New research papers, published in three different journals, highlight the adverse impact of COVID-19 on orthoptic clinical practice across the UK and also illustrate the benefits of new University of Liverpool developed tools in helping address the issues around orthoptics service delivery and patient care.
The COVID-19 pandemic has fundamentally changed the way everyone goes about their day-to-day lives; nowhere more so than in relation to our access to and the provision of vital medical services including eye care and assessment.
About two thirds of stroke survivors have visual impairment which typically relates to impaired central or peripheral vision, eye movement abnormalities, or visual perceptual defects.
Professor Fiona Rowe of the Vision, Orthoptic and Brain Injury Research Unit at the University says this suspension in delivery is leading to a 'lack of availability of necessary services' for patients requiring vision screening and inequitable care provision for stroke survivors with the potential for long-term unmet needs.
The first of a trio of novel research studies led by Professor Rowe, published in the British and Irish Orthoptics Journal, found that, as with the access and delivery of many other hospital services, COVID-19 has forced a complete change in orthoptic clinical practice across the UK and Ireland with face-to-face clinical consultations mainly preserved for urgent care. Clinical practice continued, but was scaled down, and conducted through remote consultations with use of video and telephone calls.
The impact of this remotely conducted and reduced delivery of service highlighted the urgent need for change and adaptation within the profession. The timely release of new resources may help this situation. Two new unique tools have been developed and tested for use in tandem by healthcare professionals, carers and non-clinicians. These will help in the fight against COVID-19 impacts on orthoptics service delivery and patient care (in particular in respect to stroke related visual impairment, which occurs in about three quarters of stroke survivors.)
Vision Screening Assessment tool
VISA, is a Vision Screening Assessment tool for detecting visual impairment among stroke survivors by clinicians involved in stroke care who are not specialists in vision problems and lack formal eye training. Where early visual impairment detection occurs, this facilitates prompt referral with fewer false positives and negatives. The VISA screening tool provides a standardised and validated method to screen for visual problems following stroke and may further be of potential use for visual screening in other care settings such as neurorehabilitation.
Professor Rowe, said: "Identification of visual impairment with access to early vision rehabilitation has an impact on quality of life and activities of daily living with potential cost savings to the NHS by enhancing rehabilitation and supporting early discharge."
VISA has undergone full validation in a study published in the British Medical Journal. The study was funded by the University of Liverpool and included collaboration with Bradford Teaching Hospitals NHS Foundation Trust, Salford Royal NHS Foundation Trust, Manchester University Hospital, the Walton Centre, and Arrowe Park Hospital.
The Stroke-Vision Care Pathway
The impact of visual impairment as the result of a stroke can be considerable with impaired vision leading to increased rate of personal accidents and falls, social isolation, loss of confidence, impaired mobility, reduced quality of life, increased anxiety and depression - all exacerbated by the current COVID-19 climate.
Some types of visual impairment can be easily detected and many affected individuals will report their symptoms. However, most types of visual impairment cannot be easily detected without specific assessment and some individuals do not complain of visual symptoms.
The Stroke-Vision Care Pathway has been developed collaboratively with stroke survivors, clinicians and researchers (including stroke professionals and eye professionals). It clearly identifies the potential ways in which stroke survivors with visual impairment can access health care and what the appropriate referral(s) to vision services should be relevant to their specific problem(s) and works hand in hand with VISA, the Vision Screening Assessment tool.
Addressing long-term unmet needs
The stroke-vision care pathway is available (free to download) from the VISION research unit website and available as supplemental information with the validation paper published in the Disability and Rehabilitation Journal.
Professor Rowe, said: "These studies highlight the importance of being aware of vision problems as a common consequence of stroke, how to identify them and where to refer them to. Ideally, and meeting national clinical guidelines for stroke, orthoptists would assess all stroke survivors when admitted to stroke units. However, we lack availability of ideal services.
"The VISA tool helps with screening for vision problems and the care pathway facilitates onward referral. Both are even more important now given the impact to providing specialist orthoptic services for stroke survivors during the COVID-19 pandemic where services have been suspended leading to inequitable care for stroke survivors with potential for long-term unmet needs.
"The stroke-vision care pathway has been developed collaboratively with stroke survivors, clinicians and researchers. We encourage anyone working with stroke survivors to implement the use of this screening tool and care pathway to improve detection of visual impairment and access to eye care."
Critical research
Jim Currie, Chair of 'Vision In Stroke able (VISable)', said: "As the Chair of VISable panel and a stroke survivor with visual problems I am well aware of the effects of COVID-19 has had on those who suffer with vision issues. Over the past few months I have heard of survivors with vision problems deciding to stay at home rather than go out for shopping or taking exercise.
"Concerns include bumping into people, not being able to judge the two-metre rule (and as result being abused by others), the inability to see where the sanitising equipment is and the lack of willingness of people to come forward to help. The research undertaken by Prof Rowe and her team has been critical in seeking to support those with vision issues and has made considerable impact on the quality of life for vision impaired individuals."
Integral part of stroke care
Professor Anna Horwood, Director of Research for the British and Irish Orthoptic Society, said: "In the current healthcare climate, high-COVID-risk stroke survivors are the very people for whom hospital visits and stays, and interaction with different professionals, need to be as efficient and targeted as possible, while still maintaining gold standard care. Professor Rowe's group has shown that vision and orthoptic assessment must be integral part of stroke care in both hospital and community settings. The tools her group have developed allow vision care to be delivered flexibly and comprehensively wherever the patients are."
Improving care
Dr Deborah Lowe, National Clinical Director for Stroke Medicine and Joint National Clinical Lead for Stroke Medicine, said: "Visual impairment often goes unrecognised, and the risk of this lack of identification is significantly amplified during this COVID period due to more rapid assessments, PPE, reduced patient contact and at times unstructured virtual assessments. We need to stop and think about how we deliver virtual stroke assessments and intervention to ensure we are not increasing the likelihood of stroke survivors being discharged home without appropriate management and support for their visual impairment. Also, the concept of making every patient contact count and ensuring we have diversification of skills and roles during this difficult restoration and recovery period is vital.
"The VISA tool and Stroke Vision Care Pathway as great examples of how we can do this using an evaluated tool that have been created by experts in their field, researchers and clinicians. It is exciting to think about how these tools can be used 'post COVID' to improve assessment and appropriate onward referral in services that do not currently have adequate Orthoptics services".
The full paper in the British and Irish Orthoptic Journal, entitled 'Orthoptic Services in the UK and Ireland During the COVID-19 Pandemic', can be found here.
DOI: http://doi.org/10.22599/bioj.153
The full paper in the BMJ's Cardiovascular medicine, entitled 'Vision Screening Assessment (VISA) tool: diagnostic accuracy validation of a novel screening tool in detecting visual impairment among stroke survivors', can be found here.
DOI: http://dx.doi.org/10.1136/bmjopen-2019-033639
The full paper in the Disability and Rehabilitation Journal, entitled 'Developing a stroke-vision care pathway: a consensus study', can be found here.
DOI: https://doi.org/10.1080/09638288.2020.1768302
