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Neuro-ophthalmic conditions often associated with movement disorders
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By becoming familiar with ocular conditions that often accompany movement disorders, ophthalmologists are better able to diagnose and treat these disorders.
For instance, Parkinson’s disease may result in convergence insufficiency, whereas patients with Huntington’s disease can appear easily distracted visually.
“Eye features of movement disorders include dysfunction of convergence, vertical gaze and blink rate,” David A. Clark, DO, told Ocular Surgery News. “The careful clinician can troubleshoot these problems and in many cases implement a care plan that alleviates the symptoms.”
Clark is lead author of a review of movement disorder syndromes and their ocular symptoms published in Current Opinion in Ophthalmology. The review was motivated by the effect these eye symptoms have on quality of life and the diagnostic value of recognizing these eye features, he said.
“These eye signs can help make a diagnosis when extraocular motor features are inconclusive,” Clark said. “Some of the diagnostic and therapeutic concepts in eye movement disorders have been understood for decades and are generally well known. However, there is also a lot of recent research that should be of value to ophthalmologists.”
A careful exam of eye movements can clarify an otherwise nonspecific clinical picture, Clark said. For example, progressive supranuclear palsy and multisystem atrophy can initially look similar to Parkinson’s disease, and diagnosis can take months or years.
“Eye features provide valuable diagnostic evidence and can shorten the time to diagnosis,” Clark said.
Convergence insufficiency is a prevalent feature in patients with Parkinson’s disease. Diplopia and binocular blur at close range are also features in these patients, Clark said.
“But trials of convergence exercises in adults have yielded conflicting results. However, base-in prism in the reading portion of spectacles can resolve diplopia and improve reading quality.”
Dry eye is also very common in Parkinson’s disease and results from many factors, including decreased blink rate.
“Aggressive corneal lubrication or punctal occlusion may be needed,” he said.
Progressive supranuclear palsy decreases volitional upgaze and downgaze.
“This impaired vertical gaze can make bifocal, trifocal or progressive lenses difficult to use, particularly the inferior reading portion of the lens,” Clark said. “Separate full-field reading, computer and distance glasses, while less convenient, can bring the appropriate correction into the visual axis.”
Convergence insufficiency is also widespread in progressive supranuclear palsy.
Multisystem atrophy can present with varied features, with gaze-evoked and downbeat nystagmus common in multisystem atrophy with cerebellar features.
“Volitional saccades can overshoot or undershoot the intended target,” he said.
In patients with Huntington’s disease, “fixation on a target is frequently interrupted, particularly when an alternate visual stimulus is presented,” Clark said.
Wilson disease can be a diagnostic challenge due to its varied presentation, including saccadic vertical and horizontal pursuits.
Whipple’s disease, an infectious disease, may present with supranuclear gaze palsy and characteristic oculomasticatory myorhythmia. It is treated with antibiotics, but relapse may be common.
Blepharospasm is nearly three times more prevalent in women than in men, according to one survey of patients. Half these patients had isolated blepharospasm and the other half had either Meige syndrome (a combination of blepharospasm and oromandibular dyskinesias) or a dystonia such as eyelid-opening apraxia. Nearly 75% of these patients also reported photophobia.
Botulinum A toxin is considered first-line treatment for blepharospasm.
Treatment options for hemifacial spasm are botulinum A injection and surgical decompression. – by Bob Kronemyer