INTRODUCTIONStroke is aserious life-threatening medical condition caused due to the impairment ofblood supply to the brain. The National Institute of Health and ClinicalExcellence (NICE ) in its 2008 guideline explained stroke as a preventable andtreatable disease. The International classification of diseases ,however, inits 11th revision definedstroke as an ‘acute focal neurological dysfunction’1; thecause for which could be a focal infarction, hemorrhage or a cause notidentified by advanced neuroimaging techniques. Patients after a stroke sufferfrom physical problems such as movement and balance, visual disturbance,swallowing, continence issues2, to name a few and theseproblems could affect the overall quality of a stroke survivors life, 2however, understanding of stroke as a disease process has expanded over the years and this hascontributed to significantly better outcome among patients 3.In this essay I decided to emphasize on the visual problems experienced bystroke survivors and how focused rehabilitation could improve their quality oflife.I would also discuss anatomy and physiology of eye as a part of visual system.
I intend to discuss stroke, types,risk factors , management andrecommendations focused specifically on visual field defects due to strokeThe theory and literature I use in this essaywill be supported by a case study, adhering to ‘ respect to the people’s rightto privacy and confidentiality’ 4. Gibbs´s Reflective Model(Gibbs, 1988)11 is used in this assignment to structure thecontent of this essay because this model is very clear and precise, allowingfor description, analysis and evaluation of the experience and helps a personto look into the existing practice and develop an action plan to bring outrecommendations which would be beneficial in the future. BODY 1- STATISTICS ANDDEMOGRAPHICS’Make vision count’. This was the World sightday ‘call to action for world’ theme for the year 2017, which shows us that thesense of sight, through which we perceive 80 per cent of all impressions , is by far the most important ofall senses. The world stroke organization in its report explained that strokeas a non communicable disease has attained epidemic proportions and 1 in 6 people worldwide will have a stroke intheir 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 thereare 26 million stroke survivors . Valery et al (2014)12projects that the burden of stroke due to illness, disability and early deathit causes is set to double worldwide within the next 15 years.
Stroke devastates livesaround the world 13 and it claims a life every 6 seconds.Stroke is considered to be the secondleading cause of death for people over the age of 60, and the fifth leadingcause in people aged 15 to 5914. It also affects childrenas well as both men and women. Stroke is responsible for more deaths annuallythan AIDS, tuberculosis and malaria combined14Strokestatistics 15 released by the United Kingdom StrokeAssociation in January 2017 showed that of the 1.2 million stroke survivors inthe UK, 60 per cent have vision problems immediately after their stroke andthis reduces to about 20% by three months after a stroke. Alex Pollock et al.
,2012 in his study10 pointed out that an estimated 20% to57% of people suffer from visual field defects after stroke, which affectstheir function, quality of life, ability to participate in rehabilitation,depression, anxiety, and social isolation. BODY 2 – ANATOMY AND PHYSIOLOGYVision relatedproblems occur due to the damage stroke cause to the brain and depending on thepart of the brain affected, the severity of the problems varies. For instanceGall et al( 2010)5 conducted a prospective studyto evaluate vision-related and health-related quality of life in first strokepatients with homonymous visual field defects (VFD) with respect to the extentof the lesion pointed out that, Homonymous visual field defects (VFD) are amongthe most common disorders after posterior-parietal strokes.The study whichspanned for nine years from 1998 to 2007 found out that patients who sufferedvisual field defects due to stroke had a severely reduced vision-related andhealth-related quality of life even after 2.5 years and stroke-related impairment level issignificantly exacerbated by Visual field defects. In an article written by David C Broadway 6 he pointed out that patients who already haveother co-morbidities like glaucoma might see a poor prognosis when their visionis affected by means of a stroke6.
Mrs,A, a 86year old female patient was brought tothe Accident and Emergency department following a fall and onset of right sided weakness. Assessment wasdone using NIHSS scale7 and a CT scan was done which showeda left sided partial anterior circulation infarct but patient was found to benot a suitable candidate20for thrombolysis as the time onset of the stroke was not known. Patient wasbrought in to the stroke unit and on subsequent assessment she was found tohave left homonymous hemianopsia by which her field of vision was limited toonly left side of both eyes.The World Heath Organization defined that strokeis caused by8″ the interruption of the blood supply tothe brain, usually because a blood vessel bursts or is blocked by a clotwhich cuts off the supply of oxygen andnutrients, causing damage to the brain tissue”.American Stroke Association classified stroke9 based on the pathophysiology.
Obstruction in the blood vesselssupplying blood to the brain by means of a thrombus or embolus constitutes more than 85% of strokes, 15% ofstrokes are hemorrhagic in nature and occurs when a and hemorrhagic stroke,which occurs when a blood vesselruptures . Two types of weakened blood vessels usually cause hemorrhagicstroke: aneurysms and arteriovenous malformations (AVM) are the two types ofweakened blood vessels which cause hemorrhagic stroke. According to the National institute of Heart,Lung and Blood institute16 Certain traits, conditions, and habits increasesa persons risk of having a stroke ortransient ischemic attack (TIA) and such traits, conditions, and habits areknown as risk factors. Increased number of risk factors put a person on anincreased risk of stroke. Some of the risk factors are modifiable which includehypertension and smoking, obesity, sedentary lifestyle, alcoholism and some arenon- modifiable which include age, gender and family history(Australian StrokeAssociation 2015) Vision problems occurring due to a stroke can belargely 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 visualfield (c) eye movement problems- (d)visual processing problems which include visual neglect, where brain isimpaired of information from one sideTo clearlyunderstand how stroke affects the visual pathways a knowledge on how the visualsystem work is important.
The human eye is one of the most valuable andsensitive sense organs which enables us to see the what is around us. The18human eye is like a camera and its lens system forms an image on the retina.Light enters the eye through cornea andmost of the refraction for the light rays entering the eye occurs at the outersurface of the cornea. The crystalline lens merely provides the fineradjustment of focal length required to focus objects at different distances onthe retina. We find a structure called iris behind the cornea. Iris is a darkmuscular diaphragm that controls the size of the pupil.
The pupil regulates andcontrols the amount of light Figure . The eye lens forms an inverted real imageof the object on the retina and thelight-sensitive cells get activated upon illumination and generate electricalsignals and these signals are sent to the brain via the optic nerves. The braininterprets these signals, and finally, processes the information so that weperceive objects as they are. 18A damage to any part of the visual system can lead tosignificant loss of visual functioning. For instance , if any of the structuresinvolved in the transmission of light, like the cornea, pupil, eye lens,aqueous humour and vitreous humour or those responsible for conversion of lightto electrical impulse, like the retina or even the optic nerve that transmitsthese impulses to the brain, is damaged, it will result in visual impairment.Homonymous hemianopsia is a condition which impairs the sight of person due topathologies which affect visual pathways of the brain. As the right half of thebrain 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 withit.
Pambakian and Kennard17 reported that lesions in the occipital lobe constituteforty percent of cases of homonymous hemianopsia, parietal lobe causes thirtypercent, temporal lobe causes twenty five percent, optic tract and lateralgeniculate nucleus constitutes five percent. DISCUSSION- study r/v,rehab, what is in our ward, what hap to this patient, recommendationsIt should benoted that the diagnosis of left homonymous hemianopsia in the patient whom Itook for case study was diagnosed only after one week.The delay pertained tothe unavailability of services of an opthalmologist and optometrist. Suchsituation lead to the delay in initiating visual rehabilitation and addressingthe vision problems associated with it. It isunderstood that as like other problems after stroke, with timely interventionand focused rehabilitation,vision problems also show improvement over time. Sand et alin 2012 published a study21 which is worthmentioning, where they performed a restrospective audit on the diagnosis andvisual rehabilitation of stroke patients in Norway for a period over 3 years . Thedata was taken from a community stroke registry and they included all the patients occipital lobeinfarctions and non-occipital lobe infarctions with visual field defects.
Theyidentified 353 patients ,out of 1,420stroke patients, and analyzed their data to find out the accessibility of thosepatients to perimetry and visual rehabilitation and the results are noteworthy.When 9.6 percent of patients were referred to perimetry,only 2.3 percentpatients were referred for visual rehabilitation eventhough they had trainedvisual therapists dedicated to handle visual field defects .This data aloneshows that the awareness level of the need for visual rehabilitation is verylow even in developed nations and among neurologists.
Visual rehabilitation22 is intended to improve awareness of visual field loss and toemploy strategies to promote the patient’s ability to scan in the area of thedefect. The study notes that European Stroke Organisation (ESO) guidelines24 for stroke managementunderpins the need of underline theimportance physiotherapy, occupational therapy, language training and cognitiveassessment, but fail to underline the importance of perimetry to check for visual field defectsand the need for visual rehabilitation23. The study comesout with some important finding21that clinicians give more focus on managing the motor symptoms and visual fielddefects receive less attention. The study also recommend 21that more awareness need to be created amonghealthcare staff for diagnosing stroke associated visual field defects andfocused visual rehabilitation. A word need to be added that the study ishowever retrospective in nature and the authors have not explained why referral for perimetryand visual rehabilitation was very low despite having dedicated visual therapists.Theauthors also have not explained how much time it took for patients to bereferred to visual therapist after admission .It would have been noteworthy ifcomparisons were made with other European nations to find out if the lack ofawareness is widespread.The authors have not listed the limitations of thestudy.
.The patient Itook for the case study was not able to avail visual therapy services duringher admission in the ward for almost a month after admission as therapy wasfocused on the motor aspect of the patient.My ward does not have a dedicated visual therapist so referrals had to bedone to dedicated hospitals with ophthalmology services which againdelayed focused rehabilitationAnophthalmologist,a medical practitioner specializing on eye, will be able togive more advice and most commonly visual aids are used to help with achievingoptimum level of vision after a stroke. For instance ,magnifiers and minifiersare commonly used in patients suffering from central vision loss and prismglasses are used to broaden the visual field. But these devices wereunavailable in the ward.
The patient only got one session with visual therapistand all other sessions were planned in way it happens after the discharge fromthe hospital. The multidisciplinary approach to address these problems couldhelp in pooling up of resources and avoid delays.This particularly was verystressful for the family as they believed that patients concerns in this regardwere not adequately addressedVisual problemsalso affects the social life of stroke survivors in different ways. Thelicensing authorities like DVLA has put restrictions on driving for patientsafter stroke.
As per the rules19 , after a stroke or TIAa person cannot drive a car for onemonth especially if that person suffers from double vision,blurred vision andcentral vision field loss. It is advised by the DVLA that people suffering fromvision problems after stroke must get proper visual assessment done before theyreturn to drive It is important that patients become self confident to lead aquality life with such ailments and the whole purpose of rehabilitation shouldbe focused on this. RECOMMENDATIONSIn conclusion,this essay supports the idea that visual problems are common after a stroke buta focused ,team based approach canimprove outcome among patients and with the advent of newer technologies likecomputer delivered therapies like NeuroEyeCoach, the future looks promising. REFERENCES 1.
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