How to care for stroke patients
When it comes to optometric care, stroke survivors are often an under-served population—especially when most of them have visual or ocular deficits. Stroke survivors with visual problems are often dead-ended in neuro-ophthalmology offices because the internists and cardiologists who refer them to neuro-ophthalmology don’t know that ODs can treat stroke-related visual/ocular challenges. Plus, many optometrists are unfamiliar with how they can help stroke survivors.
Although a background in behavioral optometry, vision therapy, and/or neuro-optometric rehabilitation is helpful, primary-care ODs can easily learn the basics necessary to treat the most common visual problems of those who have had a stroke.
Almost 800,000 people suffer a stroke every year, and it is the most common disability among American adults.1 A stroke occurs when there is an interruption of the blood flow to an area of the brain. There are two types of strokes: an ischemic stroke, occurring when a blood clot blocks a blood vessel, and a hemorrhagic stroke, occurring when a blood vessel in the brain ruptures and causes damage. Some strokes are preceded by brief episodes of stroke symptoms known as transient ischemic attacks (TIA), which are temporary interruptions of blood supply to the brain.
Because a TIA can occur hours, days, or weeks before a full stroke, it behooves us to be aware of the symptoms and signs—temporary episodes of weakness, numbness, paralysis of the face, arm or leg (especially on one side of the body), difficulty speaking or understanding simple statements, and loss of balance or coordination.2 These symptoms can occur on only one side of the body. To that list should be added any report of even momentary diplopia, transient loss of visual field, or a passing episode of blurry vision.
Every primary-care optometrist can—and should—as a minimum perform the following work-up on a patient presenting with any signs:
• History of stroke-related signs and symptoms
• Best-corrected visual acuity
• Pupil reflexes
• Cover test, phorias, ocular range of motion
• Threshold visual field testing
• Dilated fundus examination
• Stethoscope auscultation of the carotid arteries for bruits
Whether a clinical ocular deficit is discovered, any transient visual episode should trigger a call to the patient’s internist or cardiologist to urge the physician to schedule the patient for a physical. In addition, I proactively write the patient an Rx for carotid Doppler testing and/or a CT scan—this starts the ball rolling.
When a patient presents with a known, previously documented stroke, pay attention to current complaints of persisting hemianopsia, diplopia, or eyelid dysfunction. These conditions can often be treated by the primary-care optometrist.