Neuro-Ophthalmology in Parkinson's Care - PMD Alliance

Trouble reading? Double vision? Dry eyes?

You are not alone. Many people with Parkinson’s report complications with their vision, and we are here to help you see that there is hope in the form of neuro-ophthalmologists – specialists who focus specifically on the connection between visual symptoms and neurological diseases. Recently, Shahnaz Miri, MD joined us for one of our Spotlight® Online livestreams and it became clear 1 hour was not enough to cover all of your important questions.

Fortunately, we were able to work with Dr. Miri to compile all of your questions from that event and turn them into a resource for you. Below you will find valuable information in managing your vision while living with a movement disorder.

General questions: 
  • Is there a hereditary component to macular degeneration?
    • Macular degeneration is a leading cause of vision loss in adults after the age of 60, that is why it is called Age-related macular degeneration (AMD). Risk factors for developing macular degeneration include smoking, high blood pressure, and high cholesterol. Genetics also plays a role in Macular degeneration. If there is someone in your family with this diagnosis, your risk might be higher.
  • Can narrow angle glaucoma become worse with Sinemet?
    • Carbidopa-levodopa products (including Sinemet) are contraindicated in patients with narrow-angle glaucoma, as it can increase eye pressure. Referral to the ophthalmologist for glaucoma screening and monitoring eye pressure is recommended. Reference:
  • Ocular Migraines. Is this a problem with Parkinson’s?
    • There is no evidence of a relationship between ocular migraines and Parkinson’s disease in the literature.
  • I’ve been told that I have a “thinning lattice.” Is this related to PD?
    • There is no evidence of direct relationship between lattice and PD.
    • “Lattice Degeneration” is abnormal thinning of the peripheral retina that occurs in 8 to 10%  of the general population, without a well-understood cause. This condition is most commonly found in patients with “nearsightedness” (myopia), or those patients with collagen-vascular disease including Marfan syndrome or Ehlers-Danlos (which are not related to Parkinson’s disease).
  • Is there a way to get the exam for the retina thinning and/or dopaminergic deficiency by a visit?
    • Yes, with optical coherence tomography scan which is a routine eye imaging used in ophthalmology- optometry offices, the retina can be scanned and the retinal thinning can be detected with a 5-micron resolution. This is an infrared scan that takes only a few minutes to get the results. Dopamine deficiency would not be visible in these retinal scans.
Dry Eye Diagnosis
  • What do you recommend for extreme dry eyes with diminished blinking?
    • First line treatment for dry eyes is tear supplementation. Artificial tears can be found in drug stores without a prescription. They come in liquid, gel, or ointments. Application of warm compresses can help to soften secretions in obstructed glands at the margin of the eyelids (Meibomian gland). Some environmental coping strategies include minimizing exposure to air conditioning or heating and using humidifiers at home or indoor places.
    • If dry eye disease does not get better with the above strategies within 3-4 weeks, or if there ar moderate to severe symptoms with eye irritation, redness, or pain, you should see a doctor for eye examination. The ophthalmologist will perform a thorough slit lamp examination along with other testing to assess the status of eyelid health, Ocular surface inflammation, the lacrimal functional and possible etiologies. Treatment of eyelid inflammation (if exists) is necessary to improve symptoms. Ophthalmologists can use prescription eye drips that are more potent in treating dry eye disease.
  • Would decreased blink rate be considered a motor symptom?
    • Yes, previous research studies have shown that Parkinson’s disease patients have decreased blink rate and also have a more prolonged pause between the closing and opening phase of blinking.
  • I have dry eyes. Liquid tears are not helping. What other options are there?
    • Using artificial tears frequently, every 3-4 hours can help mild to moderate dry eyes. If not helpful, you can use gels, warm compresses. There are multiple other treatment options including antibiotics eye drops, anti-inflammatory drops that can be prescribed by physicians to help improve symptoms.
  • Once you have dry eyes, is it for the rest of your life?
    • There are multiple management options for dry eyes from eye drops, to surgical intervention (if needed), depending on the causes and severity of dry eyes. Also, if there is a co-existing ocular problem including inflammation of eyelids or infection, treatment of those conditions can improve dry eyes. Therefore, in most cases dry eyes are manageable.
  • What if you can’t get eye drops into your eyes?
    • For using artificial tears, you should tilt your head back and drop artificial tears into the eye. Keep your eyes closed for about 1 to 2 minutes. If you cannot use eye drops frequently or if you have difficulty putting them into your eyes, you might use gel forms/lubricants instead. Ointment and gel from lubricants can be used for dry eyes by placing the drug inside the lower lid and closing the eye for 1 to 2 minutes. Using ointment and gel at night will lubricate eyes throughout the night.
Blepharospasm/Depth Perception/Light Sensitivity Questions:
  • Is blepharospasm the same as eyelid opening apraxia?
    • No, these are two different conditions, but can happen at the same time in some patients.
    • Blepharospasm is also a form of focal dystonia causing episodic closure of eyelids.
    • Blepharospasm is due to “abnormal contraction of eyelid muscles” (orbicularis oculi muscle that closes the eyelids).
    • However, eyelid opening apraxia is due to “lack of contraction of the eyelid opening muscle” (Levator Palpebrae muscle which opens the upper eyelid) which leads to episodic inability to open eyes.
    • A patient may have a combination of both Blepharospasm and eyelid opening apraxia. This should be evaluated by a movement disorder specialists or a neuro-ophthalmologist.
    • Eyelid opening apraxia can be associated with other conditions such as a stroke. Therefore, it should be evaluated by a specialist to rule out other causes.
  • Any other treatment for Blepharospasm if Botox doesn’t work after several treatments?
    • Surgical intervention can help with management of patients with blepharospasm and eyelid opening apraxia refractory to botulinum toxin injections. An oculoplastic surgeon (a subspecialty in ophthalmology) performs a surgery which involves reducing the muscles around the eyelids to improve spams. Sometimes, a combination of surgery and toxin injection can be considered.
  • When driving, I used to be able to sense within an inch or two the exact position of my vehicle.  That is no longer so precise.  What is the reason for this?
    • A full eye examination with oculomotor testing is recommended. This can be due to anything from decreased visual acuity, cataract, retinal disease, to ocular misalignment. Your optometrist or ophthalmologist can comment on management options including corrective eyeglasses.
  • Can depth perception problems have an impact on going down stairs?
    • Yes, definitely. Parkinson patients might have a combination of factors for difficulty with going downstairs, including impaired depth perception with decreased contrast sensitivity, ocular misalignment (convergence insufficiency), in addition to motor components including freezing of gait and slowness of movements.
  • What are the advantages or disadvantages of using either contacts or glasses, when dealing with convergence insufficiency?
    • Prism correction in eyeglasses is used for convergence insufficiency. The prism bends the light to align the two images to improve double vision experienced in patients with convergence insufficiency.
    • Prism correction is only suitable for some types of double vision, however.
    • There is no contact lens form for prisms.
  • What can be done about the depth correction issues?  Example: treatment? Glasses? Eye exercises?
    • It depends on the cause of depth perception issues. If it is due to ocular misalignment including convergence insufficiency, then it can be improved with prism correction.
    • Sometimes it can be due to the difference in visual acuity (refractive error) between the two eyes which can be corrected with eye glasses or contact lenses. If it is due to retinal disease or brain visual processing abnormalities, it might not be corrected with glasses. But management and lifestyle adjustment strategies can help with coping.
  • I find the glare from the bright sun is blinding and I don’t drive anymore.  Can this be treated-is this related to a specific eye issue?
    • “Glare Sensitivity” can be due to different reasons. The most common reasons are cataract, corneal abnormalities (including keratoconus), or retinal diseases. An ophthalmic evaluation for detecting the underlying cause is recommended. Based on the cause of this issue, your ophthalmologist can recommend different management options. In some cases, an anti-reflective coating can be added to your eyeglasses to decrease reflected light and glare. You should consult with your ophthalmologist or optometrist about this.

Recently Dr. Miri joined us on Spotlight® Online to discuss the role of Neuro-Ophthalmology in Parkinson’s Care. If you missed it live, click below to watch the full recording.

Shahnaz Miri, MD, MBA is a board certified neurologist with advanced fellowship training in movement disorders. Dr. Miri completed medical school at the Tehran University of Medical Sciences and went on to pursue a post-doctoral fellowship at SUNY Downstate Medical Center in Brooklyn, NY. She completed her neurology residency and movement disorders fellowship at Georgetown University Hospital and is currently a clinical instructor and neuro-ophthalmology fellow at Bascom Palmer Eye Institute at the University of Miami. Dr. Miri also holds a Masters of Business Administration degree with a specialty in IT Project Management from Western Governors University.

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