This document discusses various eye problems that can occur in patients with Parkinson's disease. It outlines that neuro-ophthalmologists specialize in eye and brain interactions. Common eye issues for Parkinson's patients include dry eyes, eyelid spasms, and double vision. Blepharospasms can be treated effectively with botox injections. Dry eyes are also common due to decreased blinking and can be addressed with artificial tears or other treatments. Double vision may be caused by issues with eye alignment or convergence. Catararacts and glaucoma also need monitoring. Overall many eye symptoms in Parkinson's patients can be improved through treatments like Botox, eye exercises, and eye drop therapies.

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?