Development of a diagnostic test battery for the visual assessment of stroke survivors

Abstract

Advances in medical care and risk factor management have reduced the incidence of stroke, yet prevalence is expected to rise due to an ageing population and improved survival rates. Stroke survivors frequently experience a range of visual dysfunctions, including issues with central and peripheral vision, eye movements, vergence, accommodation, and perceptual anomalies (eg. light sensitivity, pattern glare, inattention). Primary eye care providers are increasingly required to provide visual care to these patients. However, a literature review revealed limited evidence on diagnostic methods for post-stroke ophthalmic assessment, with findings favouring kinetic over automated perimetry and automated over confrontation techniques. No evidence was found supporting the accuracy of standard ophthalmic clinical tests in this group. This thesis aimed to develop a diagnostic test battery for primary eye care through a three-round Delphi process with 11 expert practitioners (7 of whom completed). The final battery encompassed key aspects of a comprehensive eye examination, including visual, binocular, refractive, and ocular health assessments. The battery was evaluated in an observational case-controlled diagnostic study involving 48 participants (22 stroke survivors, 26 controls). Subjects underwent both a typical sight test and the trial battery, including binocular vision, pattern glare, reading assessments, perimetry, pupil dilation, and retinal imaging. The trial battery identified more ocular surface, adnexal, and binocular anomalies than the sight test, but lacked sensitivity to field loss. Stroke survivors, particularly those with visual field loss, reported significantly increased pattern glare symptoms and slower reading speeds, with limited improvement from coloured overlays. Significant retinal thinning was observed in stroke survivors, especially in their left eye. Sight testing in community optometry practice can fall short of the thorough care that stroke survivors deserve, further research is required to assess the scale and impact of this, to examine binocular vision in older adults, and investigate retinal biomarkers linked to stroke.