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National Clinical Guideline Centre (UK). Stroke Rehabilitation: Long Term Rehabilitation After Stroke [Internet]. London: Royal College of Physicians (UK); 2013 May 23. (NICE Clinical Guidelines, No. 162.)
Vision may be affected after stroke in a number of ways. People with stroke may be aware of difficulties with peripheral vision as a result of a visual field defect, double vision as a result of impaired eyed movements or poor co-ordination of eye movements, and problems arising as a result of difficulties with visual processing. This chapter focuses on the treatment of hemianopia and double vision.
10.1. Eye movement therapy
Hemianopias are estimated to affect between 8 and 25% of people with stroke17,92. This vision defect is characterised by low vision or blindness in corresponding halves of the field of vision. People suffering from hemianopia or quadrantanopia may run into objects, trip or fall, knock things over, and lose their place when reading, or be surprised by people or objects that seem to appear suddenly out of nowhere. Some people may not be aware of the deficit, especially those with associated neglect. Eye movement therapy encourages scanning into the affected visual field and is a technique used with patients with a hemianopia post stroke.
10.1.1. Evidence review: In people after stroke what is the clinical and cost-effectiveness of eye movement therapy for visual field loss versus usual care?
| Clinical Methodological Introduction | |
|---|---|
| Population: | Adults and young people 16 or older who have had a stroke |
| Intervention: | Eye movement therapy including:
|
| Comparison: |
|
| Outcomes: |
|
10.1.1.1. Clinical evidence
Searches were conducted for systematic reviews and RCTs comparing eye movement therapy as an intervention for visual field loss in people after stroke. Only studies with a minimum sample size of 10 participants (5 in each arm) and including at least 50% of participants with stroke were selected. Three RCTs were identified. Table 52 summarises the population, intervention, comparison and outcomes for each of the studies.
Table 52
Summary of studies included in the clinical evidence review. For full details of the extraction please see Appendix H.
Comparison: Eye Movement Therapy (EMT) for visual field loss versus usual care/sham visual rehabilitation
Table 53
Eye Movement Therapy versus usual care - Clinical study characteristics and clinical summary of findings.
Table 54
Restitutional training/compensatory treatment vs. usual care (occupational therapy).
Narrative Summary
The following study is summarised as a narrative because the results were not presented in numerical data that could be included in the GRADE table:
- Spitzyna et al, 2007246 compared reading moving text to a sham visual rehabilitation in hemianopic patients (mainly stroke patients). Reading moving text induced small-field optokinetic nystagmus (OKN) and preferentially affected reading saccades into the blind field. The outcomes reported were: reading speeds, eye movements and visual field perimetry. Authors246 reported a significant improvement in the reading speeds and associated eye movements with participants in the reading moving text group compared with the sham visual rehabilitation group but there was no change with the visual field perimetry across the groups.
10.1.1.2. Economic evidence
Literature review
No relevant economic evaluations comparing eye movement therapy for visual field loss with usual care were identified.
Intervention costs
In the absence of cost effectiveness analysis for this review question, the GDG considered the expected differences in resource use between the comparators and relevant UK NHS unit costs. Consideration of this alongside the clinical review of effectiveness evidence was used to inform their qualitative judgement about cost effectiveness.
The GDG considered that eye movement therapy for visual field loss would most likely be delivered by an orthoptist or an occupational therapist in the NHS and would typically consist of an initial 60 minute assessment with a 30 minute follow-up appointment every three weeks and follow-up would be required on average for 6 months. The estimated cost per hour of client contact for a band 7 orthoptist is £59o51 (typical salary band identified by clinical GDG members). This equates to an estimated total cost per patient of £285.
10.1.1.3. Evidence statements
Clinical evidence statement(s)
One study37 comprising of 33 participants showed a statistically significant improvement in the visual scanning (letter cancellation) test in the eye movement therapy group compared to the usual care group (MODERATE CONFIDENCE IN EFFECT).
One study37 comprising of 33 participants showed a statistically significant improvement in visual spatial tasks for participants who received eye movement therapy compared to the usual care group (MODERATE CONFIDENCE IN EFFECT).
Visual field enlargement
Restitutional training
- One study174 comprising of 15 participants in the restitutional training group and 15 control participants showed no significant improvement in visual field enlargement (as assessed by an attention visual field assessment) between restitutional training and control groups (LOW CONFIDENCE IN EFFECT).
Compensatory therapy
- One study174 comprising of 15 participants in the compensatory treatment group and 15 control participants showed no significant improvement in visual field enlargement (as assessed by an attention visual field assessment) between compensatory treatment and control groups (LOW CONFIDENCE IN EFFECT).
Visual search (BIT cancellation test)
Restitutional training
- One study174 comprising of 15 participants in the restitutional training group and 15 control participants showed no significant improvement in visual search ability (as assessed by the BIT cancellation task) between restitutional training and control groups (LOW CONFIDENCE IN EFFECT).
Compensatory therapy
- One study174 comprising of 15 participants in the compensatory treatment group and 15 control participants showed no improvement in visual search ability (as assessed by the BIT cancellation task) between compensatory treatment and control groups (LOW CONFIDENCE IN EFFECT).
Reading performance (reading text from Wechsler Memory Test)
Restitutional training
- One study174 comprising of 15 participants in the restitutional training group and 15 control participants showed no significant improvement in reading performance (reading text from the Wechsler Memory Test) between restitutional training and control groups (VERY LOW CONFIDENCE IN EFFECT).
Compensatory therapy
- One study174 comprising of 15 participants in the compensatory treatment group and 15 control participants showed no improvement in reading performance (reading text from the Wechsler Memory Test) between compensatory treatment and control groups (VERY LOW CONFIDENCE IN EFFECT).
Attention (Phasic Alertness)
Restitutional training
- One study174 comprising of 15 participants in the restitutional training group and 15 control participants showed no significant improvement in attention control between restitutional training and control groups (LOW CONFIDENCE IN EFFECT).
Compensatory therapy
- One study174 comprising of 15 participants in the compensatory treatment group and 15 control participants showed a statistically significant improvement in attention control associated with compensatory treatment compared to usual care (LOW CONFIDENCE IN EFFECT).
Visual conjunction search (visual scanning test)
Restitutional training
- One study174 comprising of 15 participants in the restitutional training group and 15 control participants showed no significant improvement in visual conjunction search skills (assessed by a visual scanning test) between restitutional training and control groups (VERY LOW CONFIDENCE IN EFFECT).
Compensatory therapy
- One study174 comprising of 15 participants in the compensatory treatment group and 15 control participants showed no improvement in visual conjunction search skills (assessed by a visual scanning test) between compensatory treatment and control groups (LOW CONFIDENCE IN EFFECT).
Activities of daily living (Barthel Index)
Restitutional training
- One study174 comprising of 15 participants in the restitutional training group and 15 control participants showed no significant improvement in performance of activities of daily living (assessed by the Barthel Index) between restitutional training and control groups (VERY LOW CONFIDENCE IN EFFECT).
Compensatory therapy
- One study174 comprising of 15 participants in the compensatory treatment group and 15 control participants showed no improvement in performance of activities of daily living (assessed by the Barthel Index) between compensatory treatment and control groups (LOW CONFIDENCE IN EFFECT).
Economic evidence statements
No cost effectiveness evidence was identified.
10.1.2. Recommendations and link to evidence
| Recommendation |
|
|---|---|
| Relative values of different outcomes | The outcomes of interest included in the review were: reading speed and accuracy, eye movement scanning and letter cancellation. The GDG considered that the outcomes measures included in the review were of equal value, although reading speed and accuracy represents a real life task whereas scanning and letter cancellation are impairment level measures. |
| Trade-off between clinical benefits and harms | Homonymous hemianopia can impact on a range of activities of daily living including, reading, driving, navigation, eating, hygiene related activities, and social interaction. There are significant safety issues associated with missed diagnosis including falls, injuries and motor vehicle accidents. There is a benefit to a diagnosis of persistent homonymous hemianopia in terms of access to registration of visual impairment and subsequent access to sensory rehabilitation teams. A proportion of patients do spontaneously adapt to the impairment, but the numbers are presently unknown. Persistent (non-recovered) homonymous hemianopia can have a significant impact on quality of life. The group considered that treating this condition would provide major benefits in terms of improving quality of life for the individual patient. The GDG also believed the benefits of the intervention are significant given the risks of leaving the condition untreated. Patients with homonymous hemianopia must not drive within one year of their stroke onset. They may be able to reapply to the DVLA after one year if they can prove that they have learned to compensate for the defect. (Medical practitioners At a Glance Guide to the Current Medical Standards of Fitness to Drive, DVLA, 201171). |
| Economic considerations | No cost effectiveness studies were identified. Delivering eye movement therapy for visual field loss would involve some additional costs in terms of an orthoptist or occupational therapist assessment and follow-up time. The GDG considered that the additional costs would potentially be offset by the long term benefit to patients in terms of improved quality of life. |
| Quality of evidence | One small study by Carter, 1983 37 examining a mixed population of patients with neglect and homonymous hemianopia, demonstrated an improvement in visual scanning strategies after intervention as measured by letter cancellation and visual spatial test and the confidence in these effects was graded as moderate. A second small study (Spitzyna, 2007) examined patients (75% of whom had a stroke) with persistent homonymous hemianopia, using a novel intervention of moving text. The authors reported a significant improvement in reading speed and eye movements but results were not presented in numerical data that could be included within the GRADE analysis. The GDG noted that the Carter Study was poorly defined in terms of patient recruitment and that it was unclear if the patients had hemianopa or visual neglect, or both, but the same intervention was used for both effectively. The GDG considered that there was insufficient evidence to reach generalised conclusions regarding efficacy related to activities of daily living, although there is some evidence regarding effectiveness for reading. The GDG considered that it was important for people who have had a stroke to be assessed for visual field defects and because of the impact this impairment has on the quality of the person’s life and the serious safety issues in leaving this untreated, The GDG agreed that a strongly worded recommendation needed to be made to reflect these concerns even though the evidence was limited to one small study. It was noted that further research in this area is required. |
| Other considerations | The GDG were uncertain about the prevalence of homonymous hemianopia within a stroke population and requested that an additional literature search be conducted. Six studies17;45;79; 99;92; 261 were identified which addressed prevalence, these were of varying quality, often examining a selected population within a hospital setting. On the basis of these studies, the GDG felt a prevalence of persistent homonymous hemianopia in the community was likely to be between 8 and 25%. Half of the patients within the papers reviewed were not aware that they were suffering from homonymous hemianopia. It was noted that routine screening for visual field defects was not currently universal and therefore potential patients were not identified or referred for therapy. Attention should be paid at stroke onset to eliciting visual field defects. The group considered that performing screening assessment is good practice and should be undertaken. |
10.2. Diplopia or other ongoing visual symptoms after stroke
A stroke may lead to problems with eye movements which result in both eyes not working together as a pair. This can make it difficult to focus on specific things because of blurred vision as well as diplopia (or double vision) which impacts on reading, walking and performing everyday activities. Treatment can involve prisms, exercises and occlusion.
A search for systematic reviews was carried out for evidence on the management of diplopia and ongoing visual symptoms in people after stroke. No reviews were identified and therefore recommendations in this section were based on modified Delphi consensus statements which were based on recommendations from published national and international guidelines. Below we provide tables of statements that reached consensus and statements that did not reach consensus and give a summary of how they were used to draw up the recommendations. For details on the process and methodology used for the modified Delphi survey see Appendix F. This section of the Delphi survey was aimed at Delphi panel members with the relevant experience to comment on visual impairments in stroke. Other members could opt out of this section. Therefore the response rate was lower.
10.2.1. Evidence review: How should people with visual impairments including diplopia be best managed after a stroke?
| Population | Adults and young people 16 or older who have had a stroke |
|---|---|
| Components |
|
| Outcomes |
|
10.2.2. Delphi statements where consensus was achieved
Table 55Table of consensus statements, results and comments (percentage in the results column indicates the overall rate of responders who ‘strongly agreed’ with a statement and ‘amount of comments’ in the final column refers to rate of responders who used the open ended comments boxes, i.e. No. people commented/No. people who responded to the statement)
| Number | Statement | Results % | Amount (No. panel members who commented/No. panel members who responded) and content of panel comments – or themes |
|---|---|---|---|
| People who have persisting double vision after stroke require a formal orthoptic assessment. | 70.8 | 1/24 (4%) panel member commented The person who commented thought that all other forms of visual impairment would also require orthoptic assessment. |
10.2.3. Delphi statement where consensus was not reached
Table 56Table of ‘non-consensus’ statements with qualitative themes of panel comments
| Number | Statement | Results % | Amount and content of panel comments – or themes |
|---|---|---|---|
| 1. | All people who have impaired acuity, double vision or a visual field defect following a stroke require a formal ophthalmology assessment. | 23.8 | In round 2 – 7/24 (29%) panel members commented; 7/21(33%) in round 3 It was pointed out that different aspects in the statement require different actions (“Impaired acuity and double vision both require an ophthalmological diagnosis. Visual field defect after stroke is less problematic, and the diagnosis is usually known – in such cases adaptive treatments and education are the priority.”). Other comments also highlighted that this is not always needed. |
| 2. | People who have ongoing visual symptoms after a stroke, should be provided with information on compensatory strategies from: | In round 2 – 6/23 (26%) panel members commented; 9/20 (45%) in round 3 It was highlighted that it depends on availability and on the need (“Occupational Therapists are most likely to advise re rehabilitation and application to daily life whereas orthoptists can advise on vision strategies. Ophthalmology will Ax and Rx eye problems but perhaps not so much advise on strategies.”). One panel member was involved in the development of web-based therapies that work by inducing compensatory eye movements | |
| • Ophthalmology services | 15.7 | ||
| • Orthoptic services | 50.0 | ||
| • Occupational therapy services | 31.5 | ||
| 3. | People who have had a stroke and have visual impairments should be provided with contact details for the RNIB or Stroke Association for further information on visual impairments after stroke. | 38.1 | In round 2 – 4/23 (17%) panel members commented; 1/21 (5%) in round 3 People who have persisting double vision after stroke require a formal orthoptic assessment. It was pointed out that this should be done if symptoms persist and not given routinely to everybody. |
| 4. | Assessment and information for registering as sight impaired or severely sight impaired should be provided by referral to an ophthalmologist. | 47.6 | In round 2 – 2/24 (8%) panel members commented; 5/21 (24%) in round 3 It was commented that: “All involved in stroke care should realise that only ophthalmologists can sign the certification of visual impairment form.” Others queried whether an orthoptist could also do this. |
10.2.4. Recommendations and links to Delphi consensus survey
| Statements | 27. People who have persisting double vision after stroke require a formal orthoptic assessment. |
|---|---|
| |
| Economic considerations | There are costs associated with a formal orthoptic assessment. The estimated cost per hour of client contact for a band 7 orthoptist is £59p51 (typical salary band identified by clinical GDG members). There is currently a lack of convincing evidence in favour of any intervention for the treatment of diplopia after stroke. However, the GDG thought that a formal orthoptic assessment might indicate underlying individual causes that may lead to possible treatment activities. For this reason, the GDG considered the costs associated with orthoptic assessment likely to be offset by its benefits. |
| Other considerations | The GDG interpreted the lack of consensus as indicating no conclusive agreement could be drawn from the Delphi panel on what is beneficial for diplopia. The GDG took into account that this is a condition that would seriously affect an individual’s quality of life and that it is therefore important that this is formally assessed. Even though there is not enough robust evidence to support one treatment over another for diplopia at present, the GDG thought that the results may indicate a path of treatment options based on individual need. It is also possible that a formal orthoptic assessment might indicate underlying individual causes that may lead to possible treatment activities, such as prisms or patching. The GDG also considered that that the provision of information to the person who experiences diplopia post stroke and their carer/family is central in this process (including available treatment options). However, the GDG stressed that it is important for clinicians to keep in mind that there is currently a lack of convincing evidence in favour of any intervention. It is therefore necessary in discussions with the patient and their carers/family to be sensitive and set realistic goals. |
- p
Estimated based on data and methods from the Personal Social Services Research Unit ‘Unit costs of health and social care’ report and Agenda for Change salary band 7. Assumed that an orthoptist is costed similar to other allied health professionals.
Footnotes
- o
Estimated based on data and methods from the Personal Social Services Research Unit ‘Unit costs of health and social care’ report and Agenda for Change salary band 7. Assumed that an orthoptist is costed similar to other allied health professionals.
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