Expert Briefing: Vision Changes

Jim Beck 0:01
Hi there. My name is Jim Beck, and I'm the Chief Scientific Officer at the Parkinson's Foundation. I want to welcome you to our fourth webinar in the Parkinson's Foundation 10th Expert Briefing series. Today's topic is Seeing Clearly with PD: Vision Changes.

As I've often commented before, these webinars aren't created in isolation and really depend upon you and the Parkinson's community to give us feedback and advice on where we should be going with our Expert Briefing series. We've been asking that periodically, and we thank you for it. I also want to thank our partner Parkinson's organizations in the United States who are part of the Alliance of Independent Regional Parkinson Organizations, or AIRPO. They've worked with us as well to help us design these webinar series.

If you're looking at the domain screen and you're interested in downloading these slides, you can. There's an opportunity to download slides. There's a little button on the page on the left-hand side where you can download the PowerPoint slide deck, and you can look at it offline.

If you're a health professional, I want you to know that you can earn one free CEU through the American Society on Aging. If you registered as a health professional and indicated you'd like a CEU, you'll receive an email by the end of today with steps on how to go on and collect that CEU. But remember, you only have 30 days, which is until April 5, to collect that free CEU. So do that so you can add that to your requirements.

Now it's my distinct pleasure to welcome our guest speaker for today. Dr. Dan Gold is assistant professor of neurology, ophthalmology, neurosurgery and otolaryngology, with head and neck surgery at Johns Hopkins Hospital. Dr. Gold is an assistant professor and was a neurologist with fellowship training in neuro-ophthalmology and additional training in neuro-vestibular disorders.

Dr. Gold maintains an active clinical practice and sees patients with dizziness and imbalance, as well as neuro-ophthalmic conditions. He's heavily involved with the education of the residents and fellows at Johns Hopkins, and he gives frequent lectures on topics related to this very specific area, in addition to leading the neuro-ophthalmology and oculomotor bedside teaching rounds for residents and students. So, Dr. Gold?

Dr. Dan Gold 2:16
Thanks so much. It's my pleasure to be here.

I'm going to talk about vision, what patients with Parkinson's might expect. We're going to talk about the visual system. We're going to talk about why I'm here talking about vision to begin with, what a neuro-ophthalmologist is and why you might need to meet a neuro-ophthalmologist.

First of all, why should I care about vision? Vision is an important sense. About two-thirds of this brain mass outlined here is dedicated in some way to processing visual information or visual inputs to perceive what you see in your environment.

The brainstem is there. There are a variety of structures that course throughout the brainstem that are solely dedicated to the coordination of eye movements. And why do you need to move your eyes to be able to see? The cerebellum has a significant role in fine-tuning those eye movements, again, so that you can bring the eyes to where they need to be in order for you to see the clearest image possible.

How does vision work? The retina, which is this orange-pink substance, is made up of a variety of cells that communicate with each other. Some of these use the neurotransmitter dopamine, which I know that everyone here has heard of. This would be the right fundus, as if the person is looking back at you, and this will give you a better sense of what we're talking about.

I showed you where the retina was. Here are the macula and the optic nerve. Basically, the light comes in. The image that you're looking at comes in and stimulates the nerve cells in the retina and in a specific portion of the retina called the macula. The macula is where we see our best, 20/20 clearest vision. So when we want to look at something and be able to see it as clearly as possible, we need to move the eyes. We need to aim the macula at whatever it is that we want to see. The visual information then flows from the retina and the macula via nerve cells, about one million of them, to make up the optic nerve, which is the cable connecting the eyeball to the brain.

Here's an MRI scan showing the course of the visual pathways from the eyeballs, where you can see the retinas sort of flattened on the back of the globe. The flow of visual information goes from the retina to the optic nerve, and then it goes from the optic nerves back to the optic chiasm, where about 50% of the nerve cells are going to cross over.

Finally, the visual information has to make its way back to the visual part of the brain, the occipital lobes, where the brain can interpret it and make sense of what the eyes see. Effectively, if you have a problem that affects both occipital lobes, like a stroke that involves the right and the left sides, you would be blind as if you had no eyeballs at all.

What is a neuro-ophthalmologist? Eye doctors are very good with the eyeball, and optometrists as well, but tend to be less comfortable dealing with neurologic or brain-related problems. Likewise, neurologists are great with the brain but tend to be uncomfortable when it comes to the visual pathways, specifically relating to the eyeballs and the optic nerves. A neuro-ophthalmologist has specific training. About half of them are neurology trained, and about half of them are ophthalmology trained. That allows us to really have an appreciation for the interface between the eyes and the brain.

Dr. Dan Gold 6:24
There are two main parts to neuro-ophthalmology. One is the afferent system, the ability to see. We just talked about the visual pathways, how that visual information needs to make its way from the eyeballs back to the visual parts of the brain.

Secondly, there's the efferent system. We have to be able to move the eyes effectively to see. Again, we want to aim the macula, that 20/20 area, at whatever visual target needs to be seen.

As a neuro-ophthalmologist, we care about where the problem is. What part of the brain? And from the where comes the what. What could be going on? We make these determinations based on a thorough history, as well as a comprehensive eye exam, a neuro-ophthalmic exam and, commonly, a neurologic or at least pieces of the neurologic exam as well.

What visual symptoms should somebody living with Parkinson's be aware of? First of all, it's very important to know that visual symptoms in Parkinson's are extraordinarily common. About 78% of patients will report at least one.

Less common, and what we just won't have time to talk about today, include conditions that may affect patients living with Parkinson's but are typically more common in other parkinsonian conditions like progressive supranuclear palsy or multiple system atrophy, for instance. We're not going to go into them today. These include blepharospasm, a forceful contraction of the eyelids; apraxia of eyelid opening, where the motor command of opening the eyes is impaired; and significant vertical eye movement limitations, which tend to be very common in progressive supranuclear palsy, not so much in Parkinson's.

What we will talk about today are the most common conditions and symptoms that affect patients living with Parkinson's, including central and color vision abnormalities, blinking and ocular surface abnormalities, eye movement abnormalities, and hallucinations.

First, we'll talk about central and color vision abnormalities. What are the most common symptoms? There's blurriness. The images just aren't clear. There's difficulty with vision in the twilight hours or when raining. Colors look washed out or not as vibrant as they used to. Sometimes people can't really put it into words, but something just isn't the same.

What do we test in the clinic? Again, we want to know the visual acuity. We look at the eye chart at near and distance. What is the best central vision that we can measure? This is the macula. This is the 20/20 vision that I referred to before. The visual acuity is the ability to resolve the details of the stimulus, in this case, the numbers. It is affected by eye factors, usually including retinal issues or cataracts, for instance, rather than a brain problem.

Contrast sensitivity is a big one for patients living with Parkinson's. Contrast sensitivity is the ability to discriminate an object from its background. As an example, think about walking up or down carpeted stairs and having difficulty deciding where one step ends and the next begins. You can see in the photo on the right side that the right side of the photo is normal contrast vision. The left side is reduced contrast sensitivity. You see how dull and sort of non-vibrant this is, and again, it's much more difficult on the left side to discriminate these objects from the background. It's not nearly as sharp.

Patients with Parkinson's tend to do pretty well with visual acuity in tests using vision charts with letters of the same size, but with reducing contrast, as you can see in the chart on the left side, patients with Parkinson's tend to do more poorly as compared to age-matched controls, for instance. Contrast detection just isn't as good. Patients with more advanced Parkinson's may complain of poor vision that's worse in a lower-contrast or lower-light environment.

Dr. Dan Gold 11:02
Therefore, if you have problems with contrast sensitivity, having brighter ambient light is recommended to improve contrast sensitivity. Driving in low-lighting situations should be avoided, for instance, for safety reasons in affected patients. Some patients benefit from certain eyeglass tints, like amber or rose color. These can also help reduce glare or sensitivity to light.

Color vision. In the healthy brain, these are color plates that we would use to test in the neuro-ophthalmic clinic. In the healthy brain, color is processed by structures in the back of the eye in the retina. Again, I mentioned that some of those retinal cells communicate among one another using dopamine, the neurotransmitter dopamine. Color is processed in the retina but also in the visual parts of the brain. In Parkinson's, color tends to be mildly impaired, although it's not clear at what level color vision may be impaired. Is it the brain, or is it the retina?

There are other reported visual abnormalities in Parkinson's, including visual processing, where there's difficulty with orientation of lines and edges and depth perception.

Peripheral vision: patients with Parkinson's may be distracted by targets or visual information in the periphery. In addition to that, patients may have difficulty discriminating details in the periphery of images.

Object perception is another potential abnormality: difficulty identifying overlapping objects or impairment with the mental ability to rotate objects.

Visual-spatial construction can also be problematic, where copying and recalling complex figures like intersecting pentagons can be difficult.

There can be problems with motion perception, where patients have a greater difficulty detecting whether motion is occurring and in which direction, which can be particularly troublesome as you're trying to cross the street, for instance.

Patients may also have difficulty with face and emotion recognition, problems recognizing faces and facial expressions, for instance.

Patients whose balance is impaired tend to rely more heavily on visual inputs. So if your vision is impaired as well, for whatever reason, this oftentimes will aggravate the postural instability, the imbalance, even more.

Treatment: what is there to do? The deficits in visual acuity, contrast and color are thought to be at least partly due to retinal dopamine deficiency. Some of these can be helped by the addition of dopamine. Whether that's Sinemet, dopamine agonists or something else, we want to always make sure that other treatable visual issues are addressed: that the patient is in the right pair of glasses, for instance, and that there's not a cataract or glaucoma or some other non-Parkinson's-related visual problem that can be diagnosed and treated.

The important point is that, of the color and the acuity and the contrast difficulties that I mentioned, each of these is relatively subtle or mild in Parkinson's, but it could be that the combination of these is really what's problematic and what leads to symptoms.

Now we're going to talk about blinking and ocular surface abnormalities. Why do we care about the ocular surface? The ocular surface, the front part of the eye, the cornea, is responsible for optical clarity. Again, the clearest possible image gets to the back of the eye, gets to the macula, so that the macula and the visual pathways going back to the visual parts of the brain are as clear as they possibly can be. The ocular surface provides a protective barrier, decreases friction as you're blinking, and also allows for hydration, for adequate hydration.

Dr. Dan Gold 15:41
In summary, the eye has protective mechanisms such as blinking and tears, both of which tend to be impaired in Parkinson's, which we'll talk about.

But why do we blink? Blinking takes the tear film and is able to distribute it uniformly across the front part of the eye, or the cornea. It helps with secretion of tears from tear glands. The eyelids sort of milk the tears out of the glands and allow them to be released effectively.

It's important to know that everyone tends to blink less at certain times. When you're reading, when you're working on the computer, watching TV or driving, people just tend to blink less. Sometimes people need artificial tears, for instance.

What are symptoms of ocular surface irritation, that the eyes are dry? People can experience and feel like there's a dryness. There can be a gritty or sandy sensation. There can be burning or redness, crusting on the eyelashes or the eyes getting stuck shut in the morning. Sometimes a heightened sensitivity to light as well can indicate that there's irritation or a dry eye.

It's sort of two hits in Parkinson's, if you think about it. Patients with Parkinson's aren't producing tears as effectively as they should. If you're not producing tears like you should, and the blinking is intended to distribute the tears uniformly throughout the cornea but the blinking is reduced, the result is that not only do you have a poor tear film, but you can have dry eye and irritation. With regard to the blinking specifically, it has been suggested that in Parkinson's it may be a form of hypokinesia, perhaps related to decreased dopamine levels in the brain.

Certain medications can also aggravate dry eye, including Artane, but many, many others that are for other medical conditions, for instance.

How is this diagnosed? Really, a thorough evaluation by any ophthalmologist or optometrist or neuro-ophthalmologist with the fancy tools in the eye clinic, the slit lamps looking at the front of the eye, can determine that the eyes are dry.

How do you treat dry eyes? Artificial tears, preservative-free, tend to be preferable. Some people do have additional irritation when they're using artificial tears that have preservatives. You can use them three to four times a day regularly, and more as needed when you're participating in activities where you tend to blink less anyway, like using the computer, watching TV or prior to driving, for instance. Certain more viscous ointments can be used at nighttime as well. If that fails, there are prescription medications like Restasis that can be helpful.

Patients with Parkinson's may also suffer from an inflammation of the eyelids called blepharitis, which can be helped by proper eyelid hygiene using baby shampoo, hot compresses or lid scrubs. Again, any neuro-ophthalmologist, ophthalmologist or optometrist should be able to diagnose and manage these conditions.

Now we'll talk about eye movement abnormalities in Parkinson's, what to expect. First, we're going to talk about double vision. It's important to know that there are two main types of double vision. One is monocular, non-neurologic double vision, which is commonly related to cataracts or simply dry eye. If it's related to dry eye, you might see two, and then you might rest your eyes, blink your eyes or use artificial tears, and it should resolve.

Dr. Dan Gold 19:13
Monocular double vision: for instance, the patient is seeing two of the star. We're not sure if the patient is seeing two of the star in one eye or with both eyes together. We cover the left eye, and the patient is only seeing one of the stars. We cover the right eye, and the patient is seeing two. With one eye individually, the left eye viewing, the left eye sees two of the stars, sees two images. This is monocular because it's one-eye double vision in the left eye. This is almost never, with very, very rare exceptions, neurologic. Like I said, the most common culprits include things like dry eye or cataracts.

Having a patient, and usually we do this in the clinic, simply look through a pinhole can eliminate that monocular double vision. Again, that confirms to us that this is an eyeball problem. A comprehensive eye exam is necessary in these situations.

The other type of double vision is binocular, where this can be neurologic. Some people just have a long-standing strabismus, perhaps that they were born with or that they've dealt with since childhood. Basically, in this situation, now you can see, for instance, the left eye and the right eye a little bit more crossed than they were in the previous situation, and the patient is seeing two stars when they should only see one star.

You cover the camera, if you think about the eyes as cameras. If there are two, then if you cover either of the two cameras, you should only see one. In this situation, the patient sees two. You cover the left eye; the right eye sees one. You cover the right eye, and now the left eye sees one. This is binocular double vision, meaning that with both eyes viewing, you see two, but once you cover either of the two eyes, it goes back to one.

This suggests that the eyes are misaligned, and this is typically a situation where a patient gets referred to a neuro-ophthalmologist for double vision. Like I said, this can be related to a long-standing strabismus, something that's been there for a long time. This can be neurologic and potentially vision- or life-threatening, although that's really, really rare and not so common with Parkinson's disease. We will talk about the most common cause for double vision in Parkinson's disease in just a minute.

Treatment of double vision: what can we do acutely? Some people prefer to simply cover one eye. You can cover one eye with your hand. You can simply close your eye without using your hand. You can use a pirate eye patch if that's what you like. Some people benefit just as well from using Scotch tape, semi-opaque Scotch tape or gift tape. You can put the Scotch tape over one of your lenses, and it effectively occludes the vision in that eye. It's the same thing as wearing a pirate patch, the same thing as covering one eye with your hand, but it's less conspicuous, it lets light in, and generally it's more comfortable and better tolerated.

In the more subacute to chronic situation, prism is oftentimes used. Prism can be press-on or ground in. In this case, this is a press-on prism. You can actually see that this person is wearing the stick-on prism. If a patient likes it, usually this is sort of a temporary trial. If the patient likes it, then this can be ground into your glasses so that nobody can notice. Strabismus surgery is another option, but this is pretty unusual in Parkinson's.

Dr. Dan Gold 23:44
By far the most common cause for binocular double vision in Parkinson's is convergence insufficiency. Like I said, one of the most common causes of monocular double vision is something as simple as ocular surface irritation or dry eye. Commonly, the two can co-occur, so that somebody has both monocular double vision due to dry eye and binocular double vision due to convergence insufficiency.

Symptoms of convergence insufficiency include, most commonly, double vision. You have to bring the eyes together, to converge them, when you're looking at something close to you like a book. You have to diverge, or move your eyes apart, when you're looking at something far away, for instance. So when somebody experiences convergence problems, difficulty bringing the eyes together, the two images tend to be side by side or horizontally displaced.

There are other nonspecific symptoms of convergence insufficiency, but basically anything that affects your ability to read or see clearly, looking at something up close, that gets much better when you cover either eye, could absolutely represent convergence insufficiency.

Like I said, when something is close to you, like it is on the right side, the star is getting closer to the eyes, and the eyes have to converge. They have to come together. In Parkinson's disease, it's not entirely clear why convergence tends to be impaired, but it's so common that it is.

We look for the near point of convergence, the point at which the object is so close to the eyes that the eyes can no longer converge and one of the two eyes sort of pops out and the patient sees two. Usually, this is less than 10 centimeters or so. In Parkinson's disease and convergence insufficiency, it's almost always greater than 10 centimeters and sometimes greater than 20 or 30 centimeters in more significant cases.

The diagnosis of convergence insufficiency can be made during a comprehensive eye movement examination performed by your neurologist, optometrist, ophthalmologist or neuro-ophthalmologist.

How do we treat it? There are home exercises known as pencil push-ups, where essentially you're taking a small visual target, like the tip of a pencil, holding it at arm's length and doing repetitions where you're slowly bringing it from arm's length in toward your nose. You're doing repetitions. There's no clear program, but you're doing 20 or more repetitions a couple times a day for a couple weeks or so to see if this improves your ability to converge the eyes, to bring the eyes together. Sometimes vision therapy can be helpful, or computer exercises. There are some companies that have home programs that you could participate in.

Covering one eye or putting Scotch tape or satin gift tape over one lens can also be helpful. This will definitely eliminate the binocular double vision that's related to convergence insufficiency. Some people like this. Some people don't like this. Finally, prisms can be placed, but they should only be placed in the reading glasses because, again, this is a near problem. This is a problem that's only noticeable, when this is strictly convergence insufficiency, when you're looking at something close to you.

Therefore, the prisms, if they are prescribed for you, should be in reading glasses only, not in distance glasses. Patients whose balance tends to be impaired should, generally speaking, avoid progressives and bifocals and trifocals because if you're over-reliant on vision, you're looking at the floor, you're looking at your feet. When you're looking through bifocals or trifocals or progressives, you're looking through the reading portion of the glasses at your feet or at the floor, which is the wrong distance.

Dr. Dan Gold 28:00
Therefore, wearing progressives or bifocals or trifocals can actually increase visual disorientation and sometimes aggravate balance as well.

Finally, we're going to talk about hallucinations. In Parkinson's disease, hallucinations tend to be associated with the following: daytime sleepiness or difficulty falling asleep; moderate to severe cognitive problems; a longer duration of Parkinson's disease; and also an associated reduced visual acuity and visual impairment.

What about medications? As you can see, the single plus sign here indicates that this medication can contribute to or cause hallucinations. Two plus signs just suggest that that medication tends to be a bigger culprit when it comes to causing or aggravating hallucinations.

Amantadine is a big one. Some of the dopamine agonists tend to be the biggest culprits. But as you can see, every medication for Parkinson's, and the newer ones as well, can absolutely cause or contribute to hallucinations. When hallucinations are experienced, you should have a conversation with the prescribing doctor, your neurologist, for instance, about the hallucinations that you're experiencing. The medications need to be looked at and sometimes need to be modified or changed to another.

Passage hallucinations are the most common that a patient with Parkinson's might experience. Passage hallucinations usually involve insects and small animals that move across the peripheral vision. The combination of being more distracted by peripheral visual targets and difficulty discriminating the details in peripheral images might be responsible for this, although it's not entirely clear.

Illusions are also quite common. This is a misinterpretation. An illusion may occur where something innocuous, like a pile of clothes, could be misidentified as an animal. These are also commonly reported in Parkinson's and may occur for similar reasons as the passage hallucinations.

Complex hallucinations: most complex visual hallucinations involve animate objects and are typically in front of the patient, and tend to be experienced when the lighting is dim. These could relate to a lack of visual input due to impaired vision for the reasons discussed earlier, and can lead to the release of stored visual images. That's one theory for why this might happen. This is sometimes referred to as a release phenomenon.

How do we treat visual hallucinations? If they're mild, there's insight that these are not real, and the patient isn't particularly bothered by the hallucinations, then simply reassurance is perfectly appropriate. You always want to look at the medications and evaluate them, remove particular medications like amantadine, for instance, if it's thought that that's the biggest culprit. And if the hallucinations are particularly bothersome, if they're moderate to severe in intensity, you want to again evaluate and potentially remove or modify certain medications.

There are other neuroleptic medications that may lessen the frequency of visual hallucinations, including Seroquel or Clozaril. These are therapeutic options in addition to newer drugs that have been developed and approved to treat hallucinations and delusions in Parkinson's disease.

Dr. Dan Gold 32:05
In conclusion, dopamine is present in the visual system, and the lack of dopamine is thought to contribute to visual complaints in Parkinson's. That's at the level of the eyeball itself and the back of the eye and the retina. That's also along those complicated visual pathways as they work their way back to the occipital lobes, to the visual parts of the brain. All of these nerve cells need to communicate with one another, and a commonly used neurotransmitter is dopamine. The eyelids and the ocular surface protect the eye and optimize the clarity of what we see.

Again, the eyeball is all about getting the clearest possible image back to the macula, back to the best-seeing part of the eyeball. For this reason, you need the front part of the eye to be clear and clean and protected, while the eyes need to move. They need a mechanism to be able to point the macula at whatever it is that you need to see. That's why the eyes move: to see.

If somebody can't see, then there's no use for the eye movements themselves, and the eye movements can become incoordinated. They can separate and lead to ocular misalignment, and sometimes abnormal eye movements can develop as well, called nystagmus. Convergence insufficiency is a common eye movement abnormality that's seen in Parkinson's. Remember the distinction between monocular double vision and binocular double vision. In Parkinson's patients, it's very common to have both simultaneously.

For instance, monocular double vision can be due to dry eye, ocular surface irritation, or, just as people age, cataracts develop as well, which is another common cause for monocular double vision. At the same time, binocular double vision can coexist, and the most common explanation for that in Parkinson's is convergence insufficiency. A lot of the visual abnormalities that we discussed, such as visual acuity, contrast sensitivity and color vision, are mild, but once you add a few mild abnormalities in combination, they may cause significant problems.

Finally, and most importantly, the earlier the symptoms are diagnosed and addressed, the earlier treatment can be initiated and quality of life improved. Don't hesitate to see your ophthalmologist or your optometrist if you have a new visual concern. All patients should be having at least annual visits, and more depending on symptoms and depending on other eye conditions.

Thank you so much.

Jim Beck 35:01
Thank you, Dr. Gold. That was a really riveting explanation of what I think a lot of people with Parkinson's disease are experiencing, just based upon the questions that have been coming in. I think you really covered the issue regarding double vision and dry eye a lot, so I appreciate you taking the time to do that.

What I want to do right now is just a little housekeeping thing, to let people know that this is such an interesting and compelling topic. We have over 2,700 people from 27 countries and all 50 states registered today. I've got a question from Kenya that I'm going to ask you, Dr. Gold.

We've had about 1,500 people with PD and 650 care partners who are joining the call, plus about another 500 healthcare professionals who are listening in. This is something that I think many people had questions about, and I think you've done a lot to help address many of them. Nevertheless, there are still a couple questions that people have. One of them is a real basic one, Dr. Gold. How do you talk to your doctor, and when do you talk to your doctor, about a referral to someone with your specialty, a neuro-ophthalmologist?

Dr. Dan Gold 36:14
Right. A movement disorders neurologist, or basically any neurologist who treats patients with Parkinson's, is really aware of how common visual symptoms are, and they should be referring to an optometrist or ophthalmologist. That's usually the first step. Sometimes, when they know that this is a neuro-ophthalmic problem, commonly binocular diplopia sort of falls within the realm of neuro-ophthalmology.

Commonly, a neurologist or a movement disorder specialist will send directly to a neuro-ophthalmologist, but the vast majority of patients will be just fine seeing their optometrist or ophthalmologist and their neurologist. The combination of neurology and ophthalmology can really handle and treat effectively the vast majority of these concerns.

Those conditions where a neuro-ophthalmologist might be necessary would be: the neurologist has seen the patient, the ophthalmologist has seen the patient, and they're not sure what's causing the symptom. They're not sure what the problem is. Treatments have failed, and what else is being missed potentially? Those would all be great opportunities to see a neuro-ophthalmologist. That being said, not every patient with Parkinson's needs their own neuro-ophthalmologist. Like I said, the vast majority of issues can be effectively handled by the combination of optometry, ophthalmology and neurology.

Jim Beck 38:06
Fantastic. Let's say a person with Parkinson's, as you said, reaches this juncture where their ophthalmologist, as well as their neurologist, are really at a loss for what might be causing the problems. How do you go about finding someone with a neuro-ophthalmology specialty? Is there a website? How do you go about that?

Dr. Dan Gold 38:29
There is. The biggest international collection of neuro-ophthalmologists is through the North American Neuro-Ophthalmology Society, abbreviated as NANOS, N-A-N-O-S. If you simply do an internet search for NANOS, and then probably type in neuro-ophthalmology somewhere, then you will be taken to our society website, where I believe you can search for somebody based on ZIP code. I'm not sure about country, but definitely by ZIP code, you can find somebody in the United States or throughout North America.

Jim Beck 39:12
Yeah, absolutely. I think it's important to add that the idea of adding vision in there, who knows, you might get to some kind of Marvel comic-type world. It's a great abbreviation, NANOS.

A concern that we have from a person with Parkinson's in Pennsylvania and in Texas, kind of a common theme, is we talk about these vision declines. Are they progressive, or do people reach a kind of steady state once they've developed Parkinson's disease? Do they come in and this is where their vision will reach, or is it something they're already battling, one progressive neurological disease, and to add another can be kind of overwhelming? What is your perception on how these vision issues progress in people with PD? They seem overall mild, but as you pointed out, in combination they can be troublesome.

Dr. Dan Gold 40:10
Right. I agree. Most of the visual problems do tend to get worse over time, as opposed to getting better over time. Some people can absolutely sort of plateau at some point. Some people's vision can continue to decline. That being said, if there is a decline, it's a decline that isn't easily measured by typical eye exam testing methods, for instance, like visual acuity. It's extraordinarily slow over many years.

I think that the most important thing, like I said, some of the visual problems can be at least partially corrected by levodopa, by Sinemet. For instance, some of the visual problems, contrast sensitivity and color vision, that may be due to a lack of retinal dopamine, can be partially corrected by using dopaminergic medications. There's only so much that we can do.

It is extraordinarily important to have routine eye exams with your optometrist, with your ophthalmologist, because as people age, eye conditions become more and more common. The eyes tend to dry out over time, so dry eye becomes a very common problem. Some people can develop glaucoma, which can affect your visual fields.

Cataracts are extraordinarily common as well. People can have retinal issues and retinal detachments and macular degeneration and other problems that tend to affect people as they age. Some of those, or most of those problems, those visual issues, do have well-known and evidence-based therapies. Make sure that you're not dealing with something that is treatable, like a cataract that's impacting your vision. You can have cataract surgery for that. From a Parkinson's standpoint, it's hard to predict what will happen to somebody's vision in the future.

But as this is a neurodegenerative, progressive problem, unfortunately, the visual issues do tend to get worse over time as well.

Jim Beck 42:45
Yeah. Dr. Gold, I think you brought up a good point that these are issues which people deal with as they age in general, so Parkinson's disease just may complicate them.

Another question that's brought up is especially regarding some of these convergence insufficiency issues. The muscles may not be working right. Are there exercises people can do prophylactically to help prevent some of these things, to just kind of stay in shape? We talk at the Foundation about the importance of exercise overall, and typically we're talking about cardiovascular fitness, but can we extend exercise and fitness to the eye?

Dr. Dan Gold 43:34
Right. That's an interesting question, one that I've never actually thought of. I'm not aware of any studies or any papers looking at prophylactic eye exercises to try to prevent convergence insufficiency, so I don't know if that would work.

Certainly, if somebody has a couple of hours each day to work out the rest of their body, and they have another couple of minutes to do some eye exercises, there's no harm in doing that. That being said, it could be a waste of time, or it might be a great use of their time. I just don't know. There's no data on that specifically, but it's an interesting question.

Jim Beck 44:16
Sounds like it's worthy of a potential study right there.

Dr. Dan Gold 44:21
Absolutely.

Jim Beck 44:22
I just wanted to mention to our listeners that there's a survey online right now, and we encourage everyone to fill it out and provide feedback about their thoughts on today's presentation by Dr. Gold.

Also, to alert folks that our next webinar is going to be coming up in April. It's going to be about PD medication, about what's new. Rajesh Pahwa, at our Center of Excellence at University of Kansas Medical Center, will be presenting at that time.

We've covered a lot of topics here, and I think one of the things that you brought up, which I thought was really helpful for people who are dealing with some visual perceptions, is that bifocals, trifocals and progressive lenses can exacerbate that. Would you recommend overall that people with PD who are experiencing visual problems reconsider and perhaps just get specific glasses for distance and specific ones for reading? Is that a fair takeaway from your presentation?

Dr. Dan Gold 45:29
Right. It really depends on the person. I do neuro-ophthalmology, and I also do neuro-vestibular disorders, so I see a lot of patients with balance disorders. This isn't a specific recommendation to Parkinson's. This is a recommendation for basically anyone whose balance isn't great. If your balance isn't great for whatever reason, because you have Parkinson's, because you've lost your vestibular system, like I said, people typically over-rely on visual cues and visual inputs. They look at their feet. They look at the floor.

If you're looking through progressives or trifocals or bifocals, you're looking through sort of an improper distance. The correction is the improper distance. It's not intended for foot or floor distance. It's intended for reading or book distance. That can be visually confusing.

Generally speaking, for anybody with a balance problem, it's better to have two pairs of glasses: one for distance, one for reading. Some people just really dislike having two pairs of glasses, or if they need a separate third pair for an intermediate distance like computer work, for instance, that can be extraordinarily cumbersome. It really depends on the person, but if balance is really impaired, then it's a good idea to stay away from progressives, bifocals and trifocals.

As you start talking about other parkinsonian disorders like progressive supranuclear palsy, where characteristically patients have difficulties looking down, then bifocals and progressives and trifocals are really ineffective and not a good way to go, because again, they make the patients look down through the reading portion, but the patients' eyes just can't quite get there. These recommendations are not necessarily specific to Parkinson's, but really to anyone with a balance problem.

Jim Beck 47:32
Yeah, absolutely. With so many people in our community suffering from falls, I think that simple, practical advice like this is something that can really help people avoid hitting the ground sooner than they want to. Yeah, for certain.

One of the issues that occurs for people with Parkinson's disease, and just in general, are macular degeneration issues. Do you find that they are more common in people with Parkinson's disease, and do people with PD present unusual problems regarding AMD?

Dr. Dan Gold 48:14
I'm not specifically aware of an association, or a strong association, between Parkinson's and macular degeneration. I've heard that from patients before, but I'm just not aware of it in the literature. There is a literature on an association between open-angle glaucoma, not angle-closure glaucoma, but open-angle glaucoma, which is more of a progressive problem and a painless process, and also cataract formation. It might be a little bit more common in patients with Parkinson's.

For reasons that aren't entirely clear, the cataracts with regard to open-angle glaucoma, which is thought to be another sort of potentially neurodegenerative problem, could be related to Parkinson's because of an increase in oxidative stress, for instance. But as for an association between retinal disorders like macular degeneration and Parkinson's, there's just not a robust literature linking the two at this point.

Jim Beck 49:19
Fantastic. I just wanted to give a shout-out to folks in Kenya. We have just learned that, for those who don't know their geography well, it's in Eastern Africa. We have three support groups who are listening in in the principal cities: Nairobi, Mombasa and Kisumu, which I hope I pronounced correctly. If not, I'll soon learn how to do so.

Also, just to mention that for people who have additional questions as we're nearing the top of the hour, our Helpline is there to help answer questions that people with Parkinson's have. You can reach our information specialists at 1-800-4PD-INFO. That's 1-800-4PD-INFO. Or you can visit our website at Parkinson.org, where we have lots of materials available not only regarding vision issues in Parkinson's disease, but other problems that people with Parkinson's disease experience as well.

Dr. Gold, you've mentioned some ways to deal with people who may have secretions around the eye, like good eye hygiene, use of baby shampoo or hot compresses. How do you distinguish those types of symptoms from pink eye, which can happen as well for people with Parkinson's?

Dr. Dan Gold 50:46
Right. An infection versus just an inflammation of the eyelids. Usually the infection comes on more abruptly, and it's much more symptomatic. Very significantly heightened sensitivity to light, for instance. It might just be in one eye, whereas the inflammation, the blepharitis, tends to be pretty symmetric.

But really, if there's any concern or you're having any new symptoms of red eye or painful eye or sensitivity to light, you should really see your optometrist or your ophthalmologist right away. With the tools of the eye clinic, the slit lamp in particular, they would be able to quickly tell you which of those this is. Is this an infection, in which case antibiotics might be needed, or is this inflammation, in which case they'll give you recommendations on eyelid hygiene? But anything new, out of the blue, unexplained, then I would recommend, without hesitation, go see your eye care professional.

Jim Beck 51:45
Yeah, fantastic. I think that's great advice. One of the things you pointed out was that dopamine medication can help with some of the eye issues that people with Parkinson's disease experience. We had a question come in from Washington, from one of the children of a person who has Parkinson's. They're asking: is this in addition to their regular oral medication of Sinemet and whatever other dopamine replacement therapy they might be on, or is the dopamine replacement therapy enough to help deal with some of these issues?

Dr. Dan Gold 52:26
Right. This wouldn't be an extra dose. This wouldn't be sort of an as-needed dose when your eyes are blurry. This would just be replacing, repleting the dopamine with levodopa, with Sinemet or whatever other medication you're using. Normal doses, just whatever is appropriate for that person, should replenish the dopamine in the basal ganglia, but also in the back of the eye and the retina. Like I said, the visual symptoms, at least in the beginning, tend to be pretty subtle.

There might be a partial response to these medications, but the symptoms themselves tend not to be too dramatic. They tend to be pretty subtle. Simply just repleting in the normal way that your movement disorder specialist or your neurologist would do should be adequate.

That being said, some patients can have visual symptoms in their off period. As their Sinemet is wearing off, as they're in between doses, that's when double vision or blurry vision might be experienced. You should definitely talk to your neurologist about that to try to see what can be done about the dosages, the size of the dose and the frequency of the dosing throughout the day to minimize the visual off period as well.

Jim Beck 53:51
I think you bring up a really good point about on versus off, and this ties in with a question we had from a person with Parkinson's from New Hampshire. They have vision problems where, when they're off, they have difficulty moving their eyes, like looking down in particular. But when they go visit their ophthalmologist, they're typically on, because they have to get to the doctor's office and need to be on their medication.

How do you resolve that situation where people are experiencing these problems off versus on? Is it just a matter of them coordinating care, or you coordinating care better with their primary movement disorder specialist or their Parkinson's neurologist, to ensure that they're having fewer off periods? What would your approach be and what advice might you give to a person who's trying to resolve these issues?

Dr. Dan Gold 54:46
Right. As a clinician, we always like to see the problem ourselves. While I'm sure that your ophthalmologist believes you, that you're having these off-period symptoms and eye movement issues and double vision, or whatever it is, it would be nice for that eye care specialist and for your neurologist to see you during an off period to specifically see what the problem is. By specifically understanding what the problem is, that's the best way for us to help you.

But absolutely, I would have that conversation with your neurologist. Again, do the dosages of your medication, does the frequency of your medication, need to be modified in some way to reduce those off periods?

Jim Beck 55:34
Again, I think also people who are in clinical trials often have a practically defined off, where they don't take their medication. Their last dose is at night, and then they wake up and come in for their study visits first thing in the morning when they haven't taken medication. Maybe that's something to broach as a way to have the clinicians actually see some of these symptoms. It's problematic. Yeah, no, not easily done, but it's something to consider, I guess.

Dr. Dan Gold 56:08
Right, absolutely. I would recommend trying to recreate your specific symptom in the best way that you can so that your physicians can understand what you're experiencing and do their best to help you.

Jim Beck 56:22
Absolutely. I want to ask an oddball question, which I hear my kids ask about and I hear people ask about, and that's about floaters in the eyes. I don't know exactly the origin of those, and you hear people talk about them periodically. The question coming in from a person with Parkinson's from Illinois is: are these floaters something that's inherent to Parkinson's disease, or just something that people have overall?

Dr. Dan Gold 56:52
I would say that floaters are inherent to age, not Parkinson's. As I mentioned earlier, there are just a lot of visual problems that tend to be much more frequent and much more common as people age. Floaters are one of them. Almost everyone will experience floaters at some point in their lives. Again, this has no association with Parkinson's disease per se, just simply with changes that occur in the back of the eyes with normal aging. The vitreous, the jelly-like substance that fills your eyeball, tends to separate away from the retina, the back part of the eye.

That can lead to a vitreous detachment, where people can have flashes, floaters, and oftentimes this is just a benign condition. That being said, if you do have a sudden onset of a bunch of flashes and floaters, and you never had this before, it's a good idea to have your eyes checked by your optometrist or your ophthalmologist. They need to be able to dilate your eyes and take a good look at the back. We need to make sure to rule out a retinal detachment. That's something that we could potentially help you with and do something about surgically.

If you ignore the symptoms of a retinal detachment, that can really affect, compromise and impair your vision. Floaters are just sort of inherent to age, not Parkinson's. It's just a very, very common problem.

Jim Beck 58:17
Well, thank you very much, Dr. Gold. It's been a wonderful midday break from work to get a chance to listen to you and to better understand the issues that people with Parkinson's disease have with vision and a lot of the practical advice you gave.

I also want to let folks know who are listening that if you want to listen to this webinar again, we'll have an archive that will be available starting next week on Tuesday, March 12. You can find it at Parkinson.org.

Dr. Gold, thank you very much for your time, and we'll speak to our Parkinson's community again in April. Bye-bye.

Dr. Dan Gold 58:58
Thanks so much. Bye.