Ophthalmologic features of Parkinson’s disease
Abstract
Patients with Parkinson’s disease (PD) commonly complain of impaired visual function and difficulty reading, despite normal visual acuity. Although previous studies have evaluated contrast sensitivity, color vision, visuospatial processing, visual hallucinations, and ocular movements, none has systematically evaluated the ocular complaints and ocular findings of PD patients. Thirty patients with early untreated PD and 31 control subjects without neurologic or known ocular diseases were ophthalmologically evaluated for the frequency of visual complaints, dry eyes, blepharitis, visual hallucinations, reduced blink rate, blepharospasm, and convergence insufficiency. Ocular complaints suggesting ocular surface irritation, altered tear film, visual hallucinations, blepharospasm, decreased blink rate, and decreased convergence amplitudes were more common in PD patients than in control subjects. These findings likely account for many of the visual difficulties commonly encountered by PD patients. These ocular abnormalities frequently respond to treatment.
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Received: May 29, 2003
Accepted: August 13, 2003
Published online: January 26, 2004
Published in print: January 27, 2004
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We thank Dr. Friedman for his comments regarding our article on ophthalmologic features of Parkinson's disease (PD). [1] We were equally surprised by the number of untreated PD patients reporting visual hallucinations (26.7%), which is higher than what was reported in other studies. [3]
All patients were asked to complete a detailed questionnaine including numerous questions regarding their visual function and ocular symptoms. The questionnaire was then reviewed with the patient and further questions were subsequently asked to clarify the patient's answers. The questions regarding visual hallucinations included: "Do you have visual hallucinations"; "Do you sometimes see shapes, objects or scenes that are not real"; and "Do you feel that you see things that other people do not see".
No specific details were asked about the temporal profile or the characteristics of the visual hallucinations. Flashes of light (such as phosphenes) were not considered visual hallucinations.
We also thank Drs. Tomsak and Daroff for their historical note. By publishing this, they remind us that the "fathers of neuro-ophthalmology" (and J. Lawton Smith was certainly one of them) were outstanding clinicians and teachers. Although this mnemonic "PARKINSONISM" refers to all Parkinson syndromes rather than Parkinson Disease, it should be very useful to the readers of Neurology.
References
1. Biousse V, Skibell BC, Watts RL, et al. Ophthalmologic features of Parkinson's disease. Neurology 2004;62:177-180.
2. Fenelon G, Mahieux F, Huon R, Ziegler M. Hallucinations in Parkinson's disease. Prevalencek, phenomenology and risk factors. Brain 2000; 23:733- 745.
3. Holroyd S, Currie L, Wooten GF. Prospective study of hallucinations and delusions in Parkinson's disease. J Neurol Neurosurg Psychiatry 2001;70:727-733.
The excellent review article by Biousse et al [1]reminded us of lessons learned from our mentor in neuro-ophthalmology and consummate educator, J. Lawton Smith from the Bascom Palmer Eye Institute of the University of Miami.
Smith listed 26 "Eye Signs in Parkinsonism" in his 1963 monograph on Optokinetic Nystagmus. [2] These were manifestations of "parkinsonism" and not "Parkinson's Disease", as Smith developed them before there was a clear distinction between the idiopathic and post-encephalitic forms, and prior to the popularization of the "parkinson-plus syndromes", such as Progressive Supranuclear Palsy (PSP). Later, he published mnemonics (a characteristic Smith teaching strategy) of the signs. [3,4] The wording of the two mnemonics differed and we selected the wording that seemed most appropriate. We hope the readers of Neurology find it useful.
Ocular Signs and Symptoms of Parkinsonism
P - paresis of vertical gaze (in the post-encephalitic form or parkinson-plus syndromes); paresis of convergence; pupillary changes
A - accommodative paresis, due to drugs or the disease; artificial tears needed
R - reflex blepharospasm; retraction of upper lids (Colliers sign); red eyes (external disease)
K - "kogwheeling" of eye movements (hypometric saccades and saccadic pursuit); keratitis from dry eyes, infrequent blinking, or blepharitis
I - infrequent blinking
N - nystagmus, vertical*
S - sakkdierung (cogwheel pursuit)
O - oculogyric crises; optokinetic dissociation, vertical (in association with vertical gaze paresis)
N - no (avoid) bifocals or progressive lenses; no hemianopias
I - impossible tonometry (due to blepharospasm)
S - seborrheic blepharitis; styes
M - Myerson's sign
*Footnote: The inclusion of "nystagmus" undoubtedly reflected the influence of Smith's own neuro-ophthalmological mentors, David Cogan and Frank Walsh, the fathers of American neuro-ophthalmology. In his second edition of Neurology of the Ocular Muscles [5], Cogan mentioned paresis of vertical gaze in PD, which could explain gaze paretic vertical nystagmus. Walsh, in his second edition of Clinical Neuro-Ophthalmology, [6] referring to encephalitis lethargica, described nystagmus as being "rather common during the late stages of the disease".
References
1. Biousse V; Skibell BC; Watts RL et al. Ophthalmologic features of Parkinson's disease. Neurology 2004;62:177-180.
2. Smith JL. Optokinetic Nystagmus: its use in topical neuro- ophthalmologic diagnosis. Charles C. Thomas, Springfield 1963, pp. 108- 110.
3. Smith JL. Ocular signs of parkinsonism. J. Neurosurg. 1966 24:284- 285.
4. Smith JL. The eye in parkinsonism. Modern Treatment 1968;5:316-320.
5. Cogan DG. Neurology of the Ocular Muscles, second edition, C.C. Thomas, Springfield, 1956, p. 120.
6. Walsh FB. Clinical Neuro-Ophthalmology, second edition, Williams and Wilkins, Baltimore, 1957, p. 447.
The review of ophthalmologic abnormalities in Parkinson's disease (PD) was excellent. [1] However, there was a surprising number of visual hallucinations reported (26.7%) in patients not on anti-PD medications. This number is similar to the numbers reported in PD patients taking medication [2,3] which is very different than my own experience.
I questioned 39 consecutive patients with presumed idiopathic PD, including those taking and not taking any anti-PD medications. The patients' average age was 72.4 and the duration of PD ranged from newly diagnosed to 24 years. One patient reported visual illusions before starting anti-PD medications and a single patient reported visual hallucinations before starting medications, but this occurred many years before, in the context of a primary psychotic disorder. None of the 39 consecutive patients had visual hallucinations prior to starting their PD medication.
The population described in the review was probably typical of the patients seen at most American PD centers and the difference may be due to the manner in which the history of hallucinations was obtained. The authors should describe their questionnaire in more detail.
References
1. Biousse V, Skibell BC, Watts RL, et al. Opthalmologic features of Parkinson's disease. Neurology 2004;62:177-180.
2. Fenelon G, Mahieux F, Huon R, Ziegler M. Hallucinations in Parkinson's disease. Prevalencek, phenomenology and risk factors. Brain 2000; 23:733- 745.
3. Holroyd S, Currie L, Wooten GF. Prospective study of hallucinations and delusions in Parkinson's disease. J Neurol Neurosurg Psychiatry 2001;70:727-733.