Stroke Impact: Eyes Shut, What To Do?

A stroke can cause vision problems, including an inability to open one's eyes, known as apraxia of eyelid opening (AEO). AEO is a rare condition characterised by difficulty in initiating eyelid elevation voluntarily, despite the physical ability to do so. It is often associated with neurodegenerative disorders and brain injuries. In the context of stroke, AEO has been linked to high mortality and right hemispheric infarction, with poor survival rates observed in patients who experience it.

Vision loss or impairment is a common occurrence after a stroke, affecting around two-thirds of people. This can include a range of issues, such as visual field loss, eye movement problems, visual processing difficulties, and other sight problems like light sensitivity and dry eyes. These issues can significantly impact daily life, making tasks like reading, shopping, and even moving around more challenging.

Apraxia of Eyelid Opening (AEO)

AEO was first described in 1907 by renowned German physician Max Lewandowsky, but the term 'Apraxia of Eyelid Opening' was coined in 1965 by Goldstein and Cogan. The condition is most commonly associated with neurodegenerative diseases, particularly Parkinson's disease, but can also occur with other basal ganglia disorders and specific frontal lobe lesions.

AEO can pose significant challenges to those affected, as it can interfere with daily activities such as reading, driving, and even basic facial expressions. Treatment options include botulinum toxin injections, surgical interventions, and dopaminergic medication, such as levodopa/benserazide.

Vision or visual field loss

Visual field loss happens when a stroke affects the visual pathway or the parts of the brain that process and interpret visual information. The visual pathway refers to the path that visual information takes from the eyes to different parts of the brain involved in seeing. If the right side of the brain is damaged, the left side vision in each eye may be affected, and vice versa. It is rare for strokes to affect both sides of the brain, but when it does, it can result in blindness.

Visual field loss can impact daily living, making tasks such as reading, shopping, and watching television more challenging. It can also affect your ability to get around and cause disorientation in crowded environments.

While some recovery of vision is possible, usually within the first few months after a stroke, most people with vision loss after a stroke do not fully recover their vision. Treatment options include visual training with or without optical aids, such as glasses, prisms on glasses, patching, magnifiers, and visual scanning techniques. Computer-based rehabilitation programs may also help improve scanning abilities in individuals with visual field loss.

Eye movement problems

If the nerves that control the eye muscles are damaged, the eyes may begin to turn (strabismus) or a person may experience double vision (diplopia). This is caused by a nerve that controls individual eye muscles stopping to work. Other eye nerve problems can cause an eyelid to droop (ptosis) or the pupil of the eye to become bigger.

Nystagmus, or the constant and unsteady movement of the eyes, is another possible complication of ocular nerve damage. This can cause jittery eye movements, which can be side to side, up and down, or circular. The eyes may also flicker when trying to focus on something.

If only one eye is affected by a stroke, a person will usually experience double or blurred vision. If both eyes are affected, this can result in poor depth perception.

Visual processing problems

Visual neglect is the most common type of visual processing problem, where people are not aware of, and do not respond to, things on their stroke-affected side. This can lead to safety issues and affect their independence. However, there are ways to manage and improve visual processing problems. Therapy may include training to compensate for the vision loss, such as scanning techniques that make the most of their existing vision. Prism lenses can also be used to shift images from the non-seeing to the seeing visual field.

It is important to have a comprehensive eye examination after a stroke to detect any visual processing problems, as they may not be obvious right away. Early detection can help with managing and improving these issues.

Other sight problems

There are several other sight problems that can occur after a stroke, including:

• Light sensitivity (photophobia): this is an abnormal sensitivity to light, which can make it difficult to go outside or even to perform daily tasks indoors.
• Dry eyes: this can be caused by problems with the nerves of the eyelid, the facial nerve, or the muscles of the eyelid. Dry eyes can be treated with eye drops and by taping the eyelids shut at night.
• Visual neglect: this is when people are not aware of, and do not respond to, things on their stroke-affected side. It is not related to vision itself but is caused by damage to parts of the brain that perceive and interpret vision.
• Visual agnosia: this is when people have difficulty recognising familiar faces and objects, even though their vision is intact. This is also caused by damage to parts of the brain that perceive and interpret vision.
• Eye movement problems: these can include nystagmus (constant, unsteady movement of the eyes), strabismus (eye turning), and diplopia (double vision). Eye movement problems can be caused by damage to the nerves that control eye movement or to the individual eye muscles themselves.

Frequently asked questions