At last week’s atypical parkinsonsim support group meeting at UC Irvine, a neuro-ophthalmologist spoke about eye problems in parkinsonism. The talk wasn’t specific to PSP, CBD, or MSA. Vera James is the facilitator of this PSP/CBD/MSA support group. Here are Vera’s notes, which she posted to one of the MSA-related online support groups last week.
Orange County Atypical PD+ Support Group (PSP, CBD, MSA)
UC Irvine
Meeting date: Wed, Jan 6, 2010
Notes by: Vera James, support group leader [with a few grammatical fixes by Robin]
Guest speaker: Swaraj Bose, MD, a neuro-ophthalmologist at the Gavin Herbert Eye Institute, UCI
His main reason for speaking with us was to give us a fair idea of the eye problems and why do the eyes behave in the way they do in Parkinson’s/PSP/Atypical Parkinson’s and what the caregiver can do.
The eye movement comes from the brain (head computer). We have two eyeballs that are in an orbit/socket. Each eye has 6 muscle that moves the eye left to right or up and down for the visual field. The vision comes from the back of the brain at the cortex, the middle brain, neurons of the pons. These nerve cells and area are what causes the problems.
Dr. Bose gave us a handout called “The Eye in PSP/Atypical Parkinson’s.” The information will all be in this message along with some notes I made when he made remark about some of the common things in Parkinson’s/ PSP/Atypical Parkinson’s. Some information is vision problems in PSP like the down-gaze that is common with PSP patients but some suggestion you may find will help the MSA patients also. I am also putting those in because we know that some patients may be misdiagnosef and may have these same eye issues.
Common eye complaints:
#1 – Related to disturbance of down-gaze PSP.
– Difficulty in coordinating eye movements while reading even if their vision is normal, especially through their bifocal glasses.
– Difficulty in eating because they cannot look down at their food on the plate.
– Difficulty in going downstairs and stepping off curbs.
#2 – Related to lack of convergence/fast and slow tracking- Parkinson/PSP/Atypical PD.
(Note: Convergence means to bring the eyes together)
– Difficulty in focusing, words run into each other.
– Hard to shift down to the beginning of the next line automatically after reaching the end of the first line.
– Inability to quickly move eyes up or down.
– Inability to track moving objects or maintain eye contact.
Dr. Bose said that most patients with any of these illnesses will have problems maintaining eye contact, and in tracking objects. He said this is where the problem comes in with driving and the reason that a patient shouldn’t be driving. He gave an example saying that if you are driving and a child run out in front of you 150 ft away, you will catch them going the one way, but with the slow tracking the eyes are doing, the child could be back in front of you before your tracking would get the eyes to the other side to view where the child would be. By then you could have hit the child.
– Double vision.
One eye sees one thing, the other eye sees another and the brain brings them together. Kind of the way 3D glasses do. When you have double vision, the brain isn’t bringing the eyes together to get the one vision.
#3 – Related to vision disturbances-Parkinson/PSP/Atypical PD.
– Difficulty in focusing/blurry vision/visual hallucinations.
Visual hallucinations can be in all of these illness. Some visual hallucinations can be from to much medication, but it can also be from a lack of dopamine in the cortex where the signal is fallen and gives false images and causes these visual hallucinations also. So not all visual hallucinations are psychotic. Other things that can also cause visual hallucinations are benadryl and OTC cold meds. They can also cause spasm.
– Changes of reading glasses at a quicker intervals.
– Decreased in contrast sensitivity (difficulty in distinguishing shades of gray) and color perception.
#4 – Eyelid abnormality
– Difficulty in voluntarily opening their eyes (apraxia)
– Forceful eyelid closing (blepharospasm). This is treated with botox.
– Decrease in the rate of blinking (3-4/min vs. 20/min)
#5 – Dry eyes
– Burning sensation, redness, watering, itching, excessive tearing, rubbing of eyes, blurry vision.
– Double vision with one eye. Usually results in ‘ghosting’ of images or shadowing of images.
Treatment — A multi-disciplinary approach:
Diagnosis of the movement disorder is important. This will determine the course, manifestations and outcome.
Communication with neurologist, neuro-ophthalmologist, rehabilitation personnel, nurses, therapists, care giver, neuro-psychiatrists amd primary care physicians is VITAL.
Record a thorough history.
Set realistic goals.
A thorough eye examination should include:
– Best correction for distance/near vision
– Color vision
– Visual field examination
– Detailed record of eye movements in all directions
– Prism measurement and correction. Prism lenses or prism overlays take some getting used to.
– Evaluation of eye surface including dry eyes
– Eyelid evaluation
– Convergence estimation.
– Retina and optic nerve evaluation
– Prescribe glasses for distance and near
– Optimize eye movement problems by exercises, prisms and rehabilitation
– Treat dry eyes and other associated eye conditions
Alter/Redesign equipment for reading (lighting, position), position of book and food (at eye level), devices/support for walking and stepping down stairs to prevent falls (safety).
Take medication regularly and watch for side effects.
Living and seeing well:
Safety begins at home:
– Rooms/hallways free of clutter
– Remove cords/rugs from floor
– All rooms well lit, night lights along hallways
– Install grab bars in shower, stairs to prevent falls
– Cane, walker, wheel chair
Proper reading lights (from left and behind)
Reading material (books/newspapers) at eye level. Use a piano reading stand.
Place food at patient’s eye level, raise table, small platform. Suggestion: bed or TV tray placed on the table to raise the plate higher for the PSP patient to view food. This would also be helpful for all patients who are still feeding themselves so they don’t have to work as hard to bring the food up to their mouths.
Get correct glasses prescription filled
Use separate glasses for reading and distance
Use lubricating eye drops like Systane or Refresh during the day and a gel (Genteal gel ointment) at bed time.
Regular eye exercises (when prescribed). Body and breathing exercises.
Take medications regularly
Visual hallucinations can be a side effect of medications or a lack of dopamine in the cortex.
Driving can be tricky. Speak with your eye doctor.
Keep yourself engaged with some creative activities/projects
Regular follow-up with neurologist and neuro-ophthalmologist
Join a support group
Summary:
* Visual disturbances and eye changes including problems with eye movements are commonly seen in patients with Parkinson’s/PSP/Atypical Parkinson’s
* Visual complaints are usually distortion or blurry vision, near vision problems, color vision abnormalities and even visual hallucinations
* Eye movement abnormalities include difficulty in convergence (bringing the eyes together while reading), lack of vertical movement of eyes (upward/downward gaze abnormality) and eye movement asymmetry
* Other problems include a decrease in blinking of eyelids, difficulty in opening the eyelids, dry eyes and lack of facial expression
* These eye conditions, if diagnosed early in the course of the disease, can be treated and managed by an ophthalmologist or a neuro-ophthalmologist
* Simple measures used in visual rehabilitation and medications given by the movement disorders neurologist and supportive care can significantly alter the quality of life of patients with these conditions.