Parkinson's Disease and the Eye

Eye Problems With Parkinson's

Jody Abrams, MD

Neuro-Ophthalmology/Oculoplastics

Sarasota Retina Institute

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

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


• 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


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 treatmentBOTOX


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


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


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


The injections are done around the lower and upper eyelids

Injections are also given between the eyebrows


The injections are done in the office, often in the same exam chair we see you in

The needle is a very tiny needleMost patients report minimal, if any pain



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


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


Just below the eyelid the next layer of the eye is the tear film


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


The tear film is made up of three layersThe front oil layer prevents evaporationThe middle water layer hydrates the eyeThe inner mucus layer (against the cornea) coats 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 rateThis has even been called a PARKINSON'S STARE since the

rate can be severely decreased


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!


What are symptoms of dry eyesDecreased visionBurning eyes Stinging eyesRed eyesWatery eyesGritty feeling eyesEven double vision


There are multiple ways to test for dry eyes Schirmer’s test

Fluorescein Staining


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

Parkinson’s Disease and The EyeOnce 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!


The first step is often using artificial tearsThere are multiple kinds of artificial tears and I tell

patients to try different ones to see which works best for them


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


Some patients have trouble getting eye drops into their eyes and often waste medication

Luckily there is a spray artificial tear drop


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)


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

Parkinson’s Disease and The EyeIf plugs and or tears do not help there are other

medications Restasis Steroid Eye dropsNSAIDs (ibuprofen for the eye) Fish oil (omega 3)


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


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


Cataract surgery is done as an outpatient surgery, and can be done with minimal anesthesia


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


Once the cataract material is removed, an artificial lens is placed into the eye to help the patient see clearly


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


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


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

Parkinson’s Disease and The EyeSome 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


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


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


In years past glaucoma was followed by testing the peripheral fields with a visual field machine


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



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 typesWet Dry


There are now injections avaliable to treat the wet macular degeneration

The dry type all we can offer are vitamins


Are there any questions?

Health & Medicine

Parkinson's Disease and the Eye