Vision is essential for everyday activities. However, after a stroke, many individuals experience vision loss, making activities such as dressing, bathing, cooking and cleaning more challenging. In an inpatient rehabilitation setting, occupational therapy plays a critical role in helping patients improve or compensate for post-stroke vision loss. Through targeted interventions, education and assistive technology, occupational therapists help individuals regain daily living skills and return to the community.
Vision rehabilitation is most effective when addressed through an interdisciplinary team approach. Occupational therapists are essential members of this team, developing comprehensive treatment plans. With environmental modifications, assistive technology, visual skills training and other multicomponent interventions, occupational therapists can help individuals with post-stroke vision loss return to their daily activities and their communities.
Understanding how stroke impacts vision
A stroke interrupts blood flow to areas of the brain responsible for processing visual information. Depending on the location and severity of their stroke, individuals may experience a range of vision deficits.
These may include, but are not limited to:
Visual field loss
Visual field loss, also known as hemianopsia, is a partial or complete loss of vision that can occur in different patterns. Homonymous hemianopsia affects the same side of the visual field in both eyes, while quadrantanopsia involves vision loss in one quadrant of the visual field. Visual field loss can make it difficult to navigate environments, locate objects, read, drive or participate in social activities.
Visual neglect
Visual neglect occurs when an individual does not attend to visual stimuli on one side, typically the side opposite where the stroke occurred. Individuals may neglect objects in the visual field or may neglect one side of their body. Visual neglect can impair a person's ability to perform self-care tasks, mobility, reading, writing and overall safety awareness.
Oculomotor dysfunction
A stroke can disrupt the coordination and control of eye movements, resulting in oculomotor dysfunction. This may affect smooth pursuits, saccades and fixation. As a result, individuals may have trouble with visual scanning, reading and depth perception, along with visual fatigue and headaches.
Visual processing deficits
Visual processing and visual-perceptual deficits involve difficulty perceiving and interpreting visual information. These challenges may include problems with visual discrimination, spatial relationships, visual memory, figure-ground discrimination and motor integration.
Diplopia
Diplopia, also known as double vision, can occur when the nerves or muscles controlling eye movement are affected. This condition makes it difficult for the eyes to work together, interfering with depth perception and overall visual clarity.
How visual deficits affect activities of daily living
It is important to observe how a patient's visual deficits affect their performance in activities of daily living. This observation can help identify visual search deficiencies that impact functional tasks.
Patient education is essential in helping individuals better understand their deficits. The effectiveness of interventions can be measured by the patient's level of awareness of their visual challenges.
One way to support this understanding is by having the patient perform a visual search test. This allows them to identify their current visual search pattern and recognize changes in visual attention. Repeating the test after education and cueing can demonstrate improvement and indicate that the patient may benefit from occupational therapy interventions.
Occupational therapy in an inpatient rehabilitation setting uses two primary approaches to treat visual deficits after a stroke: remediation and compensatory.
Occupational therapy approaches to post-stroke vision loss
Remediation approach
When occupational therapists use a remediation approach, interventions focus on improving impaired visual skills.
Key concepts of the remediation approach include:
- Establish an effective search strategy. Have the patient work on left-to-right linear pattern and left-to-right clockwise or counterclockwise visual search pattern. Begin a visual search strategy in the blind field and work toward the intact field.
- Encourage wide head turns and increased head and eye movements toward the blind field.
- Promote attention to visual detail in the blind field and facilitate the ability to shift attention from the central to the peripheral vision.
- Reinforce visual search strategies with games such as concentration or checkers.
- Place commonly used items on the side with reduced vision to encourage visual scanning.
- Provide sensory cues like bells, increased lighting and touch to promote attention to the affected field.
- Use visual scanning worksheets such as cancellation tasks, word search, line bisection and bells tests.
- Utilize computer software designed to remediate visual skills after a stroke, such as BITS and Dynavision.
- Address speed and accuracy of the eye movements during functional tasks.
Compensatory approach
The compensatory approach focuses on adjusting the environment or task to allow individuals to use their existing level of visual processing.
Key concepts of the compensatory approach include:
- Ensure the patient is aware of their visual deficits.
- Place necessary items for a task within their visual field.
- Educate patients and families on how the visual field loss affects function and safety during daily living tasks.
- Use anchoring techniques during reading tasks.
- Add color or contrast to door frames, furniture and thresholds or steps. Remove area rugs to reduce fall risk.
Assistive devices for vision deficits
A variety of assistive devices can help support independence for those with vision deficits post-stroke.
Occupational therapy's role in recommending assistive devices, adaptations and modifications include assessing occupational performance, as well as financial, environmental and social contexts, to ensure appropriate recommendations.
An in-depth task and activity analysis supports independence and ensures skills carry over after discharge. Referral to an occupational therapist who has a Specialty Certification in Low Vision (SCLV) or Assistive Technology Professional (ATP) may be appropriate for further assessment and intervention after inpatient rehabilitation.
Technologies used
The following low-to-high-tech adaptive equipment represents only a portion of the options available to occupational therapists.
Low-tech options
- Bright duct tape. Tape step edges and door frames with bright duct tape to improve visibility and safety.
- Handheld magnifier. Enlarges objects such as menus and newspapers for easier reading.
- Large print items. Make commonly used household items easier to see with large printed digital or analog clocks, calendars and playing cards.
- Labeling. Labels with large print can make accessing items in cabinets, pantries and other rooms easier to access.
- Lighting. Illuminate hallways, stairways and commonly used rooms with LED lights or automatic lights to always have a well-lit home environment.
High-tech options
- Smartphones. Accessibility features such as enlarged text, text-to-speech, voice control, apps and visual alerts are only a few options to ease phone use and social participation.
- Smart home devices. Smart blinds, lights and plugs can be automated or voice activated to improve independence and safety with ADL and instrumental Activities of Daily Living (iADL) tasks.
- Smart speakers. Devices from Amazon, Google and Apple can help control smart home devices and can also provide information with voice commands.
Visual deficits and the caregiver
Visual deficits post-stroke can significantly impact both the patient's quality of life and their caregiver's experience. Challenges related to driving, iADL tasks and social engagement can create uncertainty for patients and caregivers. They may wonder if visual deficits will improve and whether compensatory strategies will be needed long term. Some patients will experience meaningful recovery, but many continue to require interdisciplinary rehabilitation and intervention.
Encompass Health occupational therapists Tarah O'Shea, Tara Allen, Kathryn Dozier, Tracy Skinner, Christa Layou, Theresa Pham and Jamie Chapman contributed to this research and post.
Resources
- Vision Therapy for Post-Concussion Vision Disorders (2016)
- A Discussion and Analysis, in the context of current research to May 2016, of: A critical evaluation of the evidence supporting the practice of behavioural vision therapy
- visiontherapy.org/vision-therapy/vision-therapy-studies.html
- bouldervt.com/vision-library/vision-therapy/
- ebrsr.com/
- edhelper.com/visual_skills.htm
- www.vision3d.com/
- optometrists.org/vision-therapy/
- Green, M., Barstow, B., & Vogtle, L. (2018). Lighting as a compensatory strategy for acquired visual deficits after stroke: Two case reports. The American Journal of Occupational Therapy, 72(2), 7202210010p1-7202210010p6. https://research.aota.org/ajot/article-abstract/72/2/7202210010p1/6415/Lighting-as-a-Compensatory-Strategy-for-Acquired2
- Hunter, E. G., & Rhodus, E. (2022). Interventions within the scope of occupational therapy to address preventable adverse events in inpatient and home health postacute care settings: A systematic review. American Journal of Occupational Therapy, 76, 7601180060. https://doi.org/10.5014/ ajot.2022.047589
- Hepworth L., & Rowe F. J. (2016). Visual impairment following stroke — the impact on quality of life: a systematic review. Ophthalmology Research: An International Journal, 5(2), 1—15.
- Hong, S. E., Kim, C. H., Kim, E. J., Joa, K. L., Kim, T. H., Kim, S. K., Han, H. J., Lee, E. C., & Jung, H. Y. (2017). Effect of a Caregiver's Education Program on Stroke Rehabilitation. Annals of rehabilitation medicine, 41(1), 16—24.
- Novario, G., Fairman, A., Morris, L., & Ding, D. (2021, September). Harnessing the potential of smart home technology. OT Practice, 26(9), 10-13.
- Pendleton, H. M., & Schultz-Krohn, W. (2013). Pedretti's occupational therapy: Practice skills for physical dysfunction (7th ed.). Elsevier.
- Smallfield, S., & Kaldenberg, J. (2019). Occupational therapy interventions to improve reading performance of older adults with low vision: A systematic review. The American Journal of Occupational Therapy, 74 (1): 7401185030p1-7401185030p18.
- Zoltan, B. (2007). Vision, perception, and cognition: A manual for the evaluation and treatment of the adult with acquired brain injury (4th ed.). Slack.