parkinson's disease, Parkinson's Health, vision and PD

Vision: More than Meets the EYE! Tricks to Aid PD Patients :By Dr. De Leon

” Vision is the art of seeing what is invisible to others.” ~ Jonathan Swift

The eyes have always held a great mystery for many since ancient times. Egyptians regarded them as one of the vital organs to be preserved for the after life to them see where they were going. Others claim the eyes are the window to the soul.

Whatever their mystical significance is one thing is for certain their function its even more complex yet! So important is vision that nearly 30% of  supratentorial (this is the area of the brain that lies above the cerebellum and supports the occipital lobe) region of the brain is dedicated to the activity of deciphering, decoding and understanding what we see around us.

As a neurologist part of our exam is to evaluate eye function as it pertains to the brain. That is to say to ascertain that what we (you & me) are seeing is being processed appropriately by our brains.

Like everything else pertaining to the brain there are a myriad of intricate connections and pathways which can be disrupted along the way from the eye to the vision center (occipital lobe. Our job, then, is to find out where the problem is and try to find a solution if at all possible.

I have discovered as a neurologist and PD patient that this is not always an easy task nor is there always an easy solution.

Yet, I will attempt to give some advice on ways to make PD visual symptoms more manageable however possible.

One of my first signs of PD was significant dysfunction involving my visual system which nearly cost me my life a couple of times as well as my drivers license. Although,  as a whole my vision problems are 110% improved from where they started from time to time they continue to challenge me in my activities of daily living.  Just  a couple of days ago I had an incident while driving through the bank teller which reminded me that all is not as it should. I bounced back and forth from side to side hitting the cement dividers like a ball in a Ping-Pong machine as I tried to exit onto the street with dignity intact avoiding eye contact with those around hoping that I had not taken out another chuck out of my tire which I had just replaced!

Obviously, my medication dose was no longer working as I would like it. Time to increase my dose but also time to see an eye doctor to make sure no new abnormalities had occurred causing this behavior.

  As I said before vision is a crucial sense upon which we heavily rely on and when not working well it can wreak havoc in our lives.

Common Eye Problems with PD: There are 6 tiny Muscles which move our eyes continuously even in sleep they are moving -like other muscles in our body these too get STIFF & SLOW.

  • decrease blinking
  • decreased visual acuity- usually normal or near normal in PD- problem lies with contrast
  • decreased color vision- colors become dull and less vibrant
  • decrease in ability to detect contrast – worst with night, rain, subtle shades, glare
  • double vision
  • dry eyes
  • visual hallucination
  • decreased visual field- result into bumping into things, walls, other cars etc. due to loss of peripheral vision (caused by eye muscles being stiff and not moving in all directions)
  • Impaired convergence- difficulty bringing eyes together in sync to view an object which is near by
  • smooth pursuit is choppy – may cause trouble with reading
  • saccades ( quick eye movements) in tracking or following objects quickly we undershoot- thus missing target.

UNCOMMON eye problems for PD but COMMON  of PARKINSON’s PLUS Syndromes:

  • Blepharospasm- abnormal blinking (increased) and sustained contraction of eye lids
  • Apraxia of eyelid -inability or difficulty opening eyes on command usually have to use touch stimuli -open manually
  • decrease vertical eye movements – sine qua non of PSP

****The retina has cells that produce levodopa.*****

As we begin to loose dopamine else where in our brains, guts, our eyes can become depleted as well especially if we are constantly using to read, watch TV, drive or perform any activity which requires visual precision and concentration.

So, I went to eye doctor yesterday and my color vision detection has decreased to my surprise while my ability to tell contrast has worsened. No wonder I am running over things can differentiate subtle things yet my convergence and visual fields have improved.

How do we address these troublesome visual issues and prevent our lives from losing quality and independence.

  1. Since our visual system is very much dependent on dopamine – the first line of treatment involves replacement! I have found personally that NEUPRO works best for this because it provides a continuous dose of dopamine agonist. Azilect works well too but does not last 24 hrs.
  2. Convergence insufficiency is a common problem- one way to help this is doing “Pencil push-ups” where you bring your pencil slowly towards your nose while you focus on it and then push arm away with eyes continuing to be fixed on pencil- repeat 10 times at least 2-3 times a day. Another thing is to add prisms to your reading glasses. Also, covering an eye with scotch tape or satin gift tape for a few hours then doing the other.
  3. decrease blinking/dry eyes- artificial tears- prefer preservative free- 3-4 times a day- more often if will be driving, reading or doing computer work because these activities cause a significant decline in tear secretion and distribution; decrease reading especially on kindle -e-books, get larger print with darker ink; decrease time on computer- take frequent breaks ( every hour 15 minutes) and do ‘push- pencil’ exercises. some medications may increase dry eyes like Artane or tricyclics  e.g. Elavil.
  4. contrast deficits – have eye doctor tint your glasses yellow or brown which will help with subtle shades, at night, and with rain. have anti glare on your glasses as well. At home make paths and walk ways with distinct visual patterns /lines to avoid falling and bumping into things.
  5. visual field deficits – dopamine replacement – but prisms may also help with this.
  6. double vision in my experience usually due to medication effect- adjust medications
  7. visual hallucinations-usually a sign of underlying dementia- if not causing problems to patient – no need to treat- otherwise treat with anti-psychotics e.g. Seroquel/ Clozaril.

 Sources: http://www.pdf.org- expert briefings-Gold, D. ” Vision more than meets the eye: Visons symptoms of PD”

@copyright 2016

all rights reserved by Maria De León MD

 

chronic illness, dementia, parkinson's disease, parkinsons dementia, parkinsons health and beauty tips

Visual Hallucinations in PD: What do they look like? by Dr. De Leon

Someone asked not long ago if Parkinson’s hallucinations had a particular pattern or flavoring to them? The truth is that there are common trends seen in PD patients who experience hallucinations. First, a hallucination is a strong perception of something that is not real or does not exist. Any and all of the senses can be involved in a hallucination meaning that one can feel, taste, touch, see or hear something that is not real. Hallucinations are purely imaginary as opposed to illusions which are distortions of real things/ objects/ people/ and sounds. The second most common hallucination in my experience is olfactory (smell) hallucinations …I frequently think something is burning. other people have told me same thing. this may be related to olfactory neurons dying out.

It is estimated that at some point up to 75% of PD individuals will experience this phenomena of hallucinations particularly-visual.

It is also important to note that the timing of such events can be a huge diagnostic clue. In typical PD, these symptoms do not occur until more than 10 years into diagnosis and can be exacerbated by medications but are a part of the disease itself. So, if symptoms present at onset or within a few years of Parkinson’s symptoms then we are most likely NOT dealing with regular garden variety PD but rather a disease in the spectrum of Parkinson family like Lewy body dementia or CBGD ( corticobasalganglia degeneration) to name a few.

The most common type of hallucination in PD individuals is a visual one, as I stated earlier.  These can be either black and white or in full color and typically involve children or animals. The perceptions can last a brief period of time or hours. however, important to note that usually the images do not speak or make sounds and thus are not ordinarily distressing to the individual who for the most part remain aware that this is a hallucination (not real). In fact, a lot of my patients, as do many other PD individuals, rather enjoy seeing the children and find comfort in these images. However, although it is usually not the norm some patients can find the hallucinations distressing, anxiety provoking, and even frightening at times, these typically occur with more violent or frightening images- typically of demons and such.  When a person cannot distinguish reality from make- belief or if the images are too frightening or causing distress, this is the time for intervention.

What can you do to help?

1)  Make note as to when hallucinations are more likely to occur to try to prevent. Confusion, hallucinations and a full moon usually go hand in hand! So, keep those neuroleptic drugs handy just in case you may need during a full moon or lunar eclipse. In my experience, more patients were brought to ER because of psychosis during these days.  Typically, I would recommend pre-medicating a patient during those days if I knew they were prone to hallucinate and get distressed over the event.

2)  People that sleep a lot during the day seem to be more prone to visual hallucinations. Try to maintain normal sleep wake cycle as much as possible and prevent excess daytime sleep. On the other hand, sleep deprivation can also trigger these episodes. Therefore it is important  to discuss with your physician any sleep problems.

3)  Also be aware that certain medications like anti- cholinergics (e.g.amantadine), anti- histamines (Benadryl), anti- anxyolitics (e.g. klonopin)  even dopamine medications, more the agonists than levodopa, can induce hallucinations.

4) Other triggers for hallucinations are acute infections. In the elderly population urinary infection is the number one culprit. So maintain your loved ones well hydrated.

Even though, PD individuals may experience auditory hallucinations this is not the norm and if this is highly prevalent, one must consider other causes triggering these events, such as brain tumors, strokes, medications, etc.

Often, my grandmother who had Parkinson’s in her final stages would hallucinate. She frequently saw children playing and thought of them as the children she had lost when they were infants or toddlers. Seeing them made her happy. In this scenario I did not need to give her any type of medication for psychosis or hallucinations for its not always necessary to medicate a loved one just on the basis that they are having hallucinations. However,  there were times when she thought the house was being flooded and caused a great deal of distress thinking that she and we were going to drown especially my daughter who was only a toddler then.  At those times, I would have to give medication to decrease her anxiety.

How to handle patient when hallucinating?

1) You never want to be confrontational or argumentative or even try to change their belief about their hallucination; it would only escalate to violence.

2)  Also do not try to give medication when they are agitated or again will only cause you the caregiver increased heartache.

3) Best to walk away if they are not in imminent danger let them settle down then bring a medication best if it’s something quick acting like an orally disintegrating compound. Another good technique that works unless extremely agitated is distraction with books, pictures, coloring, games, etc.

Fortunately, we now have a new medication on the market just for PD psychosis from Acadia called Nuplazid (Pimavanserin). Medications which I frequently employed for this problem were atypical antipsychotics( neuroleptics) such as Seroquel and Clozaril since they would not interfere with motor symptoms of PD, there are other medications which can be given in smaller quantities but used because they are IV or orally disintegrating.

Finally, since rarely do hallucinations in PD occur in absence of dementia this needs to be treated.  Look for other underlying causes such as strokes, or vitamin B12 deficiency. Adjust dopamine levels and best to remove Amantadine and dopamine agonists which can exacerbate problem and start treatment with an anticholinesterase inhibitor, like Aricept. In my experience combination treatment with Namenda and Exelon or another one of its class went along way to curbing dementia and hence hallucinations.

Make sure you consult your physician regarding any changes in mental status including hallucinations.

Sources:

http://www.bioprocessonline.com/doc/acadia-s-nuplazid-receives-fda-breakthrough-therapy-designation-for-parkinson-s-psychosis-0001

http://www.epda.eu.com/en/parkinsons/in-depth/pdsymptoms/hallucinations-delusions/

 

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Dr. M. De Leon is a movement disorder specialist on sabbatical, PPAC member and research advocate for PDF (Parkinson’s Disease Foundation); Texas State Assistant Director for PAN (Parkinson’s Action Network). You can learn more about her work at http://www.facebook.com/defeatparkinsons101 you can also learn more about Parkinson’s disease at www.pdf.org or at www.wemove.org; http://www.aan.org, http://www.defeatparkinsons.blogspot.com All materials here forth are property of Defeatparkinsons. without express written consent, these materials only may be used for viewers personal & non-commercial uses which do not harm the reputation of Defeatparkinsons organization or Dr. M. De Leon provided you do not remove any copyrights. To request permission to reproduce release of any part or whole of content, please contact me at deleonenterprises3@@yahoo.com contributor http://www.assisted-living-directory.com Contributor http://www.lavozbrazoriacounty.com

parkinsons health and beauty tips

Health & Beauty Tip # 9 : Unveiling the truth behind Visual Problems in Parkinson’s Disease – By Dr. De Leon

Health & Beauty Tip # 9 : Unveiling the truth behind Visual Problems in Parkinson's Disease - By Dr. De Leon

At least 2 years before my Parkinson’s diagnosis, I began experiencing difficulty with night vision particularly in depth perception which progressively got worst thus making driving at night not only increasingly more cumbersome but also more hazardous. Of course being a neurologist my mind went immediately to a differential diagnosis including rare disorders like Refsum’s Disease known for its accumulation of long chain fatty acids which leads to night blindness.

But never was PARKINSON’s DISEASE in my differential – well at least not idiopathic (cause unknown) regular garden variety PD! YES! Several Atypical Parkinson Syndromes or Parkinson Plus Syndromes ( e.g. PSP – Supranuclear palsy known for its limitations in vertical gaze causing patients to frequently trip on side walk or drop food on their shirts, or CBGD – corticobasalgangliadegeneration which is known for having visual spatial problems- not recognizing a part of your body as your own!)

Never really seen visual disturbances early on in PD as a preclinical- pre motor symptom (now with hind sight I can recall only one patient presenting this way but no one -several PD experts including myself- thought that the visual problems were part of the PD scenario!)
Although, for years many Parkinson patients have complained of visual deficits, they typically have been non specific and because Parkinson patients as a whole tend to be older, the problems have always been assumed to be related to AGE!! ( e.g. cataracts, glaucoma, macular degeneration, other eye disease).

I began to experience even more pronounced night vision loss without a clear etiology. My ophthalmologist assured me there was “Nothing” wrong with my eye sight other than mild near sightedness “normal” for my age. There were no abnormalities on my MRI of Brain to explain this and I did not have any neuromuscular deficits although at times my symptoms acted like I had a visual field defect! As my disease progressed with increasing slowness, stiffness, gait difficulty and worsening dystonia, I realized that so was my ability to judge distance especially at night. I knew that these symptoms had to be related. Although, at this time my neurologist still could not relate it to PD nor frankly could I! At the beginning, I thought it might also be stress or fatigue related from overworked muscles and severe eye strain since symptoms appeared to wax and wane.

Initially, I was left with my frustration and only means of treatment was to wear corrective lenses at night. However, the sense of NOT Knowing Exactly how close the cars where to me hit me one night as I was nearly run over by an 18 wheeler which had appeared to be several feet further than it actually was. As I began to merge unto oncoming traffic, the sound of the horn and the lights glaring at me of the 18 wheeler, nearly blinded me but somehow I managed to swerve off the road just in the nick of time before being flattened like a pancake. After that near death experience, I did not drive at night for a long time! I still did not know for sure that my visual problems were related to my Parkinson symptoms. Nevertheless, I had a high degree of suspicion. My visual perception failed me at the most inopportune times but particularly troublesome were the times I had to park the car in the garage. I always felt a sense of accomplishment getting my car into the confines of the garage. Only to discover that what appeared to be a perfect alignment from inside the vehicle was a mere façade as I performed yet another futile attempt to climb out of my car. For you see, I had once again wedged myself up against the wall without even realizing it. So, I try to back out without hitting the garage door which was not always successful. Sometimes, I would get stuck trying to climb out of the passenger side due to the stiffness and would be stuck there for a while! Other times, don’t even know how I would park my car nearly horizontally in my garage! I would depend on my husband to realign the car so I could exit successfully from the garage once again when I need to use the car the next time. Fortunately, I never knocked down a wall. Although, I came close several times leaving several dents in my car and the garage for posterity. Since I was on L-dopa, this did not happen daily but often enough that I had to paint the far left side wall of the garage neon orange to keep me from parking so close to it. The color would serve as visual contrast reinforcement and thus help me avoid hitting the door knob in the closet in the garage which is now all bent out of shape from parking car to close to the wall. During this time of visual fluctuations, parking close to two cars in close proximity was an impossibility never not without denting one on the way in or out!

For this reason, I had my ophthalmologist make me prisms to help with the depth perception which has improved my ability to judge distances dramatically!! This is what I would typically recommend for my PSP patients so I thought I would try… I did not want to have to give up my drivers license.

My husbands solution of course is even more practical. Trade in my Lexus for a “Smart Car.” This way I would be able to fit ANYWHERE!! If I could only get in and out of one without difficulty, I would drive the “Hello Kitty” model for a while just to make a statement and lead the world in ONE BIG PARKIE parade!.

Although, the idea of riding a HELLO KITTY “Smart Car” sounded good & funny in theory, in principal not so much. Therefore, I knew something had to be done before I lost my independence completely and had to be chauffeured around. Even though my friends were terrific, I did not want to be driven around if there was a solution for my problem. So, I began researching the matter. Initially, I did not find a lot of information until the last few years when the concept of non motor symptoms and premotor symptoms have finally taken root. This is the acceptance that these symptoms which are non dopamine derived can at times precede the motor symptoms, can be the MOST troubling and disrubtive to a persons quality of life yet are the most treatable as in the case of Visual disturbances. Even tough, vision problems is a dopamine problem it is classified in the non-motor symptomatology because it is a sensory issue- how we perceive and process the world!

We have missed visual problems in Parkinson’s because traditional tests do not tell the whole story in a persons ability to see. Acuity does not tell us how some one sees in regards to contrast in background ( i.e. shades of grey). It turns out that Parkinson’s causes a decrease in contrast perception and color discrimination because the retinas uses dopamine as a transmitter!- something which I had forgotten from my neurobiology. There is also decrease in actual acuity and voluntary eye movements with poor convergence which leads to blurred vision and at times double vision ( diplopia). There is also irritation of the surface of the eye causing a decrease blinking. Compromised vision can then lead to increase occurrence of hallucinations especially in elderly, with certain medications, or if a person has other eye problems or dementia.

The best treatment and gold standard for visual problems in PD is Levodopa. This can improve volitional eye movements and rate of blinking, Also any of the dopa- agonists. Ever since I started Neupro Patch all my visual field defects and vision problems including depth perception and trouble driving at night have dissipated. However, of note as of my last eye exam my acuity had changed significantly with advance of my illness! I assumed that the reason my symptoms were fluctuating despite being on L-dopa was the off states now that I have steady states of dopamine with agonist I don’t have fluctuations in vision….my hypothesis!
I recommend to everyone that you discuss with your physician any vision problems,
maintain good visual hygiene
yearly ophthalmologic exams,
corrective refraction and/or prisms
artificial tears if needed
rest your eyes!
if you do this you too will have no need for a “Smart Car!”

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@copy right 2013

all rights reserved by Maria De León MD

suggested reading for further information on the subject:
Visual Symptoms in Parkinson’s Disease by RA Armstrong-2011
http://www.ncbi.nlm.nih.gov>journal List> Parkinsons Dis> v.2011;2011

Dr. M. De Leon is a retired movement disorder specialist,
PPAC member and research advocate for PDF; Texas state assistant director for PAN (Parkinson’s Action Network).
You can learn more about her work at http://www.facebook.com/defeatparkinsons101
you can also learn more about Parkinson’s disease at http://www.pdf.org or at http://www.wemove.org