Fanny Freeman 11.05

7/27/2019 Fanny Freeman 11.05

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Stroke Study Day 30.11.05

The Role of the Orthoptist in visual defectsafter a Stroke

by Fanny Freeman

Orthoptist

Worcestershire Royal Hospital



Eye Care Staff

• Optometrist (Optician) checks for glasses

and screens for eye conditions

• Ophthalmologist (Eye Doctor) treats Eye

Conditions

• Ophthalmic nurses

• 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



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



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

•



Why did I get started

• When working at Cheltenham General Hospital 20 yearsago found 2 patients who had double vision who had notbeen referred for many months

• Orthoptists wondered how many more patients were

missing out on treatment which could help the rehabprogramme

• Audit of 247 stroke patients showed 15% recordeddiplopia or ocular movement problems by doctor

• Audit of 26 (56 excluded) consecutive stroke patients byOrthoptist 46% recorded diplopia or ocular movementproblems



What is vision

• Form =Visual Acuity = reading=TV

• Movement = Visual Field = peripheral

vision=mobility

• Colour Vision

• Contrast Sensitivity = brightness

• Binocular Vision = 3D vision



Visual System

• Eyes

• Visual Pathways

• Control of Eye Muscles• Visual Perception





The Eye

• Lids and tear production

• Cornea

• Lens / Accommodation• Retina

• Focussing image on the fovea



Focussing the image

• Clear pathway through to retina

• Correct Glasses

• Myopia, Hypermetropia and Astigmatism• Accommodation defects

• Presbyopia aging

• Types of Glasses, single lenses, bifocalsand varifocals



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





Visual Pathways

• Complete Homonymous Hemianopia (HH)

• Left HH may get Visual Inattention

• Right HH problems with reading and visualrecognition

• Parietal Loop Inferior lose the ground

• Temporal Loop Superior lose the sky• Bilateral HH registration as blind



Control of Eye Movements

• Complex

• Saccades change the line of sight

• Smooth Pursuit keep image focussed onfovea when image moves

• Vestibular keep image focussed on fovea

while head moves• Cerebellum smoothes out movement



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





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



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



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 lesslikely if non smoking



Eye Signs suggesting

Cerebrovascular Disease

• Amaurosis fugax, transient monocular blindness need to investigate carotidartery

• TIA with homonymous hemianopia or quadrantanopia

• Ipsilateral cranial nerve palsy with

contralateral motor and/or sensory deficit• Disorders of eye gaze

• Retinal ischaemia



Circle of Willis



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

Ocular Conditions

• Gaze Palsy

• Diplopia due to III, IV and VI palsy• Internuclear Ophthalmolplegia

• Convergence and Accommodation

Defects• Occipital Lobe = Visual Field Loss



Posterior cerebral artery infarct



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



Place of Examination

• In-patient (bedside if necessary) refer

direct to Orthoptist

• Out patient refer to Ophthalmologist



Orthoptic Examination

• History

• Observations

• Visual Acuity Distance and Reading• Cover Test

• Ocular Movements / Saccades

• Convergence• Frisby



Observations

• Side of hemiparesis

• Side of facial palsy

• Head Posture

• Ocular Posture

• Ocular Appendages

• Pupils

• Glasses, Strength, Type and Fit

• Closing one eye



Visual Inattention

• Reading

• Vision

• 2 pen Test

• Albert’s Test

• Line bisection Test





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



Reduced Vision

• Plot progress

• Refer to Optician

• Refer to Ophthalmologist• Low Visual Aid Clinic



Ocular Motility Disorders

• Supranuclear = gaze palsy

• Internuclear

• Infranuclear = nerve palsy III ;IV ; VI• Skew deviation

• Manifest Squint

• Convergence / Accomm. Insufficiency• Nystagmus



Double Vision

• Fresnel Prisms to join double vision

• Occlusion (Patching)

• Abnormal Head Posture• Orthoptic Treatment

• Surgery

• Botulinum Toxin to eye muscles• Plot progress



Hemianopia

• Explain defect

• Help with reading Markers, Typoscopes

• Use of eye movements

• Prisms

• Advise re driving requirements



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



Lid defects with stroke

• Lid problems can give rise to infection

• Ptosis due to third nerve palsy

• Inability to close eye due to Facial nervepalsy

• Weeping eye due to lower lid palsy

• Lid retraction due to brain stem defect



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



Visual Defects of 100 CVA

0

10

20

30

40

50

60

Sy VF VA NVA x2 VI NAD



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



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



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



Demonstration Glasses

• Cataract / Macular Degeneration

• Visual Field loss

• Double vision

•(Glaucoma = tunnel vision)



Normal View



Out of focus/ no glasses



Left homonymous hemianopia



Bilateral homonymous hemianopia



Diabetic Retinopathy

D bl Vi i (Di l i )



Double Vision (Diplopia)



Double Vision (Diplopia)

C t t



Cataract

What to do if visual defect



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



Orthoptist’s Role in CVA

Patients undergoingrehabilitation

• 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



References

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

• Freeman C. & Rudge N ‘The Orthoptic Role in

the Management of stroke patients’ 6th

International Orthoptic Conference (1987)

• MacIntosh C Stroke revisited: ‘Visual problemsfollowing stroke’ British Orthoptic Journal (2003)

• Gilhotra J et al ‘Homonymous Visual FieldDefects and Stroke in an Older Population’Stroke 33:2417-2420 (2002)

Fanny Freeman 11.05

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