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Working with Hemianopia After a Stroke or Brain Injury: Low-Cost Workplace Adjustments and Practical Support

/ Employment, Eye Health, Sight Loss Awareness / By

An employee returns after a stroke. Their speech is clear, they walk well and their eyesight test is fine. A few weeks in, colleagues notice that they clip door frames, miss people approaching from one side, and take much longer over documents than they used to. Nobody has connected this to the stroke, and the employee may not have connected it either.

That is a common picture with homonymous hemianopia and other visual field loss. The eyes themselves are usually healthy, so the difficulty is easy to miss, and it is easy to misread as carelessness, slowness or lack of confidence. This article sets out what the condition is, how it tends to show up at work, which adjustments cost little or nothing, and what occupational health, HR and case managers can do to make a return to work assessment more useful.

A calm, well-lit desk by a window with a large indoor plant

About hemianopia and visual field loss

Hemianopia means loss of half of the visual field. In homonymous hemianopia the loss falls on the same side in both eyes, so a person loses the left or right half of what they would normally see. It can be complete, partial, or limited to a quarter of the field (quadrantanopia). Fight for Sight, in a page last updated in March 2023 and approved by Professor Fiona Rowe, describes stroke as the most common cause, followed by trauma and tumours. The British and Irish Orthoptic Society explains that the loss arises in the brain’s visual pathway rather than in the eyes, and that people can often bring the missing side into view by moving their head and eyes.

Figures vary by source and population. Fight for Sight cites about 30% of stroke survivors experiencing hemianopia. The Stroke Association says almost two thirds of people have some kind of vision problem after a stroke, which covers a wider range than field loss. Recovery is also reported differently. The orthoptic society leaflet (July 2021) says about half of people with field loss after stroke improve, usually within three to six months, and that loss persisting beyond that may be permanent, although people often feel their sight improves as they adapt. Fight for Sight reports that only around 15% fully recover their vision in the weeks after a stroke. These are not necessarily in conflict, since improving and fully recovering are different things, but nobody should plan around an assumption of recovery. Individual outlook is a matter for the treating clinicians.

It helps to understand how this differs from visual neglect, and to be careful with the distinction. Field loss is a loss of what the eyes and visual pathway can register. The Stroke Association defines visual neglect as the inability to notice things to one side, and Headway describes it as more a problem of attention than of vision, where the person can see that side if reminded to look. The two can occur together, and some people are not aware of their field loss at all. Telling them apart is a clinical task for orthoptists, neurologists and therapists, not something a manager or assessor should attempt to judge. The practical point is that prompts and strategies that work for one may not work as well for the other.

How hemianopia can affect work

Reading is often the first thing people notice. The orthoptic society leaflet explains that with loss on the left, finding the start of a line becomes hard, while with loss on the right it becomes hard to track along a line and keep one’s place. Norfolk and Norwich University Hospitals’ patient leaflet likewise notes that words at the beginning or end of a line may be missed. In an office, this shows up as slower reading of emails, spreadsheets and contracts, skipped columns and missed words that change the meaning of a sentence.

Mobility and spatial awareness come next. The orthoptic society lists bumping into objects, tripping, difficulty in crowds and being startled by sudden movement from the affected side. In a workplace that means narrow corridors, busy open plan floors, shared kitchens, canteens and stairwells. Colleagues who approach unannounced from the affected side can be an unexpected source of stress.

Fatigue sits behind all of this. Scanning to compensate for the missing field takes deliberate effort that was previously automatic, and many people also experience general post-stroke tiredness. The Stroke Association’s return to work guidance suggests more frequent breaks, a phased return and possibly a later start where mornings are hardest. Headway also notes that some people report blurred vision when tired.

Driving needs a plain mention because it affects commuting and any role that includes travel. The DVLA’s guidance for medical professionals on GOV.UK says homonymous or bitemporal defects that come close to fixation are not usually acceptable for driving, and that drivers must notify the DVLA. A limited exception route exists for some Group 1 drivers whose defect has been present for at least 12 months and is non-progressive, but each case is considered individually. Employees should check the current rules directly with the DVLA and their clinicians, and employers should not assume a licence position either way. This is a reason to think early about alternative travel arrangements, not a reason to judge anyone’s capability.

None of this makes a person unsafe or unable to work. Many people with hemianopia return to demanding roles. What changes is how the job, the space and the information are set up.

No-cost and low-cost workplace adjustments

The table below sets out suggestions that are commonly proportionate. What suits one person may not suit another, particularly depending on which side is affected and whether neglect is also present.

Area Suggested adjustment Why it helps
Desk position Position the desk so that the main approach, door and colleagues are on the seeing side, and keep the affected side against a wall or partition where practical. Reduces surprise approaches and allows more of the workspace to be seen without extra scanning.
Reading documents Provide a line guide or card with a cut-out window, and a coloured marker at the start of each line or the edge of the page. Helps the eyes find the start of a line and keep their place, which the orthoptic society identifies as the main reading difficulty.
Screen set-up Increase text size, use a single column layout where possible, and place key information within the central area of the screen. Reduces the distance the eyes must travel and the chance of missing content at the edges.
Email and documents Use plain layouts, clear headings and short lines. Avoid wide tables where an alternative exists. Content at the screen edge or the end of long rows is easier to miss.
Walkways and layout Keep corridors, floors and the immediate desk area clear of trailing cables, bags and boxes. Avoid rearranging shared spaces without warning. Cuts the risk of collisions and trips and spares effort in familiar spaces.
Colleague approach Agree that colleagues will announce themselves and approach from the seeing side. Prevents startle and avoids missed greetings or handovers.
Workload and hours Plan a phased return, scheduled short breaks and, where the role allows, some home working or a later start. Addresses fatigue, which affects concentration and scanning accuracy.
Time allowances Allow extra time for reading-heavy tasks in the early weeks, and review expectations as the person adapts. Avoids the person being judged on pre-stroke speeds while they learn new strategies.
Training and appointments Allow time for orthoptic, therapy or rehabilitation appointments and for practising scanning strategies. Gives clinicians’ recommendations a realistic chance of becoming habit.

What this means for occupational health, HR and case managers

Hemianopia is frequently under-described in referrals. A referral that says the person “had a stroke and has some vision problems” does not tell an assessor whether the loss is left or right, complete or partial, whether neglect has been identified, or whether the person has had orthoptic input. Where the employee consents, it is worth including the visual field result from the clinic, any advice already given by an orthoptist, occupational therapist or stroke team, and the DVLA position. Those facts shape every practical recommendation that follows.

A return to work assessment is most useful when it is built around the real tasks and spaces the person will face: the route in, the desk, the screens, the documents they read, the meetings they attend and how they get about. A specialist visual impairment workplace assessment can turn that into specific, proportionate recommendations that sit alongside occupational health advice, rehabilitation input and any vocational rehabilitation plan, rather than replacing any of them. Visualise assessments are practical and non-clinical, and they do not diagnose or comment on fitness for work.

The NICE guideline on stroke rehabilitation in adults (NG236, published 18 October 2023) is the national reference for multidisciplinary rehabilitation, though no specific recommendation here relies on it. Return to work after stroke is rarely a single event. The Stroke Association describes a phased return with regular reviews, a plan covering which tasks the person can do now and which they may build up to, and involvement of occupational health or vocational rehabilitation. A report that anticipates change is more helpful than one that fixes the position at week one.

Hints and tips for the individual

  • Tell your manager which side is affected and ask colleagues to approach and speak from your seeing side.

  • Use a line guide, card window or coloured marker when reading, and tell your assessor what has helped so far.

  • Turn your head deliberately towards the affected side when entering a room or crossing a busy area. Ask your orthoptist or therapist about scanning strategies suited to you.

  • Plan breaks before you are tired, and do the most reading-heavy tasks when you are freshest.

  • Keep a short note of situations that cause difficulty, to take to your manager, occupational health and your clinical team.

  • Choose who is told what. It is your decision how much to share with colleagues.

Building awareness and communication

A short, practical conversation with the team usually does more good than a long briefing. Colleagues need to know very little: where to stand, to say who they are when they approach, to keep walkways clear and to put items such as drinks and handouts on the seeing side. The employee should decide how much more is said.

A good opening for managers is to ask what is working and what is not, rather than what the person can or cannot do. It is worth acknowledging that the person may look completely well, and that a slower start with documents is not a performance issue.

Scanning strategies and compensatory training are something orthoptists and other clinicians may offer. The orthoptic society leaflet describes visual search strategies that train people to use more head movements and quick eye movements into the missing side, with exercises and sometimes computer programmes. Prisms, which shift part of the image, may also be discussed. The leaflet is clear that these do not cure the loss, but aim to speed adaptation. The Cochrane review by Pollock and colleagues (2019) rated the evidence for scanning training, prisms and restorative approaches as low or very low certainty, and said firm recommendations could not be made for most of them. Fight for Sight also notes that NHS provision is inconsistent, partly because it is unclear what works best and when to start. Employers should therefore not expect any particular programme, and should simply make room for whatever the clinical team recommends.

Legal rights and support

Under the Equality Act 2010, a person is disabled where they have an impairment with a substantial and long-term adverse effect on their ability to carry out normal day-to-day activities. Where the definition is met, the employer must make reasonable adjustments. Schedule 1, paragraph 5 of the Act provides that the effect of treatment or aids is generally ignored when deciding whether an effect is substantial, with ordinary glasses and contact lenses taken into account. Paragraph 8 can treat a person with a progressive condition as meeting the test before the effect becomes substantial, if it is likely to do so. For some people, certification as sight impaired or severely sight impaired by a consultant ophthalmologist also brings deemed disability under regulation 7 of the Equality Act 2010 (Disability) Regulations 2010. Whether the definition is met for a particular person depends on their circumstances, and this article is general information rather than legal advice.

Access to Work, run by the government, can help eligible people with costs such as specialist equipment, support workers and travel to work where public transport is not possible, according to GOV.UK. It does not pay for adjustments an employer is legally required to make, although it can advise on them. The GOV.UK page does not say whether the scheme applies in the same way in Northern Ireland, so anyone there should check locally. The Stroke Association also describes an employer-funded workplace needs assessment as one route, and points to occupational health and vocational rehabilitation support.

Summary

Hemianopia is often invisible to colleagues and, at first, to the person themselves. The sensible response is to find out which side and how much, set up the desk, the screen, the documents and the walkways around that, and expect fatigue to ease slowly. Most of the useful changes cost little. What matters is that they are chosen for the real job, reviewed as the person adapts, and supported by clear information from the clinical team.

Frequently Asked Questions

Hemianopia is a loss of half of the visual field, caused by damage to the brain's visual pathway. Visual neglect is difficulty noticing things on one side, which Headway describes as more a problem of attention than of vision. They can occur together, and a clinician needs to tell them apart.

Many people do, often with a phased return and some adjustments. Whether a particular person can do a particular role is for them and their clinicians and employer to determine, and this article does not offer a view on fitness for work.

The DVLA's guidance on GOV.UK says that homonymous field defects close to fixation are not usually acceptable for driving, and that drivers must notify the DVLA. A narrow exception route exists for some Group 1 drivers. The current rules should be checked directly with the DVLA.

Not exactly. A return to work assessment looks at the wider picture of a person's return, which may include health, hours and duties. A visual impairment workplace assessment focuses on how vision affects the person's actual tasks and environment, and recommends practical adjustments to support them.

If you or someone in your team is visually impaired and would like expert, tailored support to stay productive and comfortable at work, you can arrange a visual impairment workplace assessment with us.

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