structures
involved in the transmission of light, like the cornea, pupil, eye lens,
aqueous humour and vitreous humour or those responsible for conversion of light
to electrical impulse, like the retina or even the optic nerve that transmits
these impulses to the brain, is damaged, it will result in visual impairment.
Homonymous hemianopsia is a condition which impairs the sight of person due to
pathologies which affect visual pathways of the brain. As the right half of the
brain has visual pathways for the left hemifield of both eyes and vice versa
,damage to any one of the pathway will affect the visual field associated with
it. Pambakian and Kennard17 reported that  lesions in the occipital lobe constitute
forty percent of cases of homonymous hemianopsia, parietal lobe causes thirty
percent, temporal lobe causes twenty five percent, optic tract and lateral
geniculate nucleus constitutes five percent.


                    DISCUSSION- study r/v,
rehab, what is in our ward, what hap to this patient, recommendations

It should be
noted that the diagnosis of left homonymous hemianopsia in the patient whom I
took for case study was diagnosed only after one week.The delay pertained to
the unavailability of services of an opthalmologist and optometrist. Such
situation lead to the delay in initiating visual rehabilitation and addressing
the vision problems associated with it.

It is
understood that as like other problems after stroke, with timely intervention
and focused rehabilitation,vision problems also show improvement over time.

Sand et al
in 2012 published a study
21 which is worth
mentioning, where they performed a restrospective audit on the diagnosis and
visual rehabilitation of stroke patients in Norway for a period over 3 years . The
data was taken from a community stroke registry and they  included all the patients occipital lobe
infarctions and non-occipital lobe infarctions with visual field defects.They
identified  353 patients ,out of 1,420
stroke patients, and analyzed their data to find out the accessibility of those
patients to perimetry and visual rehabilitation and the results are noteworthy.
When 9.6 percent of patients were referred to perimetry,only 2.3 percent
patients were referred for visual rehabilitation eventhough they had trained
visual therapists dedicated to handle visual field defects .This data alone
shows that the awareness level of the need for visual rehabilitation is very
low even in developed nations and among neurologists. Visual rehabilitation22 is intended to  improve awareness of visual field loss and to
employ strategies to promote the patient’s ability to scan in the area of the
defect. The study notes that European Stroke Organisation (ESO) guidelines24 for stroke management
underpins the need of  underline the
importance physiotherapy, occupational therapy, language training and cognitive
assessment, but fail to underline the importance of  perimetry to check for visual field defects
and the need for visual rehabilitation23.  

The study comes
out with some important finding21
that clinicians give more focus on managing the motor symptoms and visual field
defects receive less attention. The study also recommend 21that more awareness need to be created among
healthcare staff for diagnosing stroke associated visual field defects and
focused visual rehabilitation. A word need to be added that the study is
however retrospective in nature and the authors  have not explained why referral for perimetry
and visual rehabilitation was very low despite having dedicated visual therapists.The
authors also have not explained how much time it took for patients to be
referred to visual therapist after admission .It would have been noteworthy if
comparisons were made with other European nations to find out if the lack of
awareness is widespread.The authors have not listed the limitations of the


The patient I
took for the case study was not able to avail visual therapy services during
her admission in the ward for almost a month after admission as therapy was
focused on the motor aspect of the patient.My 
ward does not have a dedicated visual therapist so referrals had to be
done to dedicated hospitals with ophthalmology services which again
delayed  focused rehabilitation

ophthalmologist,a medical practitioner specializing on eye, will be able to
give more advice and most commonly visual aids are used to help with achieving
optimum level of vision after a stroke. For instance ,magnifiers and minifiers
are commonly used in patients suffering from central vision loss and prism
glasses are used to broaden the visual field. But these devices were
unavailable in the ward. The patient only got one session with visual therapist
and all other sessions were planned in way it happens after the discharge from
the hospital. The multidisciplinary approach to address these problems could
help in pooling up of resources and avoid delays.This particularly was very
stressful for the family as they believed that patients concerns in this regard
were not adequately addressed

Visual problems
also affects the social life of stroke survivors in different ways. The
licensing authorities like DVLA has put restrictions on driving for patients
after stroke.  As per the rules19 , after a stroke or TIA
a person  cannot drive a car for one
month especially if that person suffers from double vision,blurred vision and
central vision field loss. It is advised by the DVLA that people suffering from
vision problems after stroke must get proper visual assessment done before they
return to drive It is important that patients become self confident to lead a
quality life with such ailments and the whole purpose of rehabilitation should
be focused on this.


In conclusion,
this essay supports the idea that visual problems are common after a stroke but
a focused ,team based  approach can
improve outcome among patients and with the advent of newer technologies like
computer delivered therapies like NeuroEyeCoach, the future looks promising.




1.   2018
ICD-10-CM Diagnosis Code I63.9

2.  Physical effects of Stroke, Stroke Assocaition
U.K April 2012

3.  Ovbiagele B. Nationwide trends in n-hospital
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4.  Nursing and Midwifery Council. (2015). The
Code. London: Nursing and Midwifery Council

5.  Vision-related quality of life in first stroke
patients with homonymous visual field defects . Gall et al. Health and Quality
of Life Outcomes 2010

6.  Visual field testing for glaucoma – a practical
guide.  David C Broadway  Community Eye Health Journal | VOLUME 25
ISSUES 79 & 80 | 2012

7.  The National Institute of Neurological Disorders
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ischemic stroke. N Engl J Med. 1995

8.  Global status report on NCDs 2014 ,World Health

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 Interventions for Visual
Field Defects in Patients With Stroke Alex Pollock, PhD; Christine Hazelton,
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 Gibbs G (1988) Learning by Doing: A guide to teaching and learning methods.

Feigin VL, et al. (2013).
Global and regional burden of stroke during 1990-2010: findings from the Global
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Feigin et al 2014-2015

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statistics ,January 2017 Stroke association,United Kingdom

for health professionals,National Heart ,Lung and Blood institute

 Pambakian ALM, Kennard C. Can visual function
be restored in patients with homonymous hemianopia? British Journal of Ophthalmology. 1997;81(4):324–328

11, Science, The National Council of Educational Research and Training (NCERT)

Visual disorders: assessing
fitness to drive,DVLA,March 2016

Thrombolysis with alteplase
3 to 4.5 hours after acute ischemic stroke Hacke W, Kaste M, Bluhmki E, Brozman
M, Dávalos A, Guidetti D, et al.. N Engl J Med (2008)

Diagnosis and Rehabilitation
of Visual Field Defects in Stroke Patients:A Retrospective Audit K.M. Sand , L.
Thomassen , H. Næss , E. Rødahl, J M Hoff Institute for Clinical Medicine,
University of Bergen, and Departments of b Neurology and Ophthalmology, Haukeland University Hospital,
Bergen , Norway

Luu S, Lee AW, Daly A, Chen
CS: Visual field defects after stroke – a practical guide for GPs. AustFam
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Hacke W: Guidelines for
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Guidelines for Management of
Ischaemic Stroke and Transient Ischaemic Attack 2008 The European Stroke
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