By Marc Dinkin, MD
Assistant Professor of Ophthalmology, Weill Cornell Medical College
Dr. Dinkin reports no financial relationships relevant to this field of study.
SYNOPSIS: Visual impairments are common in stroke survivors and should prompt a careful ophthalmologic evaluation, since many of the problems are ocular and not neurological.
SOURCE: Sand KM, et al. Vision problems in ischaemic stroke patients: Effects on life quality and disability. Eur J Neurol 2015;23(Suppl 1):1-7.
All too often, the visual deficits of acute stroke victims remain under-recognized, overshadowed by the more obvious motor and language manifestations observed at presentation. A visual field defect, for example, has to be searched for with careful confrontational visual fields, and in some cases of stroke-related diplopia, the ocular misalignment is subtle enough to escape detection by testing of ocular motility in the absence of cross-cover testing. Even when these visual deficits are recognized, they may be de-emphasized, while initial rehabilitation strategies focus on the important task of recovering mobility and speech. Ultimately, problems with vision can have a profound effect on stroke patients’ quality of life, with an increase in the risk of depression, institutionalization, and mortality. With this in mind, Sand and colleagues undertook one of the first studies to examine the long-term afferent and efferent visual outcomes in stroke patients, and their effects on quality of life.
The authors approached the question by mailing a questionnaire to all 6-month survivors of ischemic stroke who were seen at the Haukeland University Hospital in Bergen, Norway, between 2006 and 2008. The questionnaire included self-assessments of health, fatigue, mood, and pain severity, including the 15D, Euro-Qol 5D, Hospital Anxiety Depression Scale (HADS), fatigue severity scale (FSS), and Barthel Index (BI). Assessment of vision specifically was based on responses to the second question on the 15D battery, which asked patients to rate their visual abilities ranging from a score of 1 (no difficulty watching television or reading newspapers) to 5 (needs help to walk around; almost blind).
Of the 328 patients with cerebral infarction who responded, at a mean of 372 days after the stroke, 25.4% self-reported a visual problem, with 6.5% reporting either great difficulty watching television and reading, not able to watch TV or read, or not able to walk independently. Those who did report a vision problem were older, more likely to be unemployed, and more likely to have a prior infarct or prior depression. Their baseline NIHSS was higher and, not surprisingly, the sub-scores for eye movements and visual fields were higher. The study’s primary finding was that the presence of visual problems was associated with a worse self-reported sense of general health, more pain and headache, lower quality of life scores, more depression, and a smaller chance of being independent. Having vision problems was also independently associated with more difficulty with feeding, transfers, grooming, toilet use, bathing, mobility, climbing stairs, dressing, and using the bathroom.
The study concluded with an algorithm for visual rehabilitation including technical aids and structured visual stimulation and exercises aimed at normalizing fixation; saccades; visual attention; visuospatial orientation, accommodation, convergence; visual search; and binocular vision.
COMMENTARY
This study serves as a strong reminder of the relatively high prevalence of visual problems in the post-stroke population, and perhaps more importantly, of the profound effect that even mild-to-moderate visual dysfunction can have on these patients’ quality of life. It is notable that the overall EQ-5D utility score showed a fair correspondence with self-reported vision status on the 15D, underlining how crucial good vision is to patients’ daily functioning.
The authors did not evaluate the precise visual problems or even differentiate afferent from efferent dysfunction, and it is therefore likely that many of the visual problems in this population were not stroke-related. Patients with baseline glaucoma, macular degeneration, diabetic or hypertensive retinopathy, or ischemic optic neuropathy were not excluded from the study and are all more common in older patients, so it is important to understand that this paper does not describe stroke-related visual problems, but instead vision problems after stroke. Future surveys might offer more specific insights by eliciting problems with monocular vision loss, homonymous visual field loss, horizontal and vertical diplopia and oscillopsia, and asking patients to identify whether the problems began with their stroke or were unrelated. Furthermore, while the study reported higher rates of depression and fatigue in patients with greater visual problems, the cause and effect relationship is unclear. For example, a patient with depression might self-report greater difficulties from a right homonymous hemianopia as compared to a non-depressed patient with the same field defect. The authors pointed out a novel finding of the association between visual problems and fatigue, but here also, background fatigue might enhance one’s sense of visual difficulty. Despite these limitations, this study presents a powerful argument for greater attention paid to the visual consequences of stroke, and toward attempts at maximizing compensation and function through focused vision rehabilitation.
Visual impairments are common in stroke survivors and should prompt a careful ophthalmologic evaluation, since many of the problems are ocular and not neurological.
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