High incidence and prevalence of visual problems after acute stroke: An epidemiology study with implications for service delivery

Abstract

Background: Visual problems are an under-reported sequela following stroke. The aim of this study is to report annual incidence and point prevalence of visual problems in an acute adult stroke population and to explore feasibility of early timing of visual assessment.

Methods and findings: Multi-centre acute stroke unit, prospective, epidemiology study (1st July 2014 to 30th June 2015). Orthoptists reviewed all patients with assessment of visual acuity, visual fields, ocular alignment, ocular motility, visual inattention and visual perception. 1033 patients underwent visual screening at a median of 3 days (IQR 2) and full visual assessment at a median of 4 days (IQR 7) after the incident stroke: 52% men, 48% women, mean age 73 years and 87% ischaemic strokes. Excluding pre-existent eye problems, the incidence of new onset visual sequelae was 48% for all stroke admissions and 60% in stroke survivors. Three quarters 752/1033 (73%) had visual problems (point prevalence): 56% with impaired central vision, 40% eye movement abnormalities, 28% visual field loss, 27% visual inattention, 5% visual perceptual disorders. 281/1033 (27%) had normal eye exams.

Conclusions: Incidence and point prevalence of visual problems in acute stroke is alarmingly high, affecting over half the survivors. For most, visual screening and full visual assessment was achieved within about 5 days of stroke onset. Crucial information can thus be provided on visual status and its functional significance to the stroke team, patients and carers, enabling early intervention.

Fig 1. Number of days post stroke onset to first attempted visual assessment.

First attempted vision screening was undertaken from day 0 of stroke onset through to a maximum of day 404 (outlier discharged patient who failed to attend earlier outpatient appointments). The majority had been screened within 1 week of stroke onset.

Fig 2. Reasons for lack of visual assessment at visit 0 (baseline).

Full vision assessment was not possible at baseline for 627 patients. Reasons for no assessment are outlined in orange. Those with partial, but incomplete, vision assessments are outlined in blue.

Fig 3. Assessment of post-stroke visual impairment.

Breakdown of numbers screened, numbers excluded, number recruited to the study, and numbers of those visually assessed or not.

Fig 4. Categories of visual problems as sole or combined visual deficits and presence of visual problems versus primary systemic disability on admission.

(a) 186 stroke survivors had a single issue with visual function as outlined in orange. Most (566 stroke survivors) had two or more visual problems–outlined in blue. (b) Stroke survivors most commonly had a hemi- or mono-plegia/paresis. The spread of primary general disability was similar for those who did or did not have a visual problem.

Fig 5. Categories of visual problems; pre-existent, part or new onset.

Visual problems was categorised into new onset (332 stroke survivors–blue bars), pre-existent visual problems (136 stroke survivors–orange bars) and mixed new and pre-existent visual problems (284 stroke survivors–grey bars).