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Practice Guideline
. 2025 Dec;10(4):1087-1159.
doi: 10.1177/23969873251314693. Epub 2025 May 22.

European Stroke Organisation (ESO) guideline on visual impairment in stroke

Fiona J Rowe  1 , Lauren R Hepworth  1 , María Begoña Coco-Martin  2 , Celine R Gillebert  3 , Luis Leal-Vega  2 , Anja Palmowski-Wolfe  4 , Eleni Papageorgiou  5 , Stephen James Ryan  6 , Karolina Skorkovska  7 , Anne Hege Aamodt  6   8
Affiliations
Practice Guideline

European Stroke Organisation (ESO) guideline on visual impairment in stroke

Fiona J Rowe et al. Eur Stroke J. 2025 Dec.

Abstract

Visual impairment due to stroke is common. However, controversy exists on how best to screen for visual impairment, the timing at which to screen, and on the optimal management of the varying types of visual impairment. This European Stroke Organisation (ESO) guideline provides evidence-based recommendations to assist clinicians in decision-making on screening methods, timing of screening and assessment and management options in adult stroke survivors. The target audience for this guideline is health care providers involved in stroke care from prehospital screening, in stroke units and rehabilitation centres, ophthalmological departments and community stroke care, and for stroke survivors and care givers. The guideline was developed according to the ESO standard operating procedure and the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology. The working group identified relevant clinical questions, performed systematic reviews and, where possible, meta-analyses of the literature, assessed the quality of the available evidence and made specific recommendations. Expert consensus statements were provided where insufficient evidence was available to provide recommendations based on the GRADE approach. We found evidence of acceptability and feasibility of early visual screening within 1 week of stroke onset. We describe the accuracy of various vision screening tools at pre-hospital and hyper/acute stages as well as specialist vision assessment. We suggest vision screening in all patients with stroke to improve detection of their visual problems We describe a range of treatment options for visual impairment post-stroke across the typical categories of impaired central vision, ocular stroke (central retinal artery occlusion), eye movements, visual fields, visual neglect and visual perception. This guideline highlights specific areas where robust evidence is lacking and where further definitive randomised controlled trials and diagnostic accuracy studies are required.

Keywords: Guideline; eye movements; ocular stroke; screening; stroke; systematic review; treatment; vision; visual fields; visual impairment; visual neglect; visual perception.

Plain language summary

Up to three quarters of stroke survivors have visual problems with most (about 60%) being caused by the stroke. The other visual problems are usually related to already existent eye conditions. When a stroke happens, often people are not aware their vision can be affected and, frequently, visual impairment is not detected or suspected by clinical and medical teams. The types of visual impairment that can occur after stroke include eye movement problems (causing double or jumbled vision), a reduction in how well we see things clearly (our central vision), a loss in field of vision (our peripheral vision), visual neglect (lack of attention to part of the visual surroundings) and visual perceptual problems (how we process what we see, such as colour and recognition of people and objects). We don’t know how we should best screen for visual impairment or when to do this. Subsequently, how best should we manage these visual problems. In these guidelines we have carefully reviewed studies that give results on vision screening for stroke survivors and results on management of various types of visual impairment. We found a number of vision screening methods than can be used very early (within days) after stroke onset to improve the detection of visual impairment. We also found a variety of treatment options that can be recommended dependent on the different types of visual impairment that occur. In reviewing studies for this guideline, we have also found areas where evidence for vision care is poor. Therefore, we have given suggestions for future research studies that will improve the care we provide for stroke survivors with visual impairment.For diagnosis, we recommend vision screening to improve detection of visual problems in stroke survivors. Vision screening should be undertaken using a validated vision screening tool or by specialist vision team assessment. Early vision screening should be undertaken within 3–4 days after onset of stroke.For treatment, we recommend compensatory interventions of visual scanning/visual search to aid adaptation to visual field loss after stroke. We recommend thrombolysis within 4.5 h of stroke onset to aid recovery of visual function after eye stroke. We suggest early management options to improve visual acuity should be offered as soon as possible after stroke onset such as wearing glasses. We recommend referral to specialist eye services for the targeted management of eye movement disorders. We recommend individualised intervention targeted at the specific type of visual neglect or visual perception deficit that has arisen.Overall, we recommend close collaboration between stroke teams (particularly occupational therapy), neuropsychology and eye care teams (orthoptics, ophthalmology, optometry) for targeted management of visual neglect, and clinicians should provide appropriate information, resource materials and vision aids.

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Conflict of interest statement

Declaration of conflicting interestThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: All authors have completed a declaration of competing interests and details are available in Supplemental Table 1.

Figures

Graphical abstract
Graphical abstract
Figure 1.1.
Figure 1.1.
QUADAS domain for PICO 1.
Figure 1.2.
Figure 1.2.
Sensitivity and specificity forest plots for PICO 1.,,,,
Figure 2.
Figure 2.
PICO 2 – Risk of bias assessment.
Figure 3.1.
Figure 3.1.
QUADAS domain for PICO 3.
Figure 3.2.
Figure 3.2.
Sensitivity and specificity forest plots for PICO 3.,,
Figure 4.1
Figure 4.1
QUADAS domain for PICO 4.
Figure 4.2.
Figure 4.2.
Sensitivity and specificity forest plots for PICO 4.,
Figure 5.1.
Figure 5.1.
QUADAS domain for PICO 5.
Figure 5.2.
Figure 5.2.
Sensitivity and specificity forest plots for PICO 5.,
Figure 6.1.
Figure 6.1.
QUADAS domain for PICO 6.
Figure 7.1.
Figure 7.1.
QUADAS domain for PICO 7.
Figure 7.2.
Figure 7.2.
Sensitivity and specificity forest plots for PICO 7.,,
Figure 8.
Figure 8.
PICO 8 – Risk of bias assessment.
Figure 9.
Figure 9.
PICO 9 – Risk of bias assessment.
Figure 10.
Figure 10.
PICO 10 – Risk of bias assessment.
Figure 11.
Figure 11.
PICO 11 – Risk of bias assessment.
Figure 12.
Figure 12.
PICO 12 – Risk of bias assessment.
Figure 13.
Figure 13.
PICO 13 – Risk of bias assessment.
Figure 14.
Figure 14.
Summary recommendations. A: Diagnosis. *Rapid vision checklist (<5 min duration) as an adjunct to FAST to aid decision making – is this a stroke? **Rapid vision checklist (<5 min duration) as an adjunct to FAST and NIHSS to aid decision making – is this a stroke? ***Ideally, vision assessment for all stroke survivors undertaken by a member of the eye team – does this stroke survivor have a visual problem? Achieves accurate diagnosis rapidly, allowing prompt early management of visual impairment. ****Where limited/no access to eye specialist assessment, vision screening undertaken by a member of the stroke multi-disciplinary team. Use of a standardised and validated vision screening tool (<30 min duration) facilitates detection of visual impairment across main types of visual impairment occurring after stroke, allows test-retest and facilitates triage of referrals.
Figure 14.
Figure 14.
Summary recommendations. B: Management. * Management options for visual impairment should be offered as soon as possible after stroke onset, i.e. within days of stroke onset. This maximises residual visual function to promote best engagement with stroke rehabilitation. Close collaboration between stroke teams (particularly occupational therapy), neuropsychology and eye care teams (orthoptics, ophthalmology) is ideal. Clinicians should provide appropriate vision-specific information, resource materials and vision aids.
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References

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