seeing clearly with pd: vision changes · 3/5/2019 · seeing clearly with pd: vision changes dan...
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Seeing Clearly with PD:
Vision Changes
Dan Gold, DO
Assistant Professor of Neurology, Ophthalmology, Neurosurgery, Otolaryngology - Head and Neck Surgery, Emergency Medicine, The Johns Hopkins University School of Medicine
March 5, 2019
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1. Why Should I Care About Vision?
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Vision Is an Important Sense
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Vision Is an Important Sense
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Vision Is an Important Sense
![Page 6: Seeing Clearly with PD: Vision Changes · 3/5/2019 · Seeing Clearly with PD: Vision Changes Dan Gold, DO Assistant Professor of Neurology, Ophthalmology, Neurosurgery, Otolaryngology](https://reader034.vdocuments.us/reader034/viewer/2022042313/5edd5ddfad6a402d66686eb0/html5/thumbnails/6.jpg)
Vision Is an Important Sense
![Page 7: Seeing Clearly with PD: Vision Changes · 3/5/2019 · Seeing Clearly with PD: Vision Changes Dan Gold, DO Assistant Professor of Neurology, Ophthalmology, Neurosurgery, Otolaryngology](https://reader034.vdocuments.us/reader034/viewer/2022042313/5edd5ddfad6a402d66686eb0/html5/thumbnails/7.jpg)
How Does Vision Work?
RETINA
RETINA
RETINA
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How Does Vision Work?
OPTICNERVE
MACULA
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How Does Vision Work?
CHIASM
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How Does Vision Work?
OCCIPITAL LOBES
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2. What is a Neuro-ophthalmologist?
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What is Neuro-Ophthalmology?
OPHTHALMOLOGY
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What is Neuro-Ophthalmology?
NEUROLOGY
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What is Neuro-Ophthalmology?
NEU
RO
-O
PH
THA
LMO
LOG
Y
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What is Neuro-Ophthalmology?
1) Afferent
– Seeing
2) Efferent
– Moving the eyes to see
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What is Neuro-Ophthalmology?
1) Afferent
– Seeing
2) Efferent
– Moving the eyes to see
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Where is the Problem?
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3. What Visual Symptoms Should I Be Aware Of?
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Visual Symptoms are Common in PD
• 78% of patients report at least one visual symptom!
Archibald NK, Clarke MP, Mosimann UP, Burn DJ. Visual symptoms in Parkinson’s disease and Parkinson’s disease dementia. Mov Disord 2011; 26: 2387–95.
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PD and the Eye
Uncommon
– What we will not talk about today
• Blepharospasm
• Apraxia of eyelid opening
• Vertical eye movement limitations
• Other eye movement abnormalities
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PD and the Eye
Common
– What we will talk about today
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Common Visual Symptoms in PD
1) Central and color vision abnormalities
2) Blinking and ocular surface abnormalities
3) Eye movement abnormalities
4) Hallucinations
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A) Central and Color Vision Abnormalities
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SYMPTOMS of Central and Color
Abnormalities
• Blurriness
• Images aren’t clear
• Difficulty with vision in twilight hours or when raining
• Colors looked washed out/not as vibrant
• Vision “just isn’t the same”…
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DIAGNOSIS of visual symptoms?Neuro-ophthalmology exam
Visual acuity
– Near
– Distance
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DIAGNOSIS of visual symptoms?Neuro-ophthalmology exam
Contrast sensitivity
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Focusing the Brain on Better Vision, By Jan Hoffman April 6, 2015
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DIAGNOSIS of visual symptoms?Neuro-ophthalmology exam
Color vision
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Other Reported Abnormalities in PD
Visual processing
Peripheral vision
Object perception
Visuospatial construction
Motion perception
Face and emotion recognition
http://www.doctordisruption.com/design/principles-of-design-59-orientation-sensitivity/
Sun L, Zhang H, Gu Z, Cao M, Li D, Chan P. Stereopsis impairment is associated with decreased color perception and worse motor performance in Parkinson’s disease. Eur J Med Res 2014; 19: 29.
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Other Reported Abnormalities in PD
Visual processing
Peripheral vision
Object perception
Visuospatial construction
Motion perception
Face and emotion recognition
Sampaio J, Bobrowicz-Campos E, Andre R, Almeida I, Faria P, Januario C, et al. Specific impairment of visual spatial covert attention mechanisms in Parkinson’s disease. Neuropsychologia 2011; 49: 34–42.
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Other Reported Abnormalities in PD
Visual processing
Peripheral vision
Object perception
Visuospatial construction
Motion perception
Face and emotion recognition
Mosimann UP, Mather G, Wesnes KA, O’Brien JT, Burn DJ, McKeith IG. Visual perception in Parkinson disease dementia and dementia with Lewy bodies. Neurology 2004; 63: 2091–6.
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Other Reported Abnormalities in PD
Visual processing
Peripheral vision
Object perception
Visuospatial construction
Motion perception
Face and emotion recognition
Uc EY, Rizzo M, Anderson SW, Qian S, Rodnitzky RL, Dawson JD. Visual dysfunction in Parkinson disease without dementia. Neurology 2005; 65: 1907–13.
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Other Reported Abnormalities in PD
Visual processing
Peripheral vision
Object perception
Visuospatial construction
Motion perception
Face and emotion recognition
Trick GL, Kaskie B, Steinman SB. Visual impairment in Parkinson’s disease: deficits in orientation and motion discrimination. Optom Vis Sci 1994; 71: 242–5
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Other Reported Abnormalities in PD
Visual processing
Peripheral vision
Object perception
Visuospatial construction
Motion perception
Face and emotion recognition
Levin BE, Llabre MM, Reisman S, Weiner WJ, Sanchez-Ramos J, Singer C, et al. Visuospatial impairment in Parkinson’s disease. Neurology 1991; 41: 365–9.
http://www.bbc.com/future/story/20180510-why-our-facial-expressions-dont-reflect-our-feelings
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Visual Symptoms and Gait?
• Visual deficits are frequently associated with
postural instability
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TREATMENT
Deficits in visual acuity, contrast and color are at least
partly due to retinal dopamine deficiency– Corrected with dopamine?
Making sure that other treatable visual issues are
addressed
Each of these abnormalities are subtle/mild, but when they
occur in combination…
Rimona WS, et al. Visual dysfunction in Parkinson’s disease. Brain 2016 Jul 13 (epub ahead of print)
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B) Blinking and Ocular Surface Abnormalities
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Why Should We Care About The Ocular
Surface?
Optical clarity
Protective barrier
Decreased friction
Hydration
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Johnny L Gayton. Etiology, prevalence, and treatment of dry eye disease. Clinical Ophthalmology 2009.
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Why Do We Blink?
• Redistributes tear film uniformly
• Secretion of tears from tear glands
• When do we blink less?• Reading
• Computer work/television
• Driving
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Tamer C, Melek IM, Duman T. Tear film tests in Parkinson’s disease patients. Ophthalmology 112:1795–1800http://www.myvmc.com/diseases/dry-eye-syndrome-keratoconjunctivitis-sicca/
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SYMPTOMS of Ocular Surface Irritation
• Dry eyes
• Gritty/sandy sensation
• Burning
• Redness
• Crusting on the lashes
• Eyes getting stuck shut in the morning
• Sensitivity to light
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Tamer C, Melek IM, Duman T. Tear film tests in Parkinson’s disease patients. Ophthalmology 112:1795–1800
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Ocular Surface and Blinking in PD
Ocular surface
– Poor tear production
Blinking
– Reduced
Result:
– Poor tear film, dry eye and irritation
Medications?
– Artane (trihexane trihexyphenidyl)
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DIAGNOSIS
Thorough evaluation by an ophthalmologist or optometrist
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TREATMENT
Artificial tears
– 3-4 times/day + more as needed
Prescription medications
Inflammation of the eyelids (blepharitis)
– Hot compresses or lid scrubs
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C) Eye Movement Abnormalities
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DOUBLE VISION
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DIAGNOSIS of Diplopia
1) Monocular (non-
neurologic)
L R
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DIAGNOSIS of Diplopia
1) Monocular (non-
neurologic)
L R
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DIAGNOSIS of Diplopia
1) Monocular double vision in the left eye
(NOT NEUROLOGIC)
– Send to eye doc
L R
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DIAGNOSIS of Diplopia
2) Binocular (neurologic)
L R
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DIAGNOSIS of Diplopia
2) Binocular (neurologic)
L RL R
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DIAGNOSIS of Diplopia
2) Binocular (neurologic)• Eyes misaligned → neuro-ophthalmology
L RL R
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TREATMENT of Diplopia
Acutely
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TREATMENT of Diplopia
Subacute-chronic (press-on or ground in)
http://www.theblaze.com/stories/2013/01/25/the-medical-issue-that-closeup-pictures-of-hillarys-glass-may-reveal/
Strabismus surgery (unusual in PD)
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CONVERGENCE INSUFFICIENCY
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SYMPTOMS of Convergence
Insufficiency
Double vision
Headaches
Eye strain
Blurred vision
Loss of place while reading
– Excessive tiredness while reading
– Covering of one eye while reading
– Complaints of the words moving on the page
– Short attention span for reading
– Constant adjusting of the distance of a book or other to see better
Nowacka B, Lubinski W, Honczarenko K, Potemkowski A, Safranow K. Ophthalmological features of Parkinson disease. Med SciMonit 2014; 20: 2243–9
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Convergence Insufficiency
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L L RR
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Convergence Insufficiency
Near point of convergence
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L RL R
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DIAGNOSIS of Convergence
Insufficiency
• Eye movement examination performed by neurologist,
ophthalmologist, or neuro-ophthalmologist
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TREATMENT of Convergence
Insufficiency
Home exercises
– “Pencil push-ups”
Therapy or computer exercises
– Vision therapy
Covering one eye, or putting Scotch tape or satin gift tape
over one lens
Prisms placed in reading glasses ONLY
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D) Hallucinations
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Hallucinations
In Parkinson’s disease patients, associated with:
– Daytime somnolence or insomnia
– Moderate-severe cognitive issues
– Longer duration of PD
– Associated with reduced acuity
What about medications?
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Archibald NK, Clarke MP, Mosimann UP, Burn DJ. Visual symptoms in Parkinson’s disease and Parkinson’s disease dementia. Mov Disord 2011; 26: 2387–95.
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PD Medications
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Passage Hallucinations
Objects, commonly insects and small animals in the
periphery
McDowell SA, Harris JP. Visual problems in Parkinson’s disease: a questionnaire survey. Behav Neurol 1997b; 10: 77–81.
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Illusions
• Again related to peripheral visual perception?
McDowell SA, Harris JP. Visual problems in Parkinson’s disease: a questionnaire survey. Behav Neurol 1997b; 10: 77–81.
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Complex Hallucinations
Usually animate objects
Often in center of vision in dim lighting
Ffytche DH, Howard RJ. The perceptual consequences of visual loss: ‘positive’ pathologies of vision. Brain 1999; 122 (Pt 7): 1247–60.https://explorecuriocity.org/Explore/ArticleId/188/why-is-it-that-light-reflects-off-of-animal-eyes-at-night-but-not-humans-188.aspx
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TREATMENT of Visual Hallucinations
If mild with preserved insight
– Reassurance
– Evaluate/remove certain medications
If moderate to severe or bothersome
– Evaluate/remove certain medications
– Certain neuroleptic medications
• Pimavanserin (Nuplazid)
– First drug approved to treat hallucinations and delusions in PD
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CONCLUSIONS
• Dopamine is present in the visual system, and lack of dopamine contributes to visual complaints in PD
• The eyelids and ocular surface protect the eye and optimize the clarity of what we see
• Convergence insufficiency is a common eye movement abnormality seen in PD
• Many of these abnormalities are relatively mild, but in combination…
• The earlier symptoms are addressed, the earlier treatment can be initiated and quality of life improved
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Register Today for ATTP!
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Resources
Fact Sheets and Publications
Get the resources and information you need to start living a better life with Parkinson’s.
Available at 1-800-4PD-INFO or [email protected] Friday 9 am to 8 pm ET
National Helpline Podcast: Substantial Matters
New episodes every other Tuesday featuring Parkinson’s experts highlighting treatments, techniques and research.Parkinson.org/Podcast
Includes tools and information for people with PD to share with hospital staff during a planned or emergency hospital stay. Parkinson.org/Awareincare
Aware in Care Kit