About 795,000 Americans will experience a new or recurrent stroke this year, according to the Centers for Disease Control and Prevention.¹ Over 142,000 persons die per year from a stroke (about 1 in 20 deaths), making stroke the fifth leading cause of death in the United States.² Amazingly, about 80% of strokes are preventable.³ (See “Steps for Stroke Prevention” p.30).

Many side effects can occur from a stroke, including paralysis, speech and cognitive impairment, motility issues, emotional and psychological impact and, of course, visual issues. Immediate treatment may minimize the long-term effects of a stroke and even prevent death (see “BE FAST,” p.32). When the patient’s vision and ocular coordination are involved, optometrists have an opportunity to make a life-altering impact. As health care practitioners, O.D.s routinely see these patients and, oftentimes, are the first ones to diagnose, advise and refer them for further care and testing. Therefore, optometrists need to be aware of the most common patient symptoms and complaints of stroke to best prescribe for the patient, as well as communicate and work effectively with health care colleagues.

This article will provide an introduction to caring for the stroke patient in the optometric practice.

RISK FACTORS/CAUSES/CONSEQUENCES

A number of health issues are often linked to higher incidence of stroke, including hypertension, diabetes, obesity, high cholesterol, narrowed arteries and arrhythmia. Even when patients are managing health issues with medication, the risk factors remain. Other risk factors include lack of exercise, poor diet, smoking and consuming more than two alcoholic drinks per day. In addition, age, family history, race, gender, prior stroke, a transient ischemic attack (TIA) or heart attack are risk factors for stroke.⁴ Concussion is also a risk factor.⁵

Automobile accidents, assault and battery cases, suicide attempts, etc., are just a few of the situations that may also result in a stroke, typically as a result of trauma or traumatic brain injury.⁶ Oftentimes, a patient may indicate they may have had a TIA, usually referred to as a “mini-stroke,” or even suffered an injury resulting in a traumatic brain injury.

About 65% of stroke victims may experience vision issues. Most people who experience stroke-related vision loss do not fully regain their vision, but some recovery is possible. Proper diagnosis and vision rehabilitation can help patients improve most daily activities.⁶ Frequent vision problems related to stroke include ^7-11:

• Blurred or loss of vision,
• Increased light sensitivity
• Dry eyes
• Diplopia
• Visual field (VF) loss (monocular or binocular)
• Tracking or ocular muscle control issues
• Poor ductions/versions
• Decreased near point of conversion
• Decreased depth perception
• Visual hallucinations

Although rare, some patients may even suffer a total loss of color vision.¹² Poor visual memory is common and may accompany speech difficulties.¹³

Steps for Stroke Prevention

The Stroke Recovery Foundation developed the “11 Pillars of Prevention.” These steps include:

An annual physical exam 

 

Managing blood pressure 

 

Healthy diet 

 

Exercise 

 

Weight loss 

 

Smoking cessation 

 

Limiting alcohol consumption 

 

Carotid artery screening 

 

Diabetes control 

 

Attending to atrial fibrillation, if necessary, 

 

Taking supplements and medications as prescribed.

Source: The Stroke Recovery Foundation³

WHEN STARTING THE EXAM

It is important that optometrists observe their patients as they walk into the exam room, while speaking with them and while performing complete examinations. Here’s why: While the patient who visits the office may have been diagnosed as having had a stroke or a TIA, it is possible the patient may be unaware that this event occurred. These “silent strokes” do not cause noticeable symptoms — the area of damage is small and occurs in a part of the brain that does not control vital functions, so they remain undetected.

Also, it is possible this patient may have been misdiagnosed or even undiagnosed, yet may be suffering from vision issues related to stroke or TIA when seeking the O.D.’s services, often the first contact by the patient seeking a solution to a recent vision problem. Therefore, it is important to ascertain when the stroke occurred, the treatment received and any lasting effects. Listen to your patient’s responses, and observe them as closely as possible during their visit.

If your patient is unable to respond or remember or seems confused, questioning your patient or a family member (or caregiver) who accompanies your patient is always an option.

Be certain to document any pertinent information in your patient’s record, so you are better able to address the patient’s needs and communicate with their other professional team members when appropriate.

A useful reference used by health care providers in quantifying the impairment caused by a stroke is the National Institutes of Health Stroke Scale. It is comprised of 11 items, scoring specific abilities, such as level of consciousness, on a scale from 0-4.¹⁴

In addition, the question, “How was your recovery?” to those who present reporting a stroke can elicit a significant amount of information with respect to the severity of the stroke and the patient’s expectations regarding treatment. Also, patients can disclose information to optometrists that they may neglect to mention to intake staff. A complete dilated exam, fundus photos, VFs (even a confrontation field) and using trial lenses to finalize the prescription are tools O.D.s possess to meet these patients’ visual needs. At times, utilizing prism (or press-on Fresnel lenses) can aid in reducing diplopia, visual hallucinations and compensate for the VF defects created by the stroke.

OVERCOMING COMMUNICATION CHALLENGES

Some of the common side effects of a stroke — altered mood or temperament, impaired thinking ability, decreased attention, memory impairment and impaired problem-solving skills — can affect the optometrist’s ability to work with the patient in prescribing, as well as communicating, often requiring a lot of patience and increased chairside time on the O.D.’s part, as well as the possibility of multiple visits to finalize recommendations.

Because strokes can affect speech, some of these patients may simply not be able to communicate what they see or may not be able to correctly speak a specific letter or number, etc., even though they can actually see it. That “short circuit” between seeing and speaking is frustrating, but it doesn’t mean the patient can’t respond.

Sometimes, creative thinking on the optometrist’s part can help facilitate communication with the stroke patient. For example, inviting the patient to signal with their hand or finger when they see a letter on the Snellen chart may circumvent the “short” in their system. In such cases, O.D.s should remember to look at and speak with the patient (as well as the caregiver, if they are in the exam room), even if the patient is unable to actually speak or communicate. Returning for a full dilation, further VF testing, trial lens verification, etc., is often necessary, as these patients may tire quickly, become frustrated or even appear to shut down during the initial visit.

In addition, referral for specialist care — to a colleague who practices low vision, vision therapy or neuro-optometry, for example — may also be appropriate.¹⁵

‘BE FAST’

Every minute matters in the immediate treatment of a stroke patient. Some 40% of stroke survivors experience moderate-to-severe impairments that require some type of specialized care, with some 10% requiring care in a long-term care facility.¹⁶ The longer the patient goes without any treatment, the greater the physical and mental disability. Use the “BE FAST”* method to spot and act on a possible stroke:

* Thanks to Loma Linda University Medical Center News.¹⁷

PARTICIPATING IN COLLABORATIVE CARE

Communication with the patient’s primary care physician is essential. Other team members who may be working with the optometrist’s patient, in addition to the vision specialists mentioned above, include a neurologist, speech therapist, occupational and physical therapist, rehab provider, vocational therapist and psychologist or psychiatrist. It is important to interact with other team members whenever possible, by report, phone, fax, email, etc. If your patient doesn’t know who is on the team, contact the primary health care provider.

Additionally, the role of the patient’s family, among other support personnel, is critical when working with the stroke patient and should never be overlooked or minimized.

MAKING THE DIFFERENCE

It is important to remember that stroke patients may be seeing or have seen a lot of health care professionals, and the O.D. may actually be the one who can truly help make a difference in their quality of life. It takes patience, as well as an understanding of the frustrations facing the patient to help them regain independence or just improve their ability to function and live. O.D.s may be the difference between a patient who both sees and functions well, and the patient who is frustrated and plagued with unresolved vision issues that continue to impair their quality of life. OM

REFERENCES

1. Stroke Facts. Centers for Disease Control and Prevention. https://www.cdc.gov/stroke/facts.htm . Accessed 10/22/2021.
2. About Stroke. The American Stroke Association. https://www.stroke.org/en/about-stroke . Accessed 10/22/2021.
3. Stroke Prevention. The Stroke Recovery Foundation. https://strokerecoveryfoundation.org/stroke-prevention/?keyword_session_id=vt~adwords|kt~can%20you%20prevent%20having%20a%20stroke|mt~b|ta~385575154789&_vsrefdom=wordstream&gclid=CjwKCAjwn8SLBhAyEiwAHNTJbdadAdWcxWhor2t2fNmpba_Q_3ae-tp17SB0RBhi4vau7HwgC34BORoCpvUQAvD_BwE . Accessed 10/22/2021.
4. Stroke Risk Factors. The American Stroke Association. https://www.stroke.org/en/about-stroke/stroke-risk-factors . Accessed 10/22/2021.
5. Stroke survivors may have higher suicide risk. American Stroke Association International Stroke Conference – Presentation P237. https://newsroom.heart.org/news/stroke-survivors-may-have-higher-suicide-risk . Accessed 10/22/2021.
6. Trauma-Informed Care in Behavioral Health Services. Treatment Improvement Protocol (TIP) Series, No. 57. Center for Substance Abuse Treatment. https://www.ncbi.nlm.nih.gov/books/NBK207192/ . Accessed 10/25/2021.
7. Stroke and Vision Changes. The American Stroke Association. https://www.stroke.org/-/media/stroke-files/lets-talk-about-stroke/life-after-stroke/lets-talk-about-stroke-and-vision-sheet.pdf?la=en . Accessed 10/22/2021. Accessed 10/22/2021.
8. Veterans Association/Department of Defense Clinical Practice Guideline – Stroke Rehabilitation Patient Summary – https://www.healthquality.va.gov/guidelines/Rehab/stroke/ . Accessed 10/22/2021.
9. Stroke-Related Eye Conditions. Royal National Institute of Blind People. https://www.rnib.org.uk/eye-health/eye-conditions/stroke-related-eye-conditions#visual-symptoms-stroke . Accessed 10/22/2021.
10. Stroke-Related Vision Loss. Wilmer Eye Institute, Johns Hopkins Medicine. https://www.hopkinsmedicine.org/wilmer/services/low_vision/Stroke-Related_Vision_Loss_low_vision.html . Accessed 10/22/2021.
11. Common Vision Problems and Symptoms Following a Brain Injury. Neuro-Optometric Rehabilitation Association. http://noravisionrehab.org/patients-caregivers/about-brain-injuries-vision/common-vision-problems-symptoms-following-a-brain-injury . Accessed 10/22/2021.
12. Boyd K. Stroke’s Effect on Vision. American Academy of Ophthalmology. Mar 31, 2017. https://www.aao.org/eye-health/tips-prevention/strokes-effect-on-vision . Accessed 10/22/2021.
13. Schouten EA, Schiemanck SK. Long-term deficits in episodic memory after ischemic stroke: evaluation and prediction of verbal and visual memory performance based on lesion characteristics. J Stroke Cerebrovasc Dis. Mar-Apr 2009;18(2):128-38. doi: 10.1016/j.jstrokecerebrovasdis.2008.09.017.
14. Lyden P. Using the National Institutes of Health Stroke Scale. Stroke. 2017;48:513–519. https://doi.org/10.1161/STROKEAHA.116.015434 . Accessed 10/22/2021.
15. Rowe FJ. Vision In Stroke cohort: Profile overview of visual impairment. Brain Behav. Published online 2017 Oct 6. doi: 10.1002/brb3.771. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5698855 . Accessed 10/25/2021.
16. Rehabilitation Therapy After Stroke. American Stroke Association. https://www.stroke.org/en/life-after-stroke/stroke-rehab/rehab-therapy-after-a-stroke . Accessed 10/25/2021.
17. Ringer J. Never ignore the signs of a stroke. Loma Linda University Health. May 10, 2018. https://news.llu.edu/patient-care/never-ignore-signs-of-stroke . Accessed 10/22/2021.

DR. MILLER opened her solo practice in 1973 in Highland, Cal. She is a life member of the American Optometric Association, a charter member of the AOA Contact Lens Section, an American Academy of Optometry Fellow and a Distinguished Practitioner in the National Academies of Practice. Dr. Miller lectures extensively and has written seven books and over 300 articles, while serving as a contributing editor to numerous journals for over 40 years. She lectures internationally on a wide variety of topics.