The European Stroke Organization issued its first recommendations on the management of visual and visual perceptual disorders after stroke, calling for systematic early screening and wider implementation of evidence-based rehabilitation strategies.

Early Screening

“There were no clear recommendations for the management of poststroke visual disorders. This document aims to provide standardization and harmonize practices by presenting a synthesis of the available data,” said Anja Palmowski-Wolfe, MD, from the University Eye Hospital Basel, University of Basel, Basel, Switzerland, in an interview with Medscape’s French edition.

The objective is, in particular, to present rehabilitation techniques that have demonstrated efficacy, with the aim of promoting their broader use for the benefit of patients. “Post stroke visual rehabilitation improves daily life and overall quality of life.” It also reduces the risk for falls and accidents in individuals already vulnerable to stroke-related complications.

Up to three quarters of stroke survivors experience visual impairment, and approximately 60% of visual deficits are directly attributable to stroke, whereas the remainder are typically related to preexisting ocular disease.

Stroke related impairments include:

• Ocular motility disorders causing diplopia or blurred vision
• Reduced central visual acuity
• Visual field loss
• Visual perceptual deficits such as altered color perception and impaired recognition of people and objects

Despite objective deficits, approximately 40% of affected individuals do not report any visual symptoms. “These patients are unable to report visual deficits, minimize them, or simply do not notice them,” Palmowski-Wolfe said.

To improve the detection of these disorders, experts recommend systematic screening within 3-4 days after stroke using validated tools such as BE FAST, V-FAST, or VISA, or assessment by a specialized team, ideally in a stroke unit.

“Questionnaire-based tools can be used in less than 5 minutes for initial screening,” she said and noted that instruments such as V-FAST, developed by the University of Liverpool, are routinely used in the United Kingdom in hospital stroke units by dedicated specialist teams.

“Earlier identification facilitates the timely initiation of interventions such as eye patching, prisms, and visual scanning training,” experts write. It also enables rapid recognition of emergencies, such as central retinal artery occlusion. In suspected cases of retinal ischemia, and in the absence of contraindications, thrombolysis should be offered within 4.5 hours after symptom onset. “Data support shorter intervention time to promote better recovery of visual acuity,” she said. Delayed treatment may result in permanent loss of vision.

Approaches

In cases of homonymous hemianopia, a visual field deficit affects the corresponding halves of both eyes. Evidence favors compensatory visual scanning training over restorative approaches, such as visual restorative therapy.

Compensatory scanning training (CST) aims to decrease the impact of the visual field defect by enlarging the functional field of view through optimizing visual scanning.

Restorative approaches, on the other hand, aim to recover the visual field by training detection of light stimuli within the deficit area.

The experts identified four randomized trials supporting CST, with significant improvements in quality of life. Other approaches, such as placing an optical prism on eyeglass lenses to deflect images from the blind side toward the functional side, have proven to be less effective than compensatory strategies.

“In cases of visual field defects, compensatory treatment is recommended in both the acute and chronic phases of stroke,” Palmowski-Wolfe said. “Patients learn to use eye movements automatically to explore the impaired visual field, which improves daily life.”

Regarding prism replacement therapy, “it tends to cause nausea.” This can produce distorted images of objects. With this technique, “it remains difficult to combine images from both the functional and dysfunctional visual fields.”

Oculomotor Rehabilitation

Approximately one third of individuals experience reduced visual acuity after a stroke. Early corrective measures, including appropriate optical correction and the use of visual aids, are recommended. When those with preexisting eye conditions are included, it is estimated that half of the individuals require visual correction after a stroke.

Oculomotor disorders account for approximately 40% of poststroke visual disorders, such as oculomotor nerve palsy, acquired strabismus, and diplopia. Those affected should be referred to ophthalmology or orthoptic services for specialized, largely symptomatic, and adaptive care, as needed.

Monocular occlusion (covering one eye) is typically the first step in the treatment of diplopia and can be highly debilitating. Orthoptic rehabilitation may improve the near point of convergence, convergence facilities, and convergence reserves for both distant and near vision. Botulinum toxin injections may also be considered in the treatment of lateral rectus muscle palsy.

Although the level of evidence remains limited and heterogeneous, experts state that the observed functional benefits support early referral for specialized care. “Some therapeutic approaches, such as the use of prisms, have been used for a long time and have already demonstrated their effectiveness in clinical practice. Therefore, we simply needed to incorporate them,” Palmowski-Wolfe said.

Rehabilitation should be multidisciplinary, with close collaboration between neurologists, neuropsychologists, orthoptists, and occupational therapists.

Integrating Visual Rehabilitation

For visual-perceptual disorders, recommendations require a targeted approach tailored to specific deficits. In unilateral spatial neglect, in which a person does not attend to the left or right side of the visual field, compensatory interventions, such as visual scanning training and prism adaptation, are recommended.

“The effectiveness of interventions for visual neglect in improving activities of daily living and quality of life has yet to be firmly established, but visual scanning and prism adaptation have shown promise.”

The consensus document emphasizes that rehabilitation requires coordinated care from neurologists, neuropsychologists, orthoptists, and occupational therapists.

“These recommendations should help expand the use of recovery methods such as visual scanning training and prism adaptation, making them more accessible and beneficial,” she said. “Many ophthalmologists, for example, are still unaware of the value of visual scanning training.”

Therefore, collaboration between specialists is essential. Neurologists and ophthalmologists should refer individuals with poststroke visual disturbances to orthoptists or occupational therapists specializing in low-vision rehabilitation.

According to Palmowski-Wolfe, visual disturbances after stroke remain undertreated. “Spontaneous recovery is often expected, especially in younger individuals. However, recovery does not occur frequently in these patients. We hope neurologists and ophthalmologists will be more inclined to prioritize.”

This story was translated from Medscape’s French edition.