This patient with idiopathic Parkinson Disease PD shows by jennyyingdi


Convergence Insufficiency
A 73-year old man with known PD for 10
years, complained of horizontal double
vision for 18 months. He could see the
images move apart and refocus a single
image by blinking. Diplopia was most
marked reading, driving and watching TV.
Three ophthalmologists gave him 3 separate
sets of glasses. Past hx –ve for strabismus or
prism glasses.
Presenting Symptoms

Difficulty walking
Generalized rigidity
Tremor of the hands at rest
Diplopia reading
      Ocular Motor Signs
Impaired convergence
Slow hypometric saccades
Saccadic substitution for smooth pursuit
Poor visual suppression of the
vestibular ocular reflex
Decreased spontaneous blink rate
Glabella tap positive
        Neurological Signs
Rigidity of the neck, head flexed and tilted
Mild head tremor
Mask-like face
Slow (akinetic) head and neck
Convergence Insufficiency

Three factors:
     Parkinson’s disease
     Medications (Sinemet)
 Etiology of Slow Saccades
Spinocerebellar Ataxias (SCA),
especially SCA2 (olivopontocerebellar
Huntington’s Disease
Progressive Supranuclear Palsy
Parkinson’s (advanced cases) and
related diseases.
Lytico-Bodig disease
        Slow Saccades
Whipple’s Disease
Wilson’s Disease
Amyotrophic Lateral Sclerosis (some
Drug intoxications: anticonvulsants,
Courtesy of Mendez F. Cummings JL. Dementia: A Clinical
Approach. Third Edition. Butterworth Heinmann 2003.
 The following illustrations of
The brain MRI
Pathology of the midbrain
Lewy body

 are taken from the case of an elderly
 woman with Parkinson’s Disease.
Figure 1 Axial T2WI through the midbrain shows the normal
pars compacta, the space between the substantia nigra and
red nuclei.
      Figure                  a patient
Figure 2 the2: Axial T2WI insubstantia with PD shows the midbrain is atrophic
             Axial T2WI in a patient with PD showsother because
              red nuclei and            nigra almost touch each
                                                                the midbrain
is atrophic and the red and substantia nigra almost touch
      the pars compacta is greatly reduced.
each other because the pars compacta is greatly reduced.
                                                 Courtesy Anne Osborn, MD
Figure 3 Axial gross autopsy in patient with PD shows striking
reduction of the pars compacta, especially well seen on the right
side where the red nucleus and substantia nigra are actually
     Figure PD_Lewy body        Section of the brain showing cytoplasmic
     inclusion body within a surviving neuron with an eosinophilic core
     surrounded by a clear the brain showing cytoplasmic inclusion
Figure 4 Section ofhalo. The lewy body is not entirely specific, but it is
bodyawithin a surviving neuron with an eosinophilic core
       highly sensitive marker for PD.
surrounded by a clear halo. The Lewy body is not entirely
specific, but it is a highly sensitive marker for PD
    Parkinson’s Disease
Due to dopaminergic cell death
leading to dopamine deficiency
Defective gene for  synuclein on
Chr. 4q
Second locus on Chr. 2p

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