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Impact of ocular abnormalities on quality of life among stroke survivors: A cross-sectional study
*Corresponding author: Ekele Alih, Biostatistics Unit, Department of Mathematical Sciences, Federal University Oye-Ekiti, Oye, Nigeria. ekele.alih@fuoye.edu.ng
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Received: ,
Accepted: ,
How to cite this article: Ocheni SE, Osayande-Osawe O, Babatunde A, Mahmoud AO, Alih E. Impact of ocular abnormalities on quality of life among stroke survivors: A cross-sectional study. Global J Cataract Surg Res Ophthalmol. doi: 10.25259/GJCSRO_56_2025
Abstract
Objectives:
Stroke is a major cause of long-term disability globally, and visual impairment is among its most common sequelae. With improved survival, attention has shifted from acute management to addressing long-term outcomes that influence quality of life (QoL). Ocular abnormalities represent a significant but often overlooked complication of stroke. This study assessed the quality of life of stroke survivors and examined the impact of ocular abnormalities on vision-related quality of life scores.
Materials and Methods:
A retrospective cross-sectional study involving 83 consecutive new stroke patients seen at the Federal Teaching Hospital, Lokoja, over 3 months was conducted. Data were collected using a structured questionnaire comprising biodata, visual history, ocular examination results and the National Eye Institute Visual Function Questionnaire-25 QoL instrument. Descriptive statistics, Chi-square and Fisher’s exact tests were used for analysis.
Results:
The 83 participants (166 eyes) were aged 40–71 years (mean 55.3 ± 7.1), with 59.0% males. Most participants were employed (67.5%) and 48.2% had tertiary education. Ocular abnormalities were present in 69 participants, leading to a prevalence of 83.1%. QoL scores were generally high. Overall, 96.4% of participants reported high QoL in general health/vision, 89.2% reported high QoL in difficulty-with-activities and 79.5% reported high QoL in responses to vision problems. Only cataract (P < 0.001) and grade 3 hypertensive retinopathy (P = 0.039) showed statistically significant associations with QoL. Stroke-related abnormalities such as visual field defects, ptosis and ocular motor paresis showed no significant relationship with QoL.
Conclusion:
Despite a high prevalence of ocular abnormalities, most stroke survivors demonstrated high vision-related QoL, possibly due to resolution of visual deficits before assessment. Early and regular ophthalmic evaluation is recommended to optimise QoL in this population.
Keywords
Neuro-ophthalmic evaluation
Ocular abnormalities
Quality of life
Stroke survivors
Visual impairment
INTRODUCTION
Stroke is a major cause of long-term disability in adults worldwide and visual impairment is the most common consequence of stroke, particularly in low- and middle-income countries such as Nigeria. The incidence of stroke in sub-Saharan Africa seems to be rising, as indicated by the findings of Walker’s research.[1] While an earlier study reported a prevalence of 114/100,000 people for a specific condition in sub-Saharan Africa, a more recent survey in Nigeria’s Kwara State indicates that this rate has increased to approximately 134/100,000 population. Despite this evolving prevalence data, there remains a significant lack of information in Nigeria regarding the specific types and patterns of eye problems observed in stroke patients.[2,3] Among the post-stroke sequelae, ocular abnormalities including visual field defects, ocular motility disorders, diplopia and visual neglect are common but often underdiagnosed, especially in low- and middle-income countries such as Nigeria. As reported in Rowe et al.,[4] 60% of stroke survivors have at least one form of visual impairment with visual field loss being the most common of them all. Previous studies have reported that the incidence of ocular motility disorders among post-stroke patients ranges from 36.95% to 39.3% and this is often undetected during routine neurological assessment.[4,5]
As survival rates improve, attention is being shifted from acute management towards addressing the long-term consequences of stroke that collectively influence quality of life (QoL). As defined by the World Health Organization QOL Group, QoL is an individual’s perception of his/her position in life in the context of the culture and value systems in which they live in relation to their goals, expectations, standards and concerns.[6] Among the post-stroke sequelae, ocular abnormalities are a significant complication that is often not given enough attention. QoL among stroke survivors is strongly influenced not only by motor deficits and cognitive impairment but also by visual dysfunction, which affects mobility, reading, self-care, social engagement and independence. Recent studies underscore the importance of integrating ophthalmic assessment into post-stroke care, and hence, there is growing interest in understanding the specific contribution of visual problems to QoL after stroke. Notably, several studies have examined ocular abnormalities as predictors of poor QoL among stroke survivors.[7-9]
In addition to the assessment of disability arising from stroke, the assessment of the QoL of patients with stroke is also important, especially when considering long-term survival and functional outcomes following stroke. Evaluation of the QoL in stroke survivors can provide a rich description of the multifaceted effects that occur following a stroke and provide insights above those recorded with the usual measures of impairment.[10] Various scales have been developed to measure the QoL in stroke patients, some generic and others specific to the brain injury occurring in stroke.[11] Some of the available scales include the Short Form 36 and the EUROQoL, which are generic scales for measuring health-related QoL in stroke patients.
The National Eye Institute Visual Function Questionnaire-25 (NEI VFQ-25) has been widely used in assessing the health-related QoL of visually impaired subjects who also have other chronic illnesses. Its wide acceptance is based on its strong psychometric properties as it has been found to have the highest number of positive ratings in quality assessments.[11] It is composed of 11 vision-related subscales which are vision rating, near vision activities, distance vision activities, role limitation, social functioning, dependency, driving, mental health, peripheral vision, colour vision and ocular pain. It also possesses an additional section for a self-evaluated general health rating. Studies have used this instrument with great results in assessing visual impairment following stroke as related to their QoL.[12-14]
Given the importance of vision in daily functioning and rehabilitation outcomes, there is a need for context-specific research exploring the burden and consequences of ocular abnormalities in Nigerian stroke survivors. Hence, this study aims to determine the proportion of stroke patients with ocular abnormalities, examine the QoL of stroke survivors and determine the effect of ocular abnormalities on QoL of stroke survivors in Federal Teaching Hospital Lokoja.
MATERIALS AND METHODS
Study design
This study employed a retrospective cross-sectional design to assess the impact of ocular abnormalities on the QoL among stroke survivors at the Federal Teaching Hospital, Lokoja.
Sample size determination
The sample size for this study was calculated in G*Power using the Leslie-Kish formula. Following the reported prevalence of P= 0.1, we set the precision level d = 5% and the level of significance α = 5%, leading to an initial sample size n= 138.[15,16] We further applied the correction factor since the total number of registered stroke patients, n = 160 < 10,000, leading to the final sample size of nf = 80 after accounting for rate of possible attrition.
Inclusion and exclusion criteria
The inclusion criteria for patients recruited into this study include patients who are age 18 years or older and who have had clinical/radiological diagnosis of stroke at the neurological unit, managed by the department of medicine and are willing and able to provide informed consent personally or through a legally authorised representative. The exclusion criteria include patients with prior ocular trauma and/or injury affecting vision, co-existing blinding eye conditions such as glaucoma or retinal detachment and refusal or unable to provide informed consent.
Data collection procedure
Consecutive patients diagnosed with stroke and subsequently attending the weekly neurology outpatient clinic or on admission in the medical ward who met the inclusion criteria were recruited. Visual field assessment and neuroophthalmic evaluation were conducted and visual acuity was measured. The NEI VFQ-25 questionnaire was thereafter administered, and data were collected on biodata, visual history, results of ocular assessment and the NEI VFQ-25 QoL between 30 May 2018 and 28 August 2028.
Data analysis method
Data analysis was performed using the Statistical Package for the Social Sciences for Windows version 23.0. Univariate analyses were conducted in the form of tables, charts, frequencies, percentages, mean, range and standard deviation. Bivariate analyses were performed using the Chi-square for measuring relationships among categorical variables, while the student t-statistic was used to examine the magnitude of mean differences for continuous variables.
RESULTS
Demographic profile of participants
A total of 83 patients (166 eyes) with age range of 40–71 years and a mean (±standard deviation) age of 55.3 (±7.1) years were recruited. The age distribution showed that participants were predominantly older adults in a way that 47% were aged 51–60 years, 26.5% were 61–70 years, 22.9% were 41–50 years, 2.4% were ≤40 years, whereas only 1.2% were ≥70 years. In the study population, 49 (59.0%) were males while 34 (41.0%) were females leading to a male: female ratio of 1:0.7. Employment status showed that 56 (67.5%) of the patients were employed, 18 (21.7%) were retired workers, while 9 (10.8%) were housewives. Furthermore, 4 (4.8%) had no formal education, 16 (9.3%) had primary education, 23 (27.7%) had secondary education, while 40 (48.2%) patients had tertiary education [Table 1].
| Variables | No (%) | Mean (±standard deviation) |
|---|---|---|
| Age group | ||
| ≤40 | 2 (2.4) | 40.0±0.0 |
| 41-50 | 19 (22.9) | 46.1±2.7 |
| 51-60 | 39 (47.0) | 56.1±3.1 |
| 61-70 | 22 (26.5) | 62.9±2.2 |
| ≥70 | 1 (1.2) | 71.0±00 |
| Gender | ||
| Male | 49 (59.0) | - |
| Female | 34 (41.0) | - |
| Employment status | ||
| Employed | 56 (67.5) | - |
| Housewife | 9 (10.8) | - |
| Retired | 18 (21.7) | - |
| Educational level | ||
| Informal | 4 (4.8) | - |
| Primary | 16 (19.3) | - |
| Secondary | 23 (27.7) | - |
| Tertiary | 40 (48.2) | - |
Proportion of stroke survivors with ocular abnormalities
Ocular abnormalities were analysed on a per-eye basis; therefore, participants with bilateral involvement were counted under both right-eye and left-eye categories. Table 2 presents the results of ocular abnormalities in stroke survivors. The results indicated that ocular abnormalities were identified in 69 of the 83 stroke survivors, yielding a prevalence of 0.831. Right-eye abnormalities were present in 60 participants (72.3%), while left-eye abnormalities were observed in 58 participants (69.9%).
| Variables | Yes (%) | No (%) |
|---|---|---|
| Overall ocular abnormalities | 69 (83.1) | 14 (16.9) |
| Right eye ocular abnormalities | 60 (72.3) | 23 (27.7) |
| Left eye ocular abnormalities | 58 (69.9) | 25 (30.1) |
Vision-related QoL of stroke survivors
In the general health and vision segment with total maximum QoL score of 400, 80 (96.4%) of the patients had a high QoL while 3 (3.6%) had average QoL score. In the difficulty with activities part containing a maximum score of 1000, 74 (89.2%) of the respondents had high QoL, 7 (8.4%) of respondents had average QoL while 2 (2.4%) had low QoL. In the responses to vision problems with a maximum score of 900, 66 (79.5%) of responders had a high QoL, 14 (16.9%) had average scores while 3 (3.6%) had low QoL scores [ Figure 1]. In summary, a low percentage of patients had low QoL in the responses to the vision problems subsection and the difficulty with activities subsection.
- Responses to vision problems as a subsection of quality of life in patients.
Effect of ocular abnormalities on QoL
The results of ocular abnormalities on vision-related QoL of stroke survivors are presented in Tables 3-5. Only cataract (P = 0.000) and grade 3 hypertensive retinopathy (P = 0.039) which are due to age and risk factors (hypertension), respectively, were the ocular abnormalities with statistical significance with vision-related QoL of stroke survivors. Despite the relationship, a significant proportion of patients with high vision-related QoL had cataract and grade 3 hypertensive retinopathy. Visual field defects, ptosis and ocular motor paresis which are possible complications of stroke had no significant statistical relationship with vision-related QoL.
| Acuity | QoL | FEPV | ||
|---|---|---|---|---|
| Average (%) | High (%) | Total (%) | ||
| Visual acuity | ||||
| Normal/mild VI | 7 (9.5) | 67 (90.5) | 74 (100.0) | 0.000 |
| Moderate VI | 1 (16.7) | 5 (83.3) | 6 (100.0) | 0.219 |
| Severe VI | 1 (33.3) | 2 (66.7) | 3 (100.0) | 1.000 |
VI: Visual impairment. FEPV: Fisher’s exact probability value, QoL: Quality of life
| Variable | QoL | FEPV | ||
|---|---|---|---|---|
| Average (%) | High (%) | Total (%) | ||
| Ptosis | 0 (0.0) | 2 (100.0) | 2 (100.0) | 1.000 |
| Cornea anaesthesia | 1 (100.0) | 0 (0.0) | 1 (100.0) | 0.588 |
| Restricted ocular motility | 1 (33.3) | 2 (66.7) | 3 (100.0) | 1.000 |
| Relative afferent pupillary defect | 3 (60.0) | 2 (40.0) | 5 (100.0) | 1.000 |
| Cataract | 7 (12.3) | 50 (87.7) | 57 (100.0) | 0.000 |
| Abnormality | QoL | FEPV | ||
|---|---|---|---|---|
| Average (%) | High (%) | Total (%) | ||
| Posterior segments/visual field | ||||
| Age-related macular degeneration | 4 (33.3) | 8 (66.7) | 12 (100.0) | 0.388 |
| Glaucomatous optic atrophy | 0 (0.0) | 3 (100.0) | 3 (100.0) | 0.676 |
| Macular hole | 1 (50.0) | 1 (50.0) | 2 (100.0) | 1.000 |
| Hypertensive retinopathy (grade 1) | 0 (0.0) | 8 (100.0) | 8 (100.0) | 1.000 |
| Hypertensive retinopathy (grade 2) | 0 (0.0) | 21 (100.0) | 21 (100.0) | 0.788 |
| Hypertensive retinopathy (grade 3) | 1 (11.1) | 8 (88.9) | 9 (100.0) | 0.039 |
| Homonymous hemianopia | 2 (50.0) | 2 (50.0) | 4 (100.0) | 1.000 |
| Central scotoma | 0 (0.0) | 1 (100.0) | 1 (100.0) | 1.000 |
FEPV: Fisher’s exact probability value, QoL: Quality of life
DISCUSSION
This study examined the incidence of ocular abnormalities and their effects on vision-related QoL among stroke survivors who participated in the study. The findings highlighted a high burden of ocular abnormalities in the study population, yet most participants had relatively good vision-related QoL.
The observed ocular abnormality rates align with prior studies documenting frequent visual complications post-stroke. Disruption to visual pathways, ocular movement centres and cortical processing typically causes field defects, motility issues and acuity loss. Pre-existing conditions such as cataracts and hypertensive retinopathy possibly compound this morbidity. These findings suggest the necessity for routine ocular evaluations in stroke care, especially where visual complaints may go unreported due to resource constraints.
Despite prevalent ocular disorder, most participants scored high across NEI VFQ-25 domains. This finding contrasts with studies linking post-stroke visual impairment to poor QoL, most likely because many stroke-related deficits (ocular motor paresis, ptosis) resolve through neuroplasticity or spontaneous recovery before study enrolment. In addition, adaptive coping mechanisms possibly preserved functional independence.
Notably, stroke-related abnormalities such as visual field defects, ptosis and motility restriction showed no significant QoL association, indicating milder or compensated deficits have minimal functional impact consistent with findings emphasising deficit severity over mere presence.
In contrast, cataracts and grade 3 hypertensive retinopathy significantly impaired QoL due to their chronic, progressive, bilateral nature tied to ageing and vascular risks. This indicates that both stroke- and non-stroke-related ocular conditions are key QoL determinants.
Clinical implications: Integrating routine ophthalmic evaluation into post-stroke protocol can possibly lead to early detection and treatment of manageable ocular conditions. In addition, neurologist-ophthalmologist-rehabilitation team coordination could enhance patient outcomes.
CONCLUSION
This study reveals that ocular abnormalities are prevalent among stroke survivors who participated in the study; however, most participants reported relatively high vision-related QoL. The absence of a significant relationship between most stroke-related ocular abnormalities and QoL may stem from partial or complete resolution of visual deficits before study enrolment, coupled with adaptive strategies among survivors. In contrast, age- and vascular risk factor-related conditions such as cataracts and advanced hypertensive retinopathy showed strong associations with worse QoL. These findings highlight the importance of integrating early ophthalmic screening in post-stroke care to detect and treat both stroke-induced and pre-existing ocular conditions, potentially improving survivors’ QoL.
Ethical approval:
The research/study was approved by the Institutional Review Board at Federal Medical Centre, Lokoja, Ethical Review Committee, number FMCL|MED|115|Vol. II|294, dated 25 September 2017.
Declaration of patient consent:
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Conflicts of interest:
There are no conflicts of interest.
Use of artificial intelligence (AI)-assisted technology for manuscript preparation:
The authors confirm that there was no use of Artificial Intelligence (AI)-Assisted Technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.
Financial support and sponsorship: Nil.
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