STROKE SERVICES FEATURE
Eye movements are important because they are going to act like a ruler . They are going to provide to the brain information about distance and dimensions in the space , helping us to build our internal map / representation of our visual world ( framework ), which is constantly updated .
Therefore , it is important to make sure that the eyes ’ movements are efficient in their use , otherwise we could be at risk of having an altered mental representation , which could impact our visual perception , and also our posture , actions and function .
There are different reasons why effective eye movement can be compromised – poor attention , altered ambient visual processing , visual field defects , cranial nerve palsy – and there is a very different management of these depending on the causes .
Our learning and improved understanding of visual processing and the neuroanatomy has permitted us to comprehend the reason of these impairments and the best intervention to maximise function and facilitate occupational performance .
Yoo et al ( 2020 ) conducted a cross-sectional survey to explore occupational therapy practice , in Canada , in the field of vision-rehabilitation for adults with acquired brain injury ( ABI ) and to determine evidence-practice gaps . A total of 25 occupational therapists responded to an online survey . Nineteen completed it and six partially completed it . Most questions were closed-ended and participants selected from drop-down options ; there were also optional comment boxes . Descriptive statistics were conducted to determine the frequency of interventions and participants ’ comments were grouped into recurring themes . Findings included that over half of respondents regularly used evidencebased interventions when addressing visual acuity and visual field deficits , but very few used them for oculomotor dysfunction and visual stress .
EVIDENCE LINK
Our journey For the last six years , we have developed a special interest in neurovisual processing and how it is affected following a stroke .
We were noting that a high number of our patients were being discharged home from the hospital with visual impairment and an uncertainty about the management and follow up of their visual difficulties , impacting on their quality of life , participation and compromising safety and therapy engagement .
Through our regular occupational therapy peer support group we recognised our own limitations at that time , which included : limited clinical knowledge about visual impairments after stroke ; reduced confidence in how to assess and manage visual difficulties ; and lack of understanding about which eye specialist services we should be referring patients to .
We reflected on how we could improve our patients ’ care and experience in relation to visual impairment and created a clear action plan that targeted the clinical knowledge gap , the patient journey experience , and the need for service development .
We discovered that this was not a local issue ; it was and continues to be a national issue . Fiona Rowe , Professor of Orthoptics and Health Services Research at University of Liverpool , identified this in her Care provision and unmet need for post stroke visual impairment report ( 2013 ), where it was estimated that 60 per cent of stroke survivors have visual impairment immediately after their stroke .
In response to our patients ’ deficits and using our developing knowledge , in 2014 we produced an in-house community visual screening tool to allow us to identify visual problems when assessing our patients in the community .
This screening tool enabled us to meet the NICE guidelines for stroke , that recommends every stroke survivor ‘ should be examined for the presence of visual field deficit ( for example hemianopia ) and eye movement disorders ( for example strabismus and motility deficit )’ ( RCP 2016 ).
Reference Yoo PY , Scott K , Myszak F , Mamann S , Labelle A , Holmes M … Bussieres AE ( 2020 ) Interventions addressing vision , visual-perceptual impairments following acquired brain injury : a cross-sectional survey . Canadian Journal of Occupational Therapy , 87 ( 2 ), 117 – 126
Encouraged by the above and our own clinical needs demands , we decided to start a Quality Improvement Project ( QIP ) to improve stroke visual care needs in the rehabilitation journey .
The aim of the QIP was about the implementation of an agreed protocol to improve stroke visual care in the local area . As part of this project we took the lead in the following :
• highlighting the gaps within the services in relation to visual impairment ;
• bringing on board and engaging local orthoptist services and stroke units ;
• updating our screening form in order to be used in hospital and community setting ; and
• sharing our knowledge through in-service training , which increased therapist confidence in identifying visual impairments .
The acute and the earlier supported discharge teams agreed to implement a visual care pathway and a consistent approach for visual screening in both settings .
We gained consent for therapist referrals to be sent directly to orthoptist services . Unfortunately , once established , this only lasted a little more than a year , as the stroke pathway in the area changed and Hyper Acute Stroke Unit ( HASU ) and Acute Stroke Unit ( ASU ) were moved out of the county to another hospital , starting similar service development in the new area .
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