Managing Visual and Perceptual Changes Due to a Stroke

We take the information we view with our eyes to discern the shape, size, and position of the objects we see. Our brain uses this to work out where objects are located, how far away they are from us, and where they are in relation to one another. This is referred to as visual or spatial perception. This changes for the worse when a person has a stroke.

Here are a few ways to help them cope with the change. Tasks may take longer, so let the person work out the problem first, then provide a reminder or prompt or hand them the object. Remove clutter, as too many items, may be confusing or distracting. Only layout objects the person will need. Increase organization; for example, use an organizer for silverware or put clothing in compartments.

The following strategies are useful in managing and improving the visual perceptual problems of hemianopia/inattention/neglect, agnosia, and dyspraxia.

Different types of visual loss due to a stroke

Hemianopia / neglect is the physical loss of the visual field of one side of the body, while neglect is lack of attention to one side of the body. Here’s how to manage this:

• Give verbal and physical prompts by guiding the person’s hand across their body side to side, using words like, “Look for your fork on the left side of your plate.” Guide the unaffected hand toward the fork, crossing from one side of the body to the other.
• Position the person’s face forward so they must turn their head to follow another person walking past on the affected side.
• Encourage them to look at both sides. Place a line or ruler to the left side when writing or reading the calendar to encourage looking to the left. Place a line on the table so they can practice looking beyond it. Remind them to look to the involved side for items and personal objects.
• Consider their safety, as the person may not know of the dangers of neglected space. The person may get their hand caught under their own body or between the spokes of the wheels of a wheelchair.
• Take extra care outside due to moving objects, obstacles, etc.
• Play scanning games like word search puzzles, connect 4, dot to dot puzzles, and dominoes. Scan newspaper headlines or items in a line on a shelf.
• Put their watch on the wrist of the involved side.
• The person may need close supervision to walk in order to avoid bumping into door frames, people, and furniture. Walk on their involved side.

Agnosia is an impaired sensory ability to recognize objects. Here are ideas on how to cope with this:

• Only complete tasks when the person is feeling rested and work on only one task at a time.
• Use a simple picture checklist that will enable the person to break up tasks in the activity.
• Break up each activity into a smaller activity, and as each step is achieved add another. For example, after recognizing and locating the orange juice and glass and completing the movements and timing to remove the bottle cap and bringing the glass next to it, add the step of pouring the juice into the glass.
• Encourage use of other senses – touch, texture, and smell may give added clues.
• Don’t take over unless a safety problem is present. Let the person continue to attempt activities with your support.
• Practice – repetition and routine make the person more familiar with items, as it creates new neural pathways in the brain for mastering activities.
• Safety awareness is crucial, as the person with apraxia may not realize when a situation is dangerous.

Dyspraxia / Apraxia is a difficulty with skilled movements and an inability to perform familiar activities even when you have the ability and desire to do so. Here’s how to cope:

• Start with simple tasks and work towards more complex ones. Tasks that are simple may seem simple and automatic to us. It can take a person with dyspraxia a long time to relearn them.
• Try a simple picture guide or list to help the person follow the correct order or sequence.
• Keep all items for a specific task together.
• Give extra time to let the person try to complete as much as they can for themselves. Although it may be simpler and timesaving for you to do the task, unless they try to do the task on their own, they will become more dependent.
• Practice and only add a step when the person has learned the prior steps of an activity.
• Place clothes on to a flat surface such as a bed in the sequence they should be put on. Ensure the clothes are not inside out. Avoid too many fastenings.
• Dressing in front of a mirror can sometimes help the person check that they have put their clothes on correctly. The mirror must be large enough or placed in such a location to see the entire body. (This may not work for all people with dyspraxia.)
• It may help if you hold the involved arm while they attempt to dress. Bring the arm in front of the body where they can see it. Do not pull on the involved arm, but support it as they may have a painful shoulder.
• Try sewing a colored tag on the inside of the right sleeve if they have difficulty with right/left and inside/outside. They may need a reminder about what the colored tag means. Do the same for the right shoe using the same-colored marker.

Eye movement problems

A stroke can affect your ability to move your eyes the way you want. This may make looking from one object to another difficult or affect the way you judge distances between things. You could also have difficulty moving your eyes up and down, or one eye might move when the other won’t.

Your eyes may constantly move or twitch, causing dizziness and blurriness. You may also find that you are no longer able to judge how far objects are from you due to impairment in depth perception. For example, you can no longer judge how high a step is or the height of the coffee you poured into your mug.

You can cover or patch your eye when doing activities like this or when reading or watching television.

It can also mean that your eye is constantly moving so that objects seem to wobble. This is called nystagmus. Using large print or turning up the print size on your computer can help as well as improve lighting and reduced glare.

These eye movement problems are a result of damage to the different nerves that control your eyes.

Below are some strategies to retrain and regain the control of your eye movements.

Computer games. Word search games are available for free from several websites. They can improve your visual tracking, or the ability to maintain your focus on a moving object and move your eyes from one object to another. Two such websites are Eye Can Learn and Lumosity. While the activities are for children with developmental eye problems, adults can do them, too.

Transitioning exercises. Focus on an object near to you, and then look to an object farther away. Try to increase your speed between the two items until you can go back and forth quickly.

Tracking exercises. Have a caregiver hold a pencil in front of your face, about 18 inches from your eyes. Have them move the pencil slowly, first up and down and then side to side, as you follow it with your eyes. Keep your head still and only move your eyes.

Seek the services of a vision rehabilitation specialist. An occupational therapist can help with visual perceptual or eye movement problems. An orthoptist who also specializes in eye movement disorders and problems with binocular vision (the ability to create an image using both eyes) can help.