?This paper accompanied a lecture to the North American Neuro-Ophthalmology Society [NANOS] in March 1999 by Dr. Jacqueline Winterkorn. Her office address is Neuro-Ophthalmology, Suite 210, 900 Northern Blvd., Great Neck, NY 11021. NEURO-OPHTHALMOLOGIC MANIFESTATIONS OF PARKINSON'S DISEASE © 1999 Jacqueline M.S. Winterkorn, Ph.D., M.D. New York, New York 1. INTRODUCTION - DEMOGRAPHICS Parkinson's disease [PD] is known to affect over 1 million Americans and its diagnosis is becoming increasingly common, including 50,000 new patients per year26. Some epidemiologic studies involving door-to-door canvassing suggest underdiagnosis by as much as 25%14. In the over-60 population, the incidence is 1-2%. Despite the common myth that Parkinson's affects only the elderly, in fact the average age of symptom onset is 57, with over a third of all victims starting symptoms in their 20's, 30's, and 40's. PD is characterized by tremor, rigidity, bradykinesia, and impaired balance26. Most patients with Parkinson's disease [PD] develop some ophthalmic complaints, e.g. blurred vision, double vision, photophobia, asthenopia, or trouble reading. As many as 75% of PD patients have been reported to show oculomotor signs10. PD is mainly a motor disorder, caused by death of dopaminergic neurons in the substantia nigra compacta, leading to loss of dopamine in the putamen. The depletion of dopamine from the other regions of the brain, especially from the visual cortex6 and from amacrine and interplexiform cells of the retina16, 30 in patients with PD has prompted studies looking for visual perceptual abnormalities19. It behooves us as neuro-ophthalmologists to know the eye signs of PD, which ones the patients complain about, and what relief or management can be offered. 2. NEURO-OPHTHALMIC DEFICITS Lawton Smith described an acrostic for PD problems 36, 37, which I present here with modifications. Pareses of gaze-- Clinical observations of patients with PD have described slow, hypometric saccades and incomplete upgaze10. A differential response to an optokinetic stimulus in the horizontal and vertical plane has been described, with OKN present in the horizontal plane, but absent or poorly-formed vertically 36, 37. These old studies may reflect the high prevalence of post- encephalitic PD at that time. Although vertical gaze abnormality has been associated with PD, limited upgaze to command is common in older people33 and may be a non-specific defect. Moreover, the eye movement disorder characteristic of idiopathic PD is mild and may not be apparent in the early stages of PD or in patients well-controlled by levodopa39. Pursuit gain is decreased, leading to jerky pursuit, referred to as “cogwheel,” since reminiscent of the ratchety limb movements in PD10, 41. Saccades to novel stimuli usually remain unaffected, with normal latency, peak velocity and duration 11. However, saccades that are made not to an actual visual stimulus, but rather to a remembered location, or repeated predictive saccades tend to be dysmetric11. These saccades are hypometric, show delayed initiation, and may be slowed34. In patients with hypometric saccades, saccadic amplitude has been shown to normalize after a dose of L-dopa. In patients having Levodopa-induced dyskinesias, eye movements may become more frequent and saccades hypermetric. Imbalance and postural instability are reflected in poor stabilization of images and impaired eye-head coordination 38, 41. Head movements may also become smaller and slower than normal. Despite their visual complaints, examination of patients with idiopathic PD often shows only minor impairment of ocular motility. If saccades are dramatically slow or downgaze is severely impaired, the diagnosis of idiopathic PD should be questioned39. Parkinson's Plus syndromes should be differentiated from idiopathic PD, by severity of eye movements abnormalities. Disorders such as Progressive Supranuclear Palsy [PSP], cortical-basal ganglionic [corticobasal] degeneration, olivopontocerebellar atrophy, and nigrostriatal degeneration show far more severe eye movement deficits. For example, the eye movements of PSP are characterized by interruption of fixation by numerous square wave jerks, very slowed saccadic speeds, and supranuclear vertical ophthalmoplegia, with early absence of downgaze12, 13. These signs do not respond to L-dopa. Accommodative paresis -- Accommodative insufficiency is a common problem in people with PD, causing double vision and difficulty with reading1, 33. Difficulties with accommodation also can result from medications, especially the anticholinergics [e.g. Artane, Cogentin, benedryl] given to control tremor. Despite normal convergence amplitudes, a distant near point can be demonstrated. Convergence insufficiency has been described as a consistent abnormality, contributing to asthenopia or diplopia at near33. Less often, divergence insufficiency leads to diplopia in the distance. Reflex Blepharospasm and Blepharoplegia-- Eyelid abnormalities including blepharospasm and apraxia of eyelid opening and low blink rate are typical in PD1. Inability to open the eyes in a person with PD may be caused by [1] blepharospasm, either reflexive or essential, [2] apraxia of eyelid opening, [3] diplopia avoidance, or [4] dry eyes. Both Essential Blepharospasm and apraxia of eyelid opening have been associated with postencephalitic-PD42 and PSP. Frontal lobe activity may be abnormal35. Having PD does not exempt a patient from common eye diseases such as glaucoma, cataract, macular degeneration, refractive errors and presbyopia. However, blepharospasm makes examination for these conditions especially difficult, for example, by interfering with obtaining intraocular pressure by applanation. Keratitis Sicca -- Dryness of the cornea is the result of autonomic dysfunction, exacerbated by medications1. Seborrheic dermatitis affecting the lids and face is common, especially in patients with compromised hygiene. Tear secretion is reduced with abnormal composition, and chalazia [styes] may develop. A poor tear film also results from infrequent blinking24. Eye pain and blurred vision frequently are caused by corneal surface abnormalities. Infrequent Blinking -- Infrequent blinking contributes to the wide-eyed expressionless stare characteristic of PD. Hypokinesia of the levator make the lids appear retracted. The blink rate may be as low as 1-2 per minute [nl 16-18 per minute]24. This complicates management of the dry eye syndrome. No hemianopsia-- except after pallidotomy. Visual fields have not been shown to be abnormal in patients with PD, except after surgical procedures, such as pallidotomy. In the early years of this surgery, as many as 40% of patients were left with contralateral homonymous hemianopsias resulting from involvement of the optic tract in the lesion intended for the adjacent ansa lenticularis. Today, even with advanced neurosurgical methods of recording VEPs in order to avoid lesioning the optic tract, pallidotomy surgery still results in contralateral superior quadrantanopsias in 5-10% of patients4. Sensory Abnormalities -- Although many studies of visual perception have documented abnormalities, few clinical correlates are apparent 28. [See TABLE] Visual acuity may be slightly decreased in PD patients compared with controls 23 ,33 but more often it is normal after careful refraction and corneal wetting. Performance has been impaired on some more complex sensory tests. Contrast sensitivity [CS] is abnormal 8, 25, especially the form of the CS curve 6, 7, 8. This reflects diminished CS at intermediate and high frequencies, with relative absence of the low frequency drop-off. Similarly, latency of the VER is delayed to sinusoidal gratings of medium to high spatial frequency 5, 25. This has been interpreted as an indication that retinal dopaminergic cells are involved in refinement of center-surround receptive field organization7. The finding that the CS abnormality is greater for horizontal than for vertically-oriented gratings was interpreted to implicate cortical function, since orientation selectivity is a property of cells in the visual cortex 40. However, this might also reflect paucity of eye movements affecting viewing of the gratings. The degree of delay is correlated with motor impairment, with improvement shown after L-Dopa 20, 25, 29. Poor performance on color discrimination has been reported, not improved by medication 2, 9, 32. Color vision in the blue/yellow axis seems particularly affected18. Pattern ERG's show decreased amplitudes17, 29, 31. Temporal functions have been ascribed to amacrine cell abnormalities. Flicker thresholds are impaired 7. Decreased motion detection has been reported. Simple visual attention is normal, but more complex tasks may be affected3. Hallucinations are common in patients with PD, occurring in 25-40% of patients. Patients who experience hallucinations are usually older, have poor vision, or are receiving medications. As many as 10% may also have auditory hallucinations21 . Oculogyric Crises -- This unusual ocular deviation was a hallmark of postencephalitic Parkinson's (common after the pandemic influenza outbreak of 1916-1930) and is rarely seen nowadays