parkinson's disease and the eye
DESCRIPTION
This is a talk about how Parkinson's disease affects the eyes given by Dr. Jody Abrams, neuro-ophthalmologist, Sarasota Retina Institute.TRANSCRIPT
Eye Problems With Parkinson's
Jody Abrams, MD
Neuro-Ophthalmology/Oculoplastics
Sarasota Retina Institute
What is a Neuro-Ophthalmologist
A neuro-ophthalmologist is either a neurologist or ophthalmologist who has spent a year or more after normal residency to learn more about the eye and brain interactions
This includes eye muscle problems, optic nerve problems, blurred vision that is not explained by normal causes, and in, or between the eye and brain
Parkinson’s Disease and The Eye
There are many eye problems that can be seen in Parkinson's patients
These can vary from issues like dry eyes, to spasm of the eyelids to visual distortions
While most are not sight threatening like macular degeneration they can be just as debilitating if not addressed
Parkinson’s Disease and The Eye
• Blepharospasms are when the muscles around the eyes contract
• These muscles are responsible for closing the eye so when they contract the eyes squeeze shut
• The eyes look like they are blinking with a lot of force
Parkinson’s Disease and The Eye
As you can imagine this can be very irritating
The patients have hard time reading or watching TV and even doing a basic eye exam can be difficult (like following glaucoma pressures)
The good news is that this condition has a nice and proven treatmentBOTOX
Parkinson’s Disease and The Eye
Botox or botulinum toxin A has been around since the late 1970s
It was brought to medical use by an ophthalmologist, Dr. Alan Scott, to use on patients with spasms of the face/eyelids and for eyes that cross
Parkinson’s Disease and The Eye
It was in the early 90s that a dermatologist and ophthalmologist couple noticed that their patients treated with Botox had improvement of their wrinkles
This was published and the legend of cosmetic Botox was born
Today Botox for spasms is still the preferred treatment and is covered by most insurance plans
Parkinson’s Disease and The Eye
Botox works by stopping the nerve from telling the muscle to contract
This effect lasts about 3-4 months
Prior to the use of Botox, blepharospams were treated with a very disfiguring extensive eyelid surgery
Parkinson’s Disease and The Eye
The injections are done around the lower and upper eyelids
Injections are also given between the eyebrows
Parkinson’s Disease and The Eye
The injections are done in the office, often in the same exam chair we see you in
The needle is a very tiny needleMost patients report minimal, if any pain
Parkinson’s Disease and The Eye
Parkinson’s Disease and The Eye
Other issues that occur in patients’ eyelids with Parkinson's is ptosis or droopy eyelids
Is this from the disease, or from aging, is a question that can be debated, but often the two are seen together
Often times with care, patients with Parkinson’s disease can undergo lid surgery with good outcome
Parkinson’s Disease and The Eye
The main goal of these procedures is not to make the patient look better, but to help the patient see better
This is why it is covered by most medical plans including Medicare
This is a functional not cosmetic surgery
Parkinson’s Disease and The Eye
Just below the eyelid the next layer of the eye is the tear film
Parkinson’s Disease and The Eye
The tear film is often overlooked but is a critical layer for the health of the eye and for good vision
The first layer that light hits when entering the eye is the tear film. If this is defective, the light is scattered and the vision will be blurred
This can be the reason that despite multiple glasses the vision is still blurred
Parkinson’s Disease and The Eye
The tear film is made up of three layersThe front oil layer prevents evaporationThe middle water layer hydrates the eyeThe inner mucus layer (against the cornea) coats the eye
Parkinson’s Disease and The Eye
The tears are spread across the eye by eyelid blinking
The average blinking rate is around 10 blinks a minute
In patients with Parkinson’s disease there is a decreased blink rateThis has even been called a PARKINSON'S STARE since the
rate can be severely decreased
Parkinson’s Disease and The Eye
When the blink rate is decreased it allows more evaporation to occur so the tear film breaks down
There is often a decreased tear film to start with (secondary to age and medications) so coupled with a decreased blink rate, the eye can become very dry!
Parkinson’s Disease and The Eye
What are symptoms of dry eyesDecreased visionBurning eyes Stinging eyesRed eyesWatery eyesGritty feeling eyesEven double vision
Parkinson’s Disease and The Eye
There are multiple ways to test for dry eyes Schirmer’s test
Fluorescein Staining
Parkinson’s Disease and The Eye
Lissamine Green (My favorite and trademark look)
There are some new machines out that can test the tears and tell us about their makeup, how useful this information is, still is in debate
Parkinson’s Disease and The EyeOnce dry eyes are diagnosed there are multiple ways to
treat it and often they are used in combinations
We usually start with the most simple treatment and increase as needed
Also drink water!
Parkinson’s Disease and The Eye
The first step is often using artificial tearsThere are multiple kinds of artificial tears and I tell
patients to try different ones to see which works best for them
Parkinson’s Disease and The Eye
Normal preserved artificial tears can be used up to 5 times a day
If you need to use the tears more often, I recommend using nonpreserved artificial tears
Parkinson’s Disease and The Eye
Some patients have trouble getting eye drops into their eyes and often waste medication
Luckily there is a spray artificial tear drop
Parkinson’s Disease and The Eye
If artificial tears are not working I often place plugs in the tear ducts
The tear ducts are the drain for the tears, not the producer (this is the lacrimal gland)
Parkinson’s Disease and The Eye
The plugs go into the tear ducts and slow the tears from leaving the eye so rapidly, like a sponge down the drain of your sink
I usually place collagen plugs that dissolve in about 4-6 months
Parkinson’s Disease and The EyeIf plugs and or tears do not help there are other
medications Restasis Steroid Eye dropsNSAIDs (ibuprofen for the eye) Fish oil (omega 3)
Parkinson’s Disease and The Eye
If medical therapy does not work there are some surgical procedures that can help
These mainly involve tightening the lid or raising the lower lid to better cover the eye
Parkinson’s Disease and The Eye
Double vision can be a very bothersome problem in Parkinson's patients
True double vision is when the eyes are not focusing on the same object and the brain sees two separate images
This can be very disturbing
Parkinson’s Disease and The Eye
Double vision that resolves with one eye closed is called true or neurologic double vision and is due to a misalignment of the eyes
If the double vision is still present with only one eye open this is often due to a problem of the tear film, cornea or cataract
Parkinson’s Disease and The Eye
True double vision can be from a eye muscle weakness or from the brain having trouble lining up the 2 eyes
If there is a muscle weakness, the double vision is often worse when looking towards that muscle, and better if you look the other way
Parkinson’s Disease and The Eye
One of the most common causes of double vision in Parkinson's patients is convergence insufficiency
People often complain of difficulty reading and seeing objects at near
They can also notice blurred vision even at distance
Parkinson’s Disease and The Eye
Convergence insufficiency is when the the eyes do not converge or turn in together
For us to see clearly at near the eyes have to turn in slightly to focus
In convergence insufficiency the eyes stay rotated out and the eyes do not focus together giving double vision
Parkinson’s Disease and The Eye
While convergence insufficiency can occur in many settings we often see it in our Parkinson's population, and people after concussions/closed head injuries
It is not known why convergence insufficiency is so common in Parkinson's patients because we are not sure exactly where in the brain the control for it occurs
Parkinson’s Disease and The Eye
Often times we can treat convergence insufficiency with an exercise called “pencil pushups”
This is an easy exercise that can be done anywhere without breaking a sweat
Parkinson’s Disease and The Eye
If this does not work we can add prisms to the glasses for near
I often find that Parkinson's patients do better with a pair of glasses for near and another for distance
No line bifocals often cause problems for patients with Parkinson’s disease
Parkinson’s Disease and The Eye
Prisms, Botox, or even surgery can be used to resolve double vision if the cause is a specific muscle weakness
That is why it is important to get a good measurement of the deviation of the eyes
Parkinson’s Disease and The Eye
Other eye motility problems can occur in Parkinson's that can cause visual distortion and even problems with mobility
Nystagmus is a rapid repetitive involuntary movement in the eye
This constant motion of the eyes can cause problems reading since you can not follow the lines or focus on words
Parkinson’s Disease and The Eye
Nystagmus can be from medications or just changes in the brain
If a medication is causing it, we try to remove or reduce the amount of medication
If it is from changes in the brain, medications can be used to help reduce the movement
Parkinson’s Disease and The Eye
Parkinson's patients can often have problems with just normal movements of their eyes
It can lead to difficulty following objects or people, especially in crowded situations (or even following the golf ball)
If this is caused from a medication we try to limit or eliminate the medication
Parkinson’s Disease and The Eye
Just recently we had a very lucky addition to the ability to help our patients with vision problems such as alignment of the eyes
Cindy Anderson here at SMH has started an outpatient vision rehab program
Parkinson’s Disease and The Eye
She can now offer multiple areas of treatment for our patients that can dramatically improve the movement of their eyes and the brain’s ability to perceive it
Prior to her starting this program we were limited in what we could offer patients, now there is multiple areas of hope
Parkinson’s Disease and The Eye
Cataracts are not a direct effect of Parkinson’s disease but can have accelerated formation with medications and form just from natural aging
Cataracts are a clouding of the natural lens in the eye
Parkinson’s Disease and The Eye
When cataracts cause blurred vision that is not correctable with glasses it is time to talk about cataract surgery
Cataract surgery is the most common elective surgery done today in the United States
Parkinson’s Disease and The Eye
Cataract surgery is done as an outpatient surgery, and can be done with minimal anesthesia
Parkinson’s Disease and The Eye
In cataract surgery the natural lens is removed with an ultra sound machine that breaks the lens up and sucks it out all at the same time
Despite what is advertised, there is no true laser cataract surgery, all techniques use the ultra sound to break the lens up and remove it
Parkinson’s Disease and The Eye
Once the cataract material is removed, an artificial lens is placed into the eye to help the patient see clearly
Parkinson’s Disease and The Eye
One of the big areas in cataract surgery today is the new lenses that offer patients the ability to see near and far without the use of glasses
While this might be a good option for some people, I recommend not pursuing this in patients with neurologic disease, especially Parkinson's
Parkinson’s Disease and The Eye
Visual hallucinations can occur as frequent as 1 in 5 patients, with the number even higher if including those with just non-bothersome illusions
These visual hallucinations (or false images) are often nonthreatening in nature, such as small people or animals or loved ones who have died
Threatening visual hallucinations are less common
Parkinson’s Disease and The Eye
The cause of these hallucinations is related to the increased levels of dopamine, as is created with Parkinson's medications
Sleep disturbances and or stress increase the risk of visual hallucinations
Also medications such as sedatives, sleeping medication, pain meds and some urinary medications can cause increased visual hallucinations
Parkinson’s Disease and The EyeSome of the treatments to help include
Reducing or changing the Parkinson's medication Antipsychotic medications, either Seroquel or Clonazapine
Others are not recommended as they can worsen movement problems
Making sure there are no other contributing medical conditions Like an underlying infection, possibly a urinary tract infection
Improving sleep and stress
Parkinson’s Disease and The Eye
An important issue to remember through all of this is while Parkinson’s disease can cause multiple ocular issues, there are other problems that need to be watched for also
Parkinson’s Disease and The Eye
Glaucoma is a disease of the optic nerve of the eye that causes loss of the nerves
It is related to increased eye pressure
Glaucoma can cause slow permanent vision loss and needs to be detected early
Parkinson’s Disease and The Eye
In years past glaucoma was followed by testing the peripheral fields with a visual field machine
Parkinson’s Disease and The Eye
In patients with Parkinson’s disease these can be hard test to do reliably
There is an older manual machine that can be easier for patients to follow the glaucoma
A new technology is called OCT can follow the actual nerve tissue thickness and help follow progression of the disease
Parkinson’s Disease and The Eye
Parkinson’s Disease and The Eye
Macular degeneration is a leading cause of blindness in patients over 60
This is from a breakdown on the layers of the retina
There are two typesWet Dry
Parkinson’s Disease and The Eye
There are now injections avaliable to treat the wet macular degeneration
The dry type all we can offer are vitamins
Parkinson’s Disease and The Eye
Are there any questions?