Developing a stroke-vision care pathway: a consensus study

Rowe, Fiona; Hepworth, Lauren R.; Howard, Claire; Hanna, Kerry; Helliwell, Brinton

doi:10.1080/09638288.2020.1768302

Cited by 20 publications

(15 citation statements)

References 23 publications

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“…Incongruence in how sensory vision and visual perception are understood appears problematic, particularly where exact and consistent language is relied upon in information exchanges to inform clinical decision-making, such as in referral reports. Inconsistencies between referrals from stroke units to orthoptics and subsequent orthoptic diagnoses have been highlighted previously [37,38].…”

Section: Discussionmentioning

confidence: 96%

“…A potential explanation for a lack of insight into how to assess visual difficulties may stem from unclear referral pathways. A recent literature review has proposed a potential referral pathway that may lead to more appropriate and efficient referrals made [38]; future research efforts to trial these proposed pathways would go along in improving the rate at which poststroke vision assessments are made.…”

Section: Discussionmentioning

confidence: 99%

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Visual perceptual deficit screening in stroke survivors: evaluation of current practice in the United Kingdom and Republic of Ireland

Colwell

Demeyere

Vancleef

2021

Disability and Rehabilitation

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Purpose: Visual perceptual deficits are frequently underdiagnosed in stroke survivors compared to sensory vision deficits or visual neglect. To better understand this imparity, we evaluated current practice for screening post-stroke visual perceptual deficits. Methods: We conducted a survey targeted at professionals working with stroke survivors involved in screening visual perceptual deficits across the United Kingdom and the Republic of Ireland. Results: Forty orthoptists and 174 occupational therapists responded to the survey. Visual perceptual deficit screening was primarily conducted by occupational therapists (94%), with 75$100% of stroke survivors screened per month. Respondents lacked consensus on whether several common post-stroke visual deficits were perceptual or not. During the screening, respondents primarily relied on self-reports and observation (94%), while assessment batteries (58%) and screening tools were underutilised (56%) and selected inappropriately (66%). Respondents reported lack of training in visual perception screening (20%) and physical/cognitive condition of stroke survivors (19%) as extremely challenging during screening. Conclusions: Visual perceptual deficits are screened post-stroke at a similar rate to sensory vision or visual neglect. Underdiagnosis of visual perceptual deficits may stem from both reliance on subjective and non-standardised screening approaches, and conflicting definitions of visual perception held among clinicians. We recommend increased training provision and use of brief performance-based screening tools. ä IMPLICATIONS FOR REHABILITATIONLack of agreement among clinicians on what constitutes as visual perceptual or sensory vision deficits may prove problematic, as precise and exact language is often required for clinical decision-making (e.g., referrals). Biases for more familiar visual (perceptual) deficits held among clinicians during the screening process may lead to other visual deficits being missed. To avoid problems being missed, clinicians should aim to use standardised assessments rather than stroke survivor self-report and observations of function when screening for visual perceptual difficulties.

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Section: Discussionmentioning

confidence: 96%

Section: Discussionmentioning

confidence: 99%

Visual perceptual deficit screening in stroke survivors: evaluation of current practice in the United Kingdom and Republic of Ireland

Colwell

Demeyere

Vancleef

2021

Disability and Rehabilitation

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“…Although some expressed concern about a lack of specialised vision competence in their services, all groups agreed that assessing vision is an important first step to improve vision care. This is important because the first step in helping someone with a vision problem is identifying its presence [ 18 , 19 , 42 , 43 ].…”

Section: Discussionmentioning

confidence: 99%

“…In the UK, a stroke–vision pathway has been developed based on a consensus study by Rowe et al [ 43 ]. In this pathway, the authors suggest that a well-defined pathway for vision assessment and rehabilitation, together with support services, should be integrated into stroke services.…”

Section: Discussionmentioning

confidence: 99%

“…Depending on when and where the patients present their vision symptoms to HCP, there should be a procedure to provide vision care. In stroke services without immediate access to vision specialists, Rowe et al recommend the use of vision assessment tools to identify a possible vision impairment to secure a proper referral to vision care [ 43 ]. As emphasised in the current study, it is crucial that HCP working with stroke survivors are aware of VIs as a possible symptom or sequela of stroke; in this implementation study, we see that the participants are more aware of VIs and that most of them use the KROSS assessment tool.…”

Section: Discussionmentioning

confidence: 99%

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‘If we don’t assess the patient’s vision, we risk starting at the wrong end’: a qualitative evaluation of a stroke service knowledge translation project

Mathisen

Eilertsen

Ormstad

et al. 2022

BMC Health Serv Res

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Background Visual impairments (VIs) affect 60% of stroke survivors and have negative consequences for rehabilitation and quality of life poststroke. Symptoms of VIs post stroke are difficult to identify for stroke survivors and health care professionals without using a structured vision assessment. In this study, we qualitatively evaluate the implementation outcomes after implementing a structured visual assessment with the Competence, Rehabilitation of Sight after Stroke Vision (KROSS) assessment tool in stroke care services. Methods This is a qualitative study comprising four focus group interviews. The health care personnel (HCP) involved in the implementation or with experience using the KROSS assessment tool in practice were invited to participate. We used Proctor et al.’s definitions of implementation outcomes as a framework, which informed the interview guide and analysis. We used a deductive - inductive content analysis, as described by Elo and Kyngäs. Results The participants found the structured vision assessment with the KROSS tool as being acceptable; they expressed a motivation and intention to use the new routine in practice. They believed it was important to assess their patient’s visual function because it influenced other rehabilitation activities and activities of daily living. Most of the participants reported having adopted the vision assessment in their practice, except for those participants from the home care services who experienced that they have few stroke survivors to follow up on. The assessment was believed to be more appropriate to perform within the rehabilitation services where there is more of a focus on functional assessments. Although vision assessment was new to all the participants, they felt that they improved their vision assessment skills by regularly using the assessment tool. Together with sufficient instructions and supervision, they believed that vison assessment was feasible for their practise. Including the vison assessment in the existing routines and systems was important to promote sustainable implementation. Conclusion Implementing a structured vision assessment with the KROSS tool in health care services was experienced as acceptable and feasible. The new routine led to increased attention towards poststroke VIs and increased collaboration with vision experts. Tailoring the routine to each practice and how they organise their work can support the integration of a vision assessment in their routines. To promote better vision care poststroke vision assessment and follow up should be included in the stroke care pathways.

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Validation of the interdisciplinary Norwegian vision assessment tool KROSS in stroke patients admitted to hospital or rehabilitation services

Falkenberg,

Langeggen,

Munthe-Kaas

et al. 2024

Discov Health Systems

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Introduction Identifying vision problems after stroke is important for providing appropriate referral and vision rehabilitation in healthcare services. In Norway, vision assessment is not a standard routine or integrated in stroke care, due to lack of knowledge, guidelines and validated Norwegian assessment tools for healthcare professionals (HCPs) without formal vision competence. This study aimed to validate and assess the reliability of the KROSS (Competence, Rehabilitation of Sight after Stroke) tool for identifying vision problems in stroke patients. Methods The KROSS tool has 21 items, including symptoms, observations, and assessment of visual acuity, visual field, eye movements and visual inattention. The primary outcome is to identify if a vision problem is present. Sixty-seven stroke survivors (69.8 years, 28 females) were assessed twice. The first KROSS assessment was by an HCP without formal vision competence and compared to a reference assessment by an optometrist/KROSS specialist within 2 days. Sensitivity, specificity, positive and negative predictive values (PPV/NPV) and inter-rater reliability (Gwet’s AC1/Cohen’s Kappa) were calculated with 95% confidence intervals. Results The KROSS tool demonstrated high sensitivity (98%) and specificity (83%), with excellent reliability (AC1 > 0.86/Kappa > 0.83) and observer agreement (93%) for the primary outcome. A vision problem was identified in 64% of patients, where 44% reported a vision symptom. The PPV and NPV for identifying a vision problem were 0.91 and 0.95 respectively. Sensitivity scores for visual acuity, reading, and visual inattention assessments were all excellent (> 80%) and specificity scores were high for all items (> 70%). Most items showed excellent or substantial agreement (AC1 > 0.7/kappa > 0.6). The lowest agreements were for motility (AC1 > 0.8/kappa > 0.4) and peripheral visual fields (AC1 > 0.8/kappa > 0.5). Conclusions This study shows that the KROSS tool shows promise as a valuable tool for integrating vision assessment into stroke health services. It has high sensitivity and specificity, and excellent reliability, indicating high accuracy for identifying a vision problem. This indicates that the KROSS tool can reliably be used by HCPs without formal vision competence to identify a vision problem. The fact that many stroke survivors were identified with vision problems using the KROSS tool, even if they did not complain of visual symptoms, supports the significance of including structured vision assessment in stroke care.

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Developing a stroke-vision care pathway: a consensus study

Abstract: Referral -visual symptoms with an established stroke diagnosisKey visual functions affected by stroke are impaired central vision, peripheral visual field loss, eye position/movement disorders and visual inattention (table 3). Where

Cited by 20 publications

References 23 publications

Visual perceptual deficit screening in stroke survivors: evaluation of current practice in the United Kingdom and Republic of Ireland

Visual perceptual deficit screening in stroke survivors: evaluation of current practice in the United Kingdom and Republic of Ireland

‘If we don’t assess the patient’s vision, we risk starting at the wrong end’: a qualitative evaluation of a stroke service knowledge translation project

Validation of the interdisciplinary Norwegian vision assessment tool KROSS in stroke patients admitted to hospital or rehabilitation services

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