An international survey of optometric management of stroke survivors

Abstract

Objectives

A survey was conducted to describe the current status of optometric awareness and involvement regarding post-stroke management as literature suggests that visual impairment often goes undiagnosed and unmanaged in stroke survivors.

Materials and methods

A questionnaire was developed by the researchers, pilot tested by 5 other optometric researchers and 15 optometrists and modified based on the feedback. Practicing optometrists were invited to complete the anonymous online survey through optometric organizations in Canada, Hong Kong, India, UK, and US.

Results

Results showed that the majority of optometrists (61%) see 1–5 post-stroke patients per month, although 15% report seeing none. In all cases, optometrists referred stroke patients to other health care professionals more often than receiving incoming referrals from them. About 21% of all respondents were already fully involved in post-stroke vision care and 57% were interested in being more involved. Limiting factors to seeing more post-stroke patients included resources (29.8%), funding (25.8%), awareness (25.1%), and interest (9.8%). There was consensus among respondents in all countries that optometrists should be members of post-stroke care teams.

Conclusion

Optometrists are well suited to provide post-stroke visual rehabilitation but are often not included in care teams for these patients. As a result, the visual management of post-stroke patients often is unaddressed.

Introduction

According to the WHO, neurological disorders are the second major cause of death and the leading cause of disability worldwide [1]. Although there has been no significant reduction in stroke incidence, the stroke mortality rates have decreased by 36% from 1990 to 2016, and the number of stroke survivors increases every year [2]. As a result, currently, over 80 million people worldwide are living with the consequences of stroke, which is estimated to reach 200 million worldwide by 2050 [3,4].

Traditionally stroke has been defined as ‘rapidly developed clinical signs of focal (or global) disturbance of cerebral function, lasting more than 24 h or leading to death, with no apparent cause other than of vascular origin’ such as an ischemia, infarction, or a hemorrhage [5]. This definition is symptoms-based and was updated by the American Heart Association/American Stroke Association to include silent infarctions (inclusive of cerebral, spinal and retinal) and silent haemorrhages [6]. Strokes are classified into ischemic stroke, which occurs due to a blockage in a blood vessel supplying the brain, and hemorrhagic stroke, which involves bleeding in or around the brain. Hemorrhagic stroke includes intracerebral hemorrhage, characterized by bleeding within the brain tissue, and subarachnoid hemorrhage, involving bleeding in the space between the brain and its surrounding membrane [7]. An ocular stroke, or retinal artery occlusion, is a blockage of blood flow to the retina, leading to sudden vision loss in one eye. Strokes affecting the occipital lobe [8], optic pathway, brain stem, thalamus, cerebellum, as well as the visual pathways in the parietal and temporal lobes, have visual consequences [9].

Approximately 60–65% of stroke survivors are affected by visual consequences (excluding preexisting eye conditions) and the incidence of visual problems is higher among older individuals and those who experienced severe strokes [10,11]. The four broad categories of post-stroke visual consequences are: visual field defects, strabismus and ocular motility abnormalities, impaired central vision, and visual perceptual abnormalities [10,12–16]. Visual field defects are a common visual consequence, with a reported prevalence ranging from 25 to 52% at, or close to, stroke onset [9,12,15,16], reducing to 28% by 1 month and 21% by 3 months post-stroke onset [16]. The wide range may be due to differences in study design or population being sampled. The prevalence of ocular motility defects reported by a cross-sectional study in 2011 is 54% close to stroke onset [17] and the reported prevalence of strabismus ranges from 17 to 37% based on a multi-centre cohort trial [18] and an observational study [19]. Reduced visual acuity was reported in 25–70% of stroke survivors [9,13,20] with full recovery of visual function by 3 months reported in up to 71% [16]. However, a number of studies which assessed visual acuity sampled hospital in-patients whose visual acuity was uncorrected as they did not have their spectacles with them [20,21]. Contrast sensitivity impairment was reported in 62% of stroke patients in a multi-centre cohort study [12]. The estimated prevalence of visual perceptual impairment in stroke survivors is 50-80% at onset [22,23]. These visual consequences can substantially affect an individual’s quality of life by impairing various daily functions, especially mobility and reading ability [24], and may result in increased incidence of falls, leading to disability and loss of confidence.

Since individuals may not completely regain normal visual function following a stroke, early visual assessment and rehabilitation would ensure that the extent of the impairment is documented and appropriately managed. However, post-stroke visual disorders are often not diagnosed or managed as many stroke or rehabilitation units within hospitals do not assess vision or screen for vision loss [24–29] and stroke patients are rarely referred for visual assessment [30–33].

The reasons for this reduced attention towards stroke survivors’ visual difficulties are not clear and could involve lack of knowledge within the stroke care team on post-stroke visual consequences, benefits of early intervention, and availability and efficacy of rehabilitation options. Other possible reasons are lack of funding or non-availability of an eye care provider [24].

Optometrists are ideally placed to manage or co-manage these post-stroke visual disorders [34]. This survey was designed to understand the knowledge, attitudes, and practices of optometrists regarding post-stroke visual assessments, intervention, and management, and to determine to what extent they are prepared to take on this role across five countries – Canada, Hong Kong (HK), India, UK, and US. These countries were chosen due to their varied healthcare systems and differences in access to eye care. This diversity enables us to understand how different healthcare environments impact optometrists’ readiness and capacity to manage post-stroke visual impairments, providing valuable insights that can inform global strategies for enhancing optometric care in this critical area. In addition, these countries share some similarities in the scope and education of optometry [29]. The sample was also one of convenience as the research team had existing collaborations in these countries.

The objectives for this study were (1) to determine the level of knowledge among optometrists in these countries regarding post-stroke visual consequences, diagnosis, and management, (2) to explore the attitudes of optometrists towards managing post-stroke visual impairments and their perceived role in the rehabilitation process, (3) to analyze the current practices of optometrists in each country concerning post-stroke visual assessments, interventions, and management, (4) to identify barriers that optometrists face in providing post-stroke visual care, including knowledge gaps, resource availability, and referral practices, and (5) to compare the differences in optometric practices and preparedness to manage post-stroke visual impairments across the five countries. This first report focuses on the details regarding the reported general and post-stroke practice by optometrists.

Materials and methods

This survey received ethics clearance through the University of Waterloo Research Ethics Board at the School of Optometry & Vision Sciences, Research Ethics Committee at Cardiff University, and the ethics sub-committee at Vision Research Foundation (India). Additional ethics approval was not required for conducting this online survey in Hong Kong and US. The study was conducted in accordance with the Declaration of Helsinki. Informed consent was obtained from all participants prior to their participation in the study. Consent was obtained through a written method, where participants clicked on a provided link to indicate their agreement to participate before commencing the survey.

The researchers (all optometrists) developed a questionnaire based on their clinical expertise and literature knowledge. This questionnaire was pre-tested by 5 academic optometrist researchers (one from each country), who independently provided feedback regarding the appropriateness and clarity of each question for optometrists in their country. The modified questionnaire was further independently tested by 10 practicing optometrists from the different countries, who provided feedback and recorded the time needed to complete it (average: 14 min). This group included optometrists with and without expertise in rehabilitation. The questionnaire was further modified based on these optometrists’ feedback (See Supplementary material 1). The survey was translated into French for Canadian Francophones. The anonymous online REDCap survey was active from June 2021 to December 2021

Practicing optometrists from all 5 countries were invited to complete the survey through optometric organisations in each country through their email lists and electronic newsletters (if they had any). The total numbers of registered optometrists at the time of study were estimated at 5000 [35], 2000 in HK [36], 9000 in India [37], 14000 in the UK [38], and 46000 in the US [39].

Data was exported from REDCap into Excel (Microsoft^® Excel^® for Microsoft 365 MSO, Version 2112), which was used for descriptive data analysis and Jamovi (version 2.3.18.0) was used for country-specific comparisons of age, gender, and number of practicing hours (Kruskal–Wallis one-way analysis of variance). The Shapiro-Wilk test was used to assess normality. Confidence intervals for gender proportions were calculated using the Clopper–Pearson method.

Results

Two-hundred and seventy-six optometrists (age range: 21–79, females: 61%, males: 37%) participated in the survey. The percent response rate per country based on the number of registered optometrists were as follows: Canada (0.9%), HK (1.5%), India (0.4%), UK (0.2%), and US (0.3%). The demographics and weekly practicing hours of the participant population according to country are provided in Table 1. The age distribution was similar across respondents from all countries (averaging 44–49 years, range 21–79), except India, where the average was younger (p < 0.01, average: 31.5, range: 21–50). There was a significantly higher percent of female respondents from Canada (82%) compared to HK (57%), UK (47%), and US (60%). India had 71% female respondents. Participants’ weekly practicing hours ranged from 4 to 72 h (no difference between countries, p > 0.05).

Table 1.

Demographics and weekly practice hours of the respondents.

			Country of practice
		Whole data	Canada	Hong Kong	India	UK	US
Total N		276	45	30	34	30	136
Gender	Female (%)	168 (60.9%)	37 (82.2%)	11 (36.7%)	24 (70.6%)	14 (46.7%)	82 (60.3%)
	Male (%)	102 (37.0%)	6 (13.3%)	17 (56.7%)	10 (29.4%)	16 (53.3%)	52 (38.2%)
	Prefer not to say (%)	5 (1.8%)	2 (4.4%)	2 (6.7%)	0	0	1 (0.7%)
Age	Mean ± SD	44.8 ± 14.4	44.8 ± 11.6	40.6 ± 11.4	31.5 ± 8.5	49.0 ± 12.7	47.8 ± 15.2
	Range	21 to 79	29 to 70	23 to 67	21 to 50	27 to 72	27 to 79
Weekly practicing hours	Mean ± SD	31.7 ± 13.5	31.9 ± 7.8	34.8 ± 16.7	30.8 ± 20.7	28.5 ± 9.3	31.9 ± 12.7
	Range	4 to 72	8 to 45	6 to 55	8 to 72	8 to 40	4 to 60

About 34% of the respondents had more than 25 years’ experience as a qualified optometrist. 37% had 0–10 years and 29% had 11–25 years’ experience. The majority of respondents worked in a solo/independent practice setting (25%), followed by an educational institution (19%), or in a hospital (17%) (See Supplementary Table 2.1 for more details).

Ninety-four percent of respondents from India, 85% from US, 73% from HK, 67% from the UK, and 53% from Canada had an area of special interest/expertise within optometry, either low vision therapy/care/rehabilitation, binocular vision/vision therapy, ocular disease, contact lens, paediatrics, geriatrics, myopia management, computer vision, or neurorehabilitation Country-specific details are provided in Supplementary Figure 2.1.

Post-stroke specific practice

Overall, most of the respondents saw 1–5 post-stroke patients per month although about 15% saw no post-stroke patients (see Table 2 for country-specific details). About 52% of respondents from HK saw no post-stroke patients and no Canadian or HK respondents saw more than 10 post-stroke patients monthly.

Table 2.

Post-stroke patients seen monthly in optometrists’ principal practice setting.

		Country of practice
Number of post-stroke patients seen monthly	Whole data	Canada	Hong Kong	India	UK	US
0	41	7	15	6	2	10
1–5	168	33	13	20	22	79
6–10	35	5	1	5	4	20
11–15	11	0	0	0	0	11
16–20	11	0	0	2	2	7
21–25	5	0	0	0	0	5
More than 25	5	0	0	1	0	4

There were also variations in the number of post-stroke patients seen monthly by optometrists based on their practice type and area of expertise. Overall, respondents working in industries saw no post-stroke patients and more than 80% of respondents working in optometry corporate practice, beside/within optical store, private/group cost sharing practice, or solo/independent practice settings saw none or 1–5 post-stroke patients per month. The majority of respondents who saw more than 10 post-stroke patients monthly worked in hospital, within an ophthalmology practice, public health/community-based clinic, or educational institution settings (See Supplementary Table 2.2 and Supplementary Figure 2.1 for more details).

The areas of expertise of respondents who saw more than 10 post-stroke patients monthly were neurorehabilitation, computer vision, pediatrics, binocular vision and vision therapy, and low vision therapy/care/rehabilitation. 17 and 66% of respondents working in myopia management and 19 and 66% in contact lens specialties saw no or only 1–5 post-stroke patients monthly, respectively. 18 and 68% of respondents with no area of expertise also saw only 0 or only 1–5 post-stroke patients monthly, respectively (See Supplementary Figure 2.1 for country-specific details).

Participants were asked where post-stroke vision management occurs in their area (Figure 1), and 21% reported that post-stroke patients are often not managed or that they were unaware of where it occurs. Most reported that post-stroke patients were managed at hospitals (51%), but this varied by country; from 40% (Canada) to 80% (HK).

Figure 1.

Places of post-stroke vision management in their locality. The percentage of responses in each country is plotted. Participants could choose more than one response, so that cumulative percentage may be greater than 100%.

The most recommended assessments and interventions for post-stroke patients were a primary care eye exam with visual field assessment and provision of prisms for diplopia. However, there were discrepancies between the reported assessments and interventions that could be undertaken and those they actually conducted for post-stroke individuals. Specifically, while many respondents acknowledged the necessity of assessments such as visual midline shift, visual perceptual skills, visual neglect, reading assessment, tint assessment, binocular vision beyond the primary care level, and the use of a validated questionnaire, they did not frequently undertake these assessments in their practice (Figure 2). Similarly, although respondents identified interventions like reading strategies, magnification devices, vision training, environmental adaptations, full-field yoked prisms, and electronic devices as important, these were not commonly implemented in their actual practice (Figure 3). See Supplementary Material 3 for country-specific details.

Figure 2.

Percentage of optometrists who reported that an assessment is important versus percentage actually conducted an assessment for post-stroke individuals.

Figure 3.

Percentage of optometrists who reported an intervention is important versus percentage actually conducted an intervention for post-stroke individuals.

Additional assessments suggested were walking gait, motility and balance testing, pupil and ptosis evaluation, and movement perception assessment. Some respondents reported using the Brain Injury Vision Symptom Survey [40] or National Eye Institute Visual Function Questionnaire [41].

The survey also assessed respondents’ status of coordination with other professionals regarding post-stroke care (Figure 4). In all cases, optometrists referred stroke patients to other health care professionals more often than receiving referrals. Among the health care professionals listed, GPs/family doctors were most likely to refer a stroke patient to optometrists, followed by another optometrist. The discrepancies between what was considered the ideal situation and actual practice were high in referrals to and from orthoptists and low vision rehabilitation specialists. Ideally, there should be coordination with at least the specialists in the field such as orthoptists and low vision rehabilitation specialists to ensure comprehensive post-stroke care. However, in reality, such referrals were infrequent, with optometrists referring more patients to orthoptists and low vision specialists compared to the number of referrals they received from these professionals (see Supplementary material 4 for country-specific details).

Figure 4.

Status of coordination of optometrists with other professionals in the post-stroke care team.

There was consensus among respondents that optometrists should be a member of the post-stroke rehabilitation care team irrespective of their country of practice (Canada: 93%, HK & UK: 90%, India: 91%, and US: 97%).

Overall, 57% were interested in being more involved in post-stroke management. Education for other professionals (63%) as well as for optometrists (62%) were the two major changes suggested to encourage better involvement. Other changes needed were adequate government/insurance financial coverage (48%), access to equipment (34%), wheelchair accessible practice space (13%), and more office space (13%). (Figure 5). Additional suggestions were education for the general public, hands-on workshops, more patient contact time in practice, coordination/information sharing with other specialists, better research, and more referrals.

Figure 5.

Country-specific data regarding the changes required for better involvement. The percentage of responses in each country is plotted. Participants could choose more than one response, so that cumulative percentages may be greater than 100%.

About 21% of all respondents reported being already fully involved in post-stroke vision care (Table 3). The percentage of respondents who were fully involved in post-stroke vision care were 11.1% (Canada), 20.6% (India), 3.3% (UK), 33.8% (US) and 0% (HK). (See Supplementary material for country-specific reasons).

Table 3.

Reasons which prevented respondents from being more involved.

Reason	Number of respondents (%)
Fully involved	59 (21.5%)
Do not have the necessary resources	82 (29.8%)
Lack of interest	27 (9.8%)
Too time-consuming	52 (18.9%)
Lack of such patients in locality	69 (25.1%)
Specialization other than vision rehabilitation	52 (18.9%)
Lack of coverage/fee for this service through health care system/health insurance	71 (25.8%)
Other	17 (6.2%)

About 22% of respondents did not want to be more involved in post-stroke vision care and their reasons included lack of; necessary resources (7%), adequate fee (4%), time (6%), interest (6%), and being in a different specialization (10%). About 5% believed that they do not have such patients in their locality.

Discussion

The survey revealed a strong consensus among respondents that optometrists should be included in post-stroke care teams, with 57% of respondents expressing a desire for greater involvement but require increased education and financial support in order to do so.

The profile of the survey respondents indicates a diverse representation of optometrists, in terms of years working as a qualified optometrist (the majority having more than 10 years of experience), and special interests. The survey also captured a variety of practice settings, with significant participation from ­optometrists working in solo/independent settings, educational institutions, and hospitals, highlighting the multifaceted nature of optometric practice. While the response rate was low relative to the total number of registered optometrists, the data provides insights into these represented groups, aligning with previous studies that emphasize the heterogeneity in optometric practice across different regions [42,43]. Notably, respondents from India were younger compared to those from other countries, which may reflect the recent expansion of optometry as a profession in India, where a younger workforce is more prevalent. Respondents from India were younger compared to the respondents from other countries which may reflect the recent expansion of optometry as a profession in India, resulting in a younger workforce. The wide range of weekly practicing hours among Indian optometrists indicates a high variability, possibly due to the diverse nature of clinical practice settings and the varying demands of private versus institutional roles in the country.

Of those respondents who saw more than 20 post-stroke patients in a month, all except one practiced in the US and all of them had special interests related to low vision or vision rehabilitation. Despite the respondents’ experience and practice hours and the prevalence of stroke in the countries that the survey was conducted, 15% of respondents reported seeing no post-stroke patients, and 61% reported seeing only one to five post-stroke patients monthly. This supports the results from previous studies pointing to inequalities reported by patients, with most reporting a lack of suitable vision care offered as part of their neurological rehabilitation [24]. Although there are guidelines regarding post-stroke care in the UK, studies indicate that patients often had to seek their own support online, encountering inaccurate and worrying information [44]. In many locations there may still be a general lack of awareness, both among patients and other professions, of the benefits of visual rehabilitation. These findings emphasize the need for clinicians to consider the long-term impact of vision loss after neurological impairment and ensure patients receive adequate support, accurate information, and appropriate referral pathways to alleviate this burden.

Around 20% of respondents from India and US reported that post-stroke patients often do not have vision care in their locality or were not aware where they are managed, and this percentage was higher among the respondents from Canada (24%) and UK (50%) (Figure 1). Specifically, around 14% of respondents from India, UK, and US did not know where post-stroke patients were managed for their visual problems in their locality. This figure was 22% in Canada and 7% in HK. Considering that 60–65% of stroke patients may have visual consequences, this indicates a lack of access to the necessary vision care for this population [9–11,45]. In addition, 56% in HK and 30% in Canada and India reported not having any post-stroke patients in their locality (Figure 1). Considering the growing prevalence of strokes worldwide, this suggests that optometrists are often left out of the post-stroke care team and/or are not aware of individuals in need of their services, as it is unlikely that there are no stroke patients in any locality with a large enough population to support an optometrist.

Post-stroke care involves a multidisciplinary team, and the quality of care depends on effective communication and coordination among the care team. The high discrepancies observed regarding the coordination of optometrists with other professionals also corroborate that optometrists are often missing from the post-stroke care team. For example, a survey of occupational therapists regarding post-stroke visual consequences, did not include ‘optometrist’ as an option to choose regarding referrals [46].

The majority of respondents were mostly aware of the needed optometric assessments and would undertake them (Figure 2) [47]. The discrepancies between the reported and undertaken assessments could be due to multiple reasons such as lack of standardized measurement methods/tools, lack of equipment, lack of familiarity or lack of specific evidence-based guidelines regarding these assessments. Another assessment method which had high discrepancy was the use of a validated questionnaire. Although 24% considered it a necessary tool in post-stroke vision assessment, only 10% were using one, and there was a range of different questionnaires being used.

There was a much larger discrepancy between awareness and application of interventions compared to assessments (Figure 3) in all countries. Most were aware of the interventions for the post-stroke patients, but there was a large discrepancy between awareness and application, except for correction of small refractive errors.

Lack of necessary resources and adequate financial coverage were the major reasons reported by optometrists that prevented them from being fully involved in all countries. Although most of the countries involved in this survey have some form of universal health care, none cover a primary eye care examination for all the population, and depended on age, existing eye conditions and/or income. In addition, the more extensive assessment needed for post stroke patients or even low vision patients, including the assessments and interventions that optometrists consider important (Figures 2 and 3), is covered by even fewer areas [48]. This suggests that patients will likely face additional barriers in accessing optometric care, potentially leading to delayed or inadequate treatment for post-stroke visual impairments. The majority of respondents were interested in being more involved in post-stroke vision care if these barriers were addressed and if increased education regarding the optometric management of stroke survivors was provided for both other professionals and optometrists.

Limitations

Despite sending out the survey information multiple times through various organizations, the response rate represents a small percentage of optometrists in each country (0.9% Canada, 1.5% HK, 0.38% India, 0.21% UK, and 0.30% US). The low survey response rate could indicate either a lack of interest or involvement in post-stroke rehabilitation or uncertainty regarding their knowledge and resultant hesitancy in responding.

With any survey there is a possibility of bias as the population of those choosing to respond may not accurately represent the population at large. Although the survey introduction explained that the survey was meant for all optometrists and not only those working with post-stroke individuals, it is also likely that participating optometrists were those who were more interested in post-stroke care or who had an interest in specialist areas of optometry. Those who did not respond may be less involved in providing care for the stroke population or may have less awareness. There is also a higher percentage from academic settings than the whole population of optometrists. If these assumptions are true, the need for optometrists to become more involved and included in post-stroke rehabilitation is even greater than these results indicate.

Conclusion

Optometrists have the education and scope of practice to diagnose and manage post-stroke visual problems, However, this survey demonstrates the need for improved awareness and knowledge among optometrists, post-stroke patients, and other professionals involved in post-stroke care regarding the visual consequences of stroke in all the countries surveyed. Recently, a vision care pathway for stroke survivors has been suggested for the UK based on the perspectives of stroke survivors, clinicians, and researchers [49]. Such care pathways are useful, and this survey further indicates that any care pathway should include a referral to optometry so that patients can benefit from their unique skills in assessment and intervention (Tables 2 and 3). This survey also demonstrates that many optometrists are aware but are not undertaking assessments and interventions that go beyond routine optometric measures as often as needed, except for correction of small refractive errors. Including vision care in comprehensive stroke management is necessary, as published evidence suggests that more than 50% of stroke survivors are asymptomatic [45], and their impairment could go undetected if vision assessment is not conducted as part of an eye examination. Furthermore, visual impairment can confound other impairments and impede rehabilitation. This survey demonstrates that overall optometrists are willing to be more involved in post-stroke care, but are often restricted by lack of time, coverage/fee, and communication among professionals. Acknowledging the role of optometrists in post-stroke care and providing necessary resources for optometrists to fulfil the role would improve the quality of care and ultimately quality of life, for post-stroke patients.

Funding Statement

Grant support: InnoHK initiative and the Hong Kong Special Administrative Region Government.

Author contributions

Susan J. Leat was involved in the conception. Susan J. Leat, Tammy Labreche, and Amritha Stalin were involved in the design, getting ethics approvals, and interpretation of the data. Amritha Stalin was primarily involved in data collection, data analysis and the drafting of the paper. Susan J. Leat, Tammy Labreche, and Amritha Stalin were involved in revising it critically and the final approval of the version to be published. All authors agree to be accountable for all aspects of the work.

Ethical approval

This survey received ethics clearance through the University of Waterloo Research Ethics Board at the School of Optometry & Vision Sciences (#43035), Research Ethics Committee at Cardiff University (#1564), and the ethics sub-committee at Vision Research Foundation (India) (#1005-2021-P). Additional ethics approval was not required for conducting this online survey in Hong Kong and the US. The study was conducted in accordance with the Declaration of Helsinki.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

Authors agree to make data and materials supporting the results or analyses presented in their paper available upon reasonable request.