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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
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Eye Care Staff
• Optometrist (Optician) checks for glasses
and screens for eye conditions
• Ophthalmologist (Eye Doctor) treats Eye
Conditions
• Ophthalmic nurses
• Orthoptist
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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
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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
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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
•
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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
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What is vision
• Form =Visual Acuity = reading=TV
• Movement = Visual Field = peripheral
vision=mobility
• Colour Vision
• Contrast Sensitivity = brightness
• Binocular Vision = 3D vision
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Visual System
• Eyes
• Visual Pathways
• Control of Eye Muscles• Visual Perception
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The Eye
• Lids and tear production
• Cornea
• Lens / Accommodation• Retina
• Focussing image on the fovea
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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
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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
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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
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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
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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
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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
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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
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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
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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
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Circle of Willis
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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
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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
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Posterior cerebral artery infarct
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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
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Place of Examination
• In-patient (bedside if necessary) refer
direct to Orthoptist
• Out patient refer to Ophthalmologist
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Orthoptic Examination
• History
• Observations
• Visual Acuity Distance and Reading• Cover Test
• Ocular Movements / Saccades
• Convergence• Frisby
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Observations
• Side of hemiparesis
• Side of facial palsy
• Head Posture
• Ocular Posture
• Ocular Appendages
• Pupils
• Glasses, Strength, Type and Fit
• Closing one eye
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Visual Inattention
• Reading
• Vision
• 2 pen Test
• Albert’s Test
• Line bisection Test
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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
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Reduced Vision
• Plot progress
• Refer to Optician
• Refer to Ophthalmologist• Low Visual Aid Clinic
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Ocular Motility Disorders
• Supranuclear = gaze palsy
• Internuclear
• Infranuclear = nerve palsy III ;IV ; VI• Skew deviation
• Manifest Squint
• Convergence / Accomm. Insufficiency• Nystagmus
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Double Vision
• Fresnel Prisms to join double vision
• Occlusion (Patching)
• Abnormal Head Posture• Orthoptic Treatment
• Surgery
• Botulinum Toxin to eye muscles• Plot progress
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Hemianopia
• Explain defect
• Help with reading Markers, Typoscopes
• Use of eye movements
• Prisms
• Advise re driving requirements
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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
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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
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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
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Visual Defects of 100 CVA
0
10
20
30
40
50
60
Sy VF VA NVA x2 VI NAD
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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
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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
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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
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Demonstration Glasses
• Cataract / Macular Degeneration
• Visual Field loss
• Double vision
•(Glaucoma = tunnel vision)
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Normal View
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Out of focus/ no glasses
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Left homonymous hemianopia
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Bilateral homonymous hemianopia
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Diabetic Retinopathy
D bl Vi i (Di l i )
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Double Vision (Diplopia)
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Double Vision (Diplopia)
C t t
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Cataract
What to do if visual defect
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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
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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
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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)