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Parkinson's disease and the effect on the Eye
Parkinson's disease and the effect on the Eye
Parkinson's disease and the effect on the Eye
Parkinson's disease and the effect on the Eye
Parkinson's disease and the effect on the Eye
Parkinson's disease and the effect on the Eye
Parkinson's disease and the effect on the Eye
Parkinson's disease and the effect on the Eye
Parkinson's disease and the effect on the Eye
Parkinson's disease and the effect on the Eye
Parkinson's disease and the effect on the Eye
Parkinson's disease and the effect on the Eye
Parkinson's disease and the effect on the Eye
Parkinson's disease and the effect on the Eye
Parkinson's disease and the effect on the Eye
Parkinson's disease and the effect on the Eye
Parkinson's disease and the effect on the Eye
Parkinson's disease and the effect on the Eye
Parkinson's disease and the effect on the Eye
Parkinson's disease and the effect on the Eye
Parkinson's disease and the effect on the Eye
Parkinson's disease and the effect on the Eye
Parkinson's disease and the effect on the Eye
Parkinson's disease and the effect on the Eye
Parkinson's disease and the effect on the Eye
Parkinson's disease and the effect on the Eye
Parkinson's disease and the effect on the Eye
Parkinson's disease and the effect on the Eye
Parkinson's disease and the effect on the Eye
Parkinson's disease and the effect on the Eye
Parkinson's disease and the effect on the Eye
Parkinson's disease and the effect on the Eye
Parkinson's disease and the effect on the Eye
Parkinson's disease and the effect on the Eye
Parkinson's disease and the effect on the Eye
Parkinson's disease and the effect on the Eye
Parkinson's disease and the effect on the Eye
Parkinson's disease and the effect on the Eye
Parkinson's disease and the effect on the Eye
Parkinson's disease and the effect on the Eye
Parkinson's disease and the effect on the Eye
Parkinson's disease and the effect on the Eye
Parkinson's disease and the effect on the Eye
Parkinson's disease and the effect on the Eye
Parkinson's disease and the effect on the Eye
Parkinson's disease and the effect on the Eye
Parkinson's disease and the effect on the Eye
Parkinson's disease and the effect on the Eye
Parkinson's disease and the effect on the Eye
Parkinson's disease and the effect on the Eye
Parkinson's disease and the effect on the Eye
Parkinson's disease and the effect on the Eye
Parkinson's disease and the effect on the Eye
Parkinson's disease and the effect on the Eye
Parkinson's disease and the effect on the Eye
Parkinson's disease and the effect on the Eye
Parkinson's disease and the effect on the Eye
Parkinson's disease and the effect on the Eye
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Parkinson's disease and the effect on the Eye

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This is a talk on how Parkinson's disease affects the eye given by Dr. Jody Abrams, neuro-ophthalmology, Sarasota Retina Institute. I am a board certified ophthalmologist in Sarasota, Florida

This is a talk on how Parkinson's disease affects the eye given by Dr. Jody Abrams, neuro-ophthalmology, Sarasota Retina Institute. I am a board certified ophthalmologist in Sarasota, Florida

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    • 1. Eye Problems With Parkinson's Jody Abrams, MD Neuro-Ophthalmology/Oculoplastics Sarasota Retina Institute
    • 2. What is a Neuro-Ophthalmologist A neuro-ophthalmologist is either a neurologist or ophthalmologist who has spent a year or more after normal residency to learn more about the eye and brain interactions This includes eye muscle problems, optic nerve problems, blurred vision that is not explained by normal causes, and in, or between the eye and brain
    • 3. Parkinson’s Disease and The Eye There are many eye problems that can be seen in Parkinson's patients These can vary from issues like dry eyes, to spasm of the eyelids to visual distortions While most are not sight threatening like macular degeneration they can be just as debilitating if not addressed
    • 4. Parkinson’s Disease and The Eye • Blepharospasms are when the muscles around the eyes contract • These muscles are responsible for closing the eye so when they contract the eyes squeeze shut • The eyes look like they are blinking with a lot of force
    • 5. Parkinson’s Disease and The Eye As you can imagine this can be very irritating The patients have hard time reading or watching TV and even doing a basic eye exam can be difficult (like following glaucoma pressures) The good news is that this condition has a nice and proven treatment  BOTOX
    • 6. Parkinson’s Disease and The Eye Botox or botulinum toxin A has been around since the late 1970s It was brought to medical use by an ophthalmologist, Dr. Alan Scott, to use on patients with spasms of the face/eyelids and for eyes that cross
    • 7. Parkinson’s Disease and The Eye It was in the early 90s that a dermatologist and ophthalmologist couple noticed that their patients treated with Botox had improvement of their wrinkles This was published and the legend of cosmetic Botox was born Today Botox for spasms is still the preferred treatment and is covered by most insurance plans
    • 8. Parkinson’s Disease and The Eye Botox works by stopping the nerve from telling the muscle to contract This effect lasts about 3-4 months Prior to the use of Botox, blepharospams were treated with a very disfiguring extensive eyelid surgery
    • 9. Parkinson’s Disease and The Eye The injections are done around the lower and upper eyelids Injections are also given between the eyebrows
    • 10. Parkinson’s Disease and The Eye The injections are done in the office, often in the same exam chair we see you in The needle is a very tiny needle  Most patients report minimal, if any pain
    • 11. Parkinson’s Disease and The Eye  Other issues that occur in patients’ eyelids with Parkinson's is ptosis or droopy eyelids  Is this from the disease, or from aging, is a question that can be debated, but often the two are seen together  Often times with care, patients with Parkinson’s disease can undergo lid surgery with good outcome
    • 12. Parkinson’s Disease and The Eye The main goal of these procedures is not to make the patient look better, but to help the patient see better This is why it is covered by most medical plans including Medicare This is a functional not cosmetic surgery
    • 13. Parkinson’s Disease and The Eye Just below the eyelid the next layer of the eye is the tear film
    • 14. Parkinson’s Disease and The Eye The tear film is often overlooked but is a critical layer for the health of the eye and for good vision The first layer that light hits when entering the eye is the tear film. If this is defective, the light is scattered and the vision will be blurred This can be the reason that despite multiple glasses the vision is still blurred
    • 15. Parkinson’s Disease and The Eye The tear film is made up of three layers  The front oil layer prevents evaporation  The middle water layer hydrates the eye  The inner mucus layer (against the cornea) coats the eye
    • 16. Parkinson’s Disease and The Eye The tears are spread across the eye by eyelid blinking The average blinking rate is around 10 blinks a minute In patients with Parkinson’s disease there is a decreased blink rate  This has even been called a PARKINSON'S STARE since the rate can be severely decreased
    • 17. Parkinson’s Disease and The Eye When the blink rate is decreased it allows more evaporation to occur so the tear film breaks down There is often a decreased tear film to start with (secondary to age and medications) so coupled with a decreased blink rate, the eye can become very dry!
    • 18. Parkinson’s Disease and The Eye What are symptoms of dry eyes  Decreased vision  Burning eyes  Stinging eyes  Red eyes  Watery eyes  Gritty feeling eyes  Even double vision
    • 19. Parkinson’s Disease and The Eye There are multiple ways to test for dry eyes  Schirmer’s test  Fluorescein Staining
    • 20. Parkinson’s Disease and The Eye  Lissamine Green (My favorite and trademark look)  There are some new machines out that can test the tears and tell us about their makeup, how useful this information is, still is in debate
    • 21. Parkinson’s Disease and The Eye Once dry eyes are diagnosed there are multiple ways to treat it and often they are used in combinations We usually start with the most simple treatment and increase as needed Also drink water!
    • 22. Parkinson’s Disease and The Eye The first step is often using artificial tears  There are multiple kinds of artificial tears and I tell patients to try different ones to see which works best for them
    • 23. Parkinson’s Disease and The Eye Normal preserved artificial tears can be used up to 5 times a day If you need to use the tears more often, I recommend using nonpreserved artificial tears
    • 24. Parkinson’s Disease and The Eye Some patients have trouble getting eye drops into their eyes and often waste medication Luckily there is a spray artificial tear drop
    • 25. Parkinson’s Disease and The Eye If artificial tears are not working I often place plugs in the tear ducts The tear ducts are the drain for the tears, not the producer (this is the lacrimal gland)
    • 26. Parkinson’s Disease and The Eye The plugs go into the tear ducts and slow the tears from leaving the eye so rapidly, like a sponge down the drain of your sink I usually place collagen plugs that dissolve in about 4-6 months
    • 27. Parkinson’s Disease and The Eye If plugs and or tears do not help there are other medications  Restasis  Steroid Eye drops  NSAIDs (ibuprofen for the eye)  Fish oil (omega 3)
    • 28. Parkinson’s Disease and The Eye If medical therapy does not work there are some surgical procedures that can help These mainly involve tightening the lid or raising the lower lid to better cover the eye
    • 29. Parkinson’s Disease and The Eye Double vision can be a very bothersome problem in Parkinson's patients True double vision is when the eyes are not focusing on the same object and the brain sees two separate images This can be very disturbing
    • 30. Parkinson’s Disease and The Eye Double vision that resolves with one eye closed is called true or neurologic double vision and is due to a misalignment of the eyes If the double vision is still present with only one eye open this is often due to a problem of the tear film, cornea or cataract
    • 31. Parkinson’s Disease and The Eye True double vision can be from a eye muscle weakness or from the brain having trouble lining up the 2 eyes If there is a muscle weakness, the double vision is often worse when looking towards that muscle, and better if you look the other way
    • 32. Parkinson’s Disease and The Eye One of the most common causes of double vision in Parkinson's patients is convergence insufficiency People often complain of difficulty reading and seeing objects at near They can also notice blurred vision even at distance
    • 33. Parkinson’s Disease and The Eye Convergence insufficiency is when the the eyes do not converge or turn in together For us to see clearly at near the eyes have to turn in slightly to focus In convergence insufficiency the eyes stay rotated out and the eyes do not focus together giving double vision
    • 34. Parkinson’s Disease and The Eye While convergence insufficiency can occur in many settings we often see it in our Parkinson's population, and people after concussions/closed head injuries It is not known why convergence insufficiency is so common in Parkinson's patients because we are not sure exactly where in the brain the control for it occurs
    • 35. Parkinson’s Disease and The Eye Often times we can treat convergence insufficiency with an exercise called “pencil pushups” This is an easy exercise that can be done anywhere without breaking a sweat
    • 36. Parkinson’s Disease and The Eye If this does not work we can add prisms to the glasses for near I often find that Parkinson's patients do better with a pair of glasses for near and another for distance No line bifocals often cause problems for patients with Parkinson’s disease
    • 37. Parkinson’s Disease and The Eye Prisms, Botox, or even surgery can be used to resolve double vision if the cause is a specific muscle weakness That is why it is important to get a good measurement of the deviation of the eyes
    • 38. Parkinson’s Disease and The Eye Other eye motility problems can occur in Parkinson's that can cause visual distortion and even problems with mobility Nystagmus is a rapid repetitive involuntary movement in the eye This constant motion of the eyes can cause problems reading since you can not follow the lines or focus on words
    • 39. Parkinson’s Disease and The Eye Nystagmus can be from medications or just changes in the brain If a medication is causing it, we try to remove or reduce the amount of medication If it is from changes in the brain, medications can be used to help reduce the movement
    • 40. Parkinson’s Disease and The Eye Parkinson's patients can often have problems with just normal movements of their eyes It can lead to difficulty following objects or people, especially in crowded situations (or even following the golf ball) If this is caused from a medication we try to limit or eliminate the medication
    • 41. Parkinson’s Disease and The Eye Just recently we had a very lucky addition to the ability to help our patients with vision problems such as alignment of the eyes Cindy Anderson here at SMH has started an outpatient vision rehab program
    • 42. Parkinson’s Disease and The Eye She can now offer multiple areas of treatment for our patients that can dramatically improve the movement of their eyes and the brain’s ability to perceive it Prior to her starting this program we were limited in what we could offer patients, now there is multiple areas of hope
    • 43. Parkinson’s Disease and The Eye Cataracts are not a direct effect of Parkinson’s disease but can have accelerated formation with medications and form just from natural aging Cataracts are a clouding of the natural lens in the eye
    • 44. Parkinson’s Disease and The Eye When cataracts cause blurred vision that is not correctable with glasses it is time to talk about cataract surgery Cataract surgery is the most common elective surgery done today in the United States
    • 45. Parkinson’s Disease and The Eye Cataract surgery is done as an outpatient surgery, and can be done with minimal anesthesia
    • 46. Parkinson’s Disease and The Eye In cataract surgery the natural lens is removed with an ultra sound machine that breaks the lens up and sucks it out all at the same time Despite what is advertised, there is no true laser cataract surgery, all techniques use the ultra sound to break the lens up and remove it
    • 47. Parkinson’s Disease and The Eye Once the cataract material is removed, an artificial lens is placed into the eye to help the patient see clearly
    • 48. Parkinson’s Disease and The Eye One of the big areas in cataract surgery today is the new lenses that offer patients the ability to see near and far without the use of glasses While this might be a good option for some people, I recommend not pursuing this in patients with neurologic disease, especially Parkinson's
    • 49. Parkinson’s Disease and The Eye  Visual hallucinations can occur as frequent as 1 in 5 patients, with the number even higher if including those with just non-bothersome illusions  These visual hallucinations (or false images) are often nonthreatening in nature, such as small people or animals or loved ones who have died  Threatening visual hallucinations are less common
    • 50. Parkinson’s Disease and The Eye The cause of these hallucinations is related to the increased levels of dopamine, as is created with Parkinson's medications Sleep disturbances and or stress increase the risk of visual hallucinations Also medications such as sedatives, sleeping medication, pain meds and some urinary medications can cause increased visual hallucinations
    • 51. Parkinson’s Disease and The Eye Some of the treatments to help include  Reducing or changing the Parkinson's medication  Antipsychotic medications, either Seroquel or Clonazapine  Others are not recommended as they can worsen movement problems  Making sure there are no other contributing medical conditions  Like an underlying infection, possibly a urinary tract infection  Improving sleep and stress
    • 52. Parkinson’s Disease and The Eye An important issue to remember through all of this is while Parkinson’s disease can cause multiple ocular issues, there are other problems that need to be watched for also
    • 53. Parkinson’s Disease and The Eye Glaucoma is a disease of the optic nerve of the eye that causes loss of the nerves It is related to increased eye pressure Glaucoma can cause slow permanent vision loss and needs to be detected early
    • 54. Parkinson’s Disease and The Eye In years past glaucoma was followed by testing the peripheral fields with a visual field machine
    • 55. Parkinson’s Disease and The Eye In patients with Parkinson’s disease these can be hard test to do reliably There is an older manual machine that can be easier for patients to follow the glaucoma A new technology is called OCT can follow the actual nerve tissue thickness and help follow progression of the disease
    • 56. Parkinson’s Disease and The Eye Macular degeneration is a leading cause of blindness in patients over 60 This is from a breakdown on the layers of the retina There are two types  Wet  Dry
    • 57. Parkinson’s Disease and The Eye There are now injections avaliable to treat the wet macular degeneration The dry type all we can offer are vitamins
    • 58. Parkinson’s Disease and The Eye Are there any questions?

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