Primary care of the stroke patient

Excerpted from page 44 of the spring 2024 edition of AOA Focus 

Cerebrovascular accidents are commonly referred to as strokes, resulting from cardiovascular disease that affects the blood vessels supplying blood to the brain (also known as a “brain attack”). Stroke occurs when blood vessels either “burst” (hemorrhage) or become “clogged” (ischemia), depriving the brain of oxygen.  

There are two types of hemorrhages and two types of clots: 

• Cerebral and subarachnoid hemorrhages (higher fatality rate) 
• Cerebral thrombosis and embolism (most common, representing approximately 75% of all strokes) 

The STROKE acronym is a useful strategy to remember the tell-tale symptoms: (S)peech impairment, (T)ingling or numbness, (R)ecall difficulty (memory), (O)ff balance or imbalance, “(K)iller” headaches and (E)ye disturbances (loss of peripheral vision). Because it is reported that at least 10% of strokes tend to be preceded by transient ischemic attacks, it is very important to act quickly and call 911. 

As primary eye care providers, we are very likely to see more patients who are at risk or have suffered a stroke. So, we should be prepared to recognize the signs and symptoms of strokes, including the associated visual disturbances and what can be done for the patient. In addition, there are some helpful functional tests that are recommended for stroke patients: 

• Line bisection  
• Clock 
• Star cancellation 
• Trail making  
• King-Devick test 
• Spatial localization 

These tests are quick and easy to administer and will provide valuable information on the patient’s visual spatial skills. Most of these tests can be administered by the optometric staff. 

Case No. 1 

Hospital case intracranial hemorrhage: 60-year-old patient 

An MRI revealed there were multifocal strokes. Cerebral angiography helped with the diagnosis of cerebral vasculitis. Repeat imaging showed a right frontal hematoma. Craniotomy was performed to remove the hemorrhage. 

Neuro-optometry evaluation in the hospital 

Patient presented with cognitive issues and difficulty processing visually in her left field. Saccadic eye movements were present in the right field only. Patient had difficulty communicating and was not able to identify letters or numbers. With respect to ambulation, the patient was able to walk with support on the left side with her occupational therapist present for support. There was no scanning to the left side that was observed. Clinical impressions include deep-seated visual spatial inattention, unsteady fixations and deficiency of saccadic eye movements. 

While in the hospital, oculomotor vision rehabilitation activities were assigned. The initial therapies include wall saccades and reach and grasp targets while crossing midline.  

After discharge, the patient was evaluated at the neuro-optometrist’s office about six weeks later. Patient was very concerned because the central vision was reduced to 20/100 with each eye. Refraction improved the vision to a poor 20/60 with each eye. With the addition of two base-down yoked prisms, the patient reported that room looked much better (even though the acuity did not improve). Navigation skills improved significantly with the yoked prisms. There was better visual awareness of where the floor was in relation to the patient. This made a big difference for the patient’s confidence in crowded environments. Therapy was prescribed to improve eye movements, spatial localization and visual motor skills. 

Neuro-optometric follow-up 

Therapy continued at the neuro-optometrist’s office for five months. Additional improvements were made, but one major problem remained—reading. Before the stroke, the patient was an avid reader, but after the stroke even first-grade-level books were challenging. With respect to reading, multiple problems were noted. Vision was still at 20/60 best corrected; other problems included sensitivity to glare and left-side neglect. Keeping the eyes on the line of print was difficult. Three recommendations helped with reading: 

• One base in OU added to the reading Rx 
• Use of an iPad for reading to enlarge font 
• Changing the background to dark and the lettering to white 

With these changes, reading became much easier. Even two years after the stroke, there are still improvements in functional living skills being made. The patient is no longer having problems with visual spatial neglect, but a visual field defect does exist. 

Case No. 2 

Office-based case and collaboration with outpatient rehabilitation 

The stroke rehab team at a local hospital referred a 50-year-old male who was diagnosed with a left cerebellar infarct for an initial neuro-visual rehabilitation consultation. It was stated that he had first experienced “some vertigo and decreased balance,” then subsequently began to complain of blurred vision and difficulty walking, with poor balance. Further history revealed that he was observed to close one eye, which was due to his constant double vision. He was also observed to exhibit a head tilt and turn. He stated that his goals are to regain more stable vision, return to independent activities prior to the stroke and return to driving. 

The patient came in with his single vision distance glasses. The habitual visual acuities were 20/80 and 20/70 for the right and left eyes. Eye examination (trial framing) showed a mild increase in myopia but had resulted in no significant improvement in visual acuity. Ocular motilities were dysconjugate and with clockwise oculorotary nystagmus. Cover testing showed alternating hypotropia with exotropia (right eye preferred 60%). He demonstrated marked visual confusion (localization and midline) with visual spatial testing.  

Prism testing did not provide sufficient binocular fusional stability with the patient continuing to exhibit motor imbalance. Selective occlusion was then presented, and the patient reported reasonable improvement in his visual stability. Therefore, we agreed that a spot occlusion (half inch opaque, equivalent to 20/200) be worn (to be initially placed on the left lens). Periodic teleconference meetings were held with the team to review his therapeutic response during the therapies. He also has been returning for regular office visits to continue to direct and monitor his rehabilitation. This included use of yoked prism as well as directed visual activities that were part of his outpatient therapy at the hospital. Following the selective occlusion treatment, he eventually transitioned to prism glasses, which gave him stable binocular fusion. He recently reported that he had been evaluated by the Certified Driver Rehabilitation Specialist at the hospital and has returned to limited driving privileges. 

In conclusion, there is a lot that can be done for our patients who have had strokes. Vision rehabilitation is an important part of the therapy program and can be successful when the patient is identified early. In addition, the patient needs to be referred for proper treatment to the rehabilitation team. This includes neuro-optometry, physical therapy, occupational therapy and speech therapy for comprehensive rehabilitation services. 

Written by Carl Garbus, O.D., and Eric Ikeda, O.D., members of the AOA’s Vision Rehabilitation Committee. 

Disclaimer: The information contained in this article represents the opinion of the author and not the AOA. These are not clinical practice guidelines, nor has the evidence been peer-reviewed. There are additional aspects to this topic that may not be presented, or considered, based on the specifics of the case.