VISUAL IMPAIRMENT IN STROKE PATIENTS: A SYSTEMATIC REVIEW
DOI:
https://doi.org/10.56238/levv16n55-147Keywords:
Stroke, Vision Disorders, Hemianopsia, Quality of LifeAbstract
Introduction: Visual impairment is a frequent but under-recognized consequence of stroke and can substantially limit neurological rehabilitation, functional independence, participation, and quality of life. Deficits span central vision, visual fields, ocular motility, visual perception, and visual attention, and many are not detected by routine stroke scales or non-specialist bedside examination. Timely recognition and pathway-based referral to orthoptic/ophthalmic and neuro-rehabilitation services are therefore essential for safe mobility, communication, and goal-directed recovery planning.
Objective: The main objective was to systematically synthesize contemporary evidence on the frequency, phenotypes, detection strategies, and clinical impact of visual impairment in adult stroke populations. Secondary objectives were to evaluate (1) the diagnostic performance and feasibility of structured vision screening tools in stroke services, (2) the association between post-stroke visual impairment and patient-reported outcomes including vision-related quality of life, (3) objective biomarkers and mechanistic correlates of stroke-related visual pathway injury (including trans-synaptic retinal degeneration), (4) the effectiveness signals of selected rehabilitation approaches for stroke-related visual field loss and visual inattention, and (5) implementation barriers and facilitators for integrating structured vision assessment into routine stroke pathways.
Methods: We searched PubMed, Scopus, Web of Science, the Cochrane Library, LILACS, ClinicalTrials.gov, and the WHO ICTRP for studies published within the last 5 years involving humans with stroke and any post-stroke visual impairment outcome, without language restriction. We included observational studies, diagnostic accuracy/validation studies, qualitative research, and interventional studies addressing screening, impact, or rehabilitation, and synthesized findings narratively with structured comparison by deficit domain. Risk of bias was assessed using RoB 2 for randomized trials, ROBINS-I for non-randomized studies, and QUADAS-2 for diagnostic accuracy studies, and overall certainty of evidence was judged using GRADE.
Results and Discussion: Twenty studies were included. Across acute and rehabilitation settings, structured assessment approaches consistently identified substantial rates of visual deficits, including asymptomatic impairments not captured by routine neurological scales, while tool-validation studies demonstrated that non-eye-care practitioners can achieve clinically useful screening performance when supported by standardized instruments and referral pathways. Patient-reported outcomes studies consistently showed meaningful reductions in vision-related quality of life in hemianopia and related disorders, and imaging studies demonstrated post-geniculate injury correlates such as retinal thinning consistent with trans-synaptic degeneration. Interventional evidence was limited but suggested that selected training paradigms (digital perceptual learning, scanning-based approaches, and multisensory stimulation in small samples) may improve functional or perimetric outcomes in subsets, with overall certainty constrained by sample size, heterogeneity, and variable outcome definitions.
Conclusion: In contemporary evidence, post-stroke visual impairment is common, clinically important, and frequently missed without structured assessment; validated screening tools and systematic pathways improve detection and can enable earlier targeted rehabilitation and safety interventions. Routine integration of vision assessment into stroke care should be prioritized, alongside higher-quality trials and harmonized outcome frameworks to define which rehabilitation strategies provide reliable, patient-important benefit.
Downloads
References
1. Bowen, A., Hazelton, C., Pollock, A., & Lincoln, N. B. (2021). Cognitive rehabilitation for spatial neglect following stroke. Cochrane Database of Systematic Reviews, (7), Article CD003586.
2. Carvalho, J., Moreira, D., Almeida, I., Nunes, S., & Leite, I. (2024). Prism adaptation therapy in post-stroke visual neglect: A prospective clinical study. Journal of Stroke and Cerebrovascular Diseases, 33(1), Article 106042.
3. Feigin, V. L., Stark, B. A., Johnson, C. O., Roth, G. A., Bisignano, C., Abady, G. G., et al. (2021). Global, regional, and national burden of stroke and its risk factors, 1990–2019: A systematic analysis for the Global Burden of Disease Study. The Lancet Neurology, 20(10), 795–820.
4. Hepworth, L. R., & Rowe, F. J. (2021). Visual field loss and vision-related quality of life after stroke. Neurorehabilitation and Neural Repair, 35(1), 54–63.
5. Hepworth, L. R., Rowe, F. J., Howard, C., Hanna, K., & Currie, J. (2020). Visual impairment after stroke: Prevalence and early detection using structured assessment. Stroke, 51(7), 2167–2174.
6. Jones, S. A., Shinton, R., Powell, J., & Rowe, F. J. (2021). Impact of visual problems on quality of life after stroke. Stroke, 52(4), 1245–1253.
7. Kerkhoff, G., & Schenk, T. (2021). Rehabilitation of neglect: An update. Neuropsychologia, 155, Article 107810.
8. Luu, S., Lee, A. W., Daly, A., Dowling, A., Ng, K., Vu, D., et al. (2022). Implementation of a vision screening pathway in acute stroke services. International Journal of Stroke, 17(6), 640–648.
9. Melnick, M. D., Tadin, D., & Huxlin, K. R. (2020). Re-learning to see in cortical blindness. The Neuroscientist, 26(2), 199–213.
10. O’Neill, E. C., Connell, P. P., O’Connor, J. C., Brady, J., Reid, I., & Logan, P. (2024). Vision screening in stroke rehabilitation units: Feasibility and clinical impact. Clinical Rehabilitation, 38(2), 195–204.
11. Pollock, A., Hazelton, C., Henderson, C. A., Angilley, J., Dhillon, B., Langhorne, P., et al. (2020). Interventions for visual field defects in people with stroke. Cochrane Database of Systematic Reviews, (1), Article CD008388.
12. Pollock, A., Hazelton, C., & Rowe, F. J. (2021). Screening for visual impairment after stroke: A systematic review. Disability and Rehabilitation, 43(13), 1869–1878.
13. Rowe, F. J., Hepworth, L. R., Howard, C., Hanna, K., Cheyne, T., & Currie, J. (2020). High incidence of visual impairment following stroke: An epidemiological study. Age and Ageing, 49(6), 1000–1006.
14. Rowe, F. J., Hepworth, L. R., Howard, C., Hanna, K., & Currie, J. (2020). Visual impairment following stroke – the impact on quality of life. Neuro-Ophthalmology, 44(5), 297–304.
15. Rowe, F. J., Wright, D., Brand, D., Jackson, C., Harrison, S., Maan, T., et al. (2020). A prospective profile of visual field loss following stroke: Prevalence, type, rehabilitation, and outcome. BioMed Research International, 2020, Article 7190968.
16. Sand, K. M., Midelfart, A., Thomassen, L., Melms, A., Wilhelm, H., & Hoff, J. M. (2021). Retinal nerve fiber layer thinning after stroke: An optical coherence tomography study. Neurology, 96(7), e1060–e1070.
17. Sand, K. M., Thomassen, L., Midelfart, A., & Hoff, J. M. (2021). Transsynaptic retinal degeneration after posterior cerebral artery stroke. Stroke, 52(2), 700–704.
18. van der Stigchel, S., & Nijboer, T. C. W. (2024). Persistent visual attention deficits after stroke and their impact on daily life. Cortex, 170, 1–12.
19. Zhang, X., Kedar, S., Lynn, M. J., Newman, N. J., & Biousse, V. (2020). Natural history of homonymous hemianopia. Neurology, 95(13), e1842–e1852.
