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Manifestations oculomotrices dans la maladie de Parkinson

Parkinsonian patients are particularly exposed to develop oculomotor symptoms. We aimed to raise awareness for these symptoms in our clinical practice when dealing with this population by reporting the case of a patient with Parkinson disease (PD), complaining from intermittent diplopia with oculomotor and sensory abnormalities.

we report a case of a sixty years-old male patient with history of parkinson's disease who presented with intermittent binocular dipolpia.

A sixty years-old diabetic patient suffering from PD consulted for binocular diplopia in August 2019. The medical history study showed that the patient was followed up in our department for three years (between 2016 and 2018), for proliferative diabetic retinopathy with a cystoid macular edema of the right eye. The patient reported binocular diplopia since June 2019.  It was intermittent complete oblique nearby and distance diplopia that occurred daily. The ophthalmological examination found a best-corrected visual acuity (BCVA) of 6/10 in both eyes. The fundus examination, fluorescein angiography, and OCT showed, that the retinopathy was stable, the patient had stage 2 ischemic maculopathy and there was no macular oedema. We completed the clinical examination with a Hess Lancaster test that showed a small limitation of the left superior oblique muscle. The optometric assessment showed a convergence insufficiency and impaired stereopsis. The patient's MRI was normal. The patient was referred to his neurologist who informed us that he was under Pramipexole and that the Pramipexole dose was increased progressively from 0.7 mg per day to 2.64 mg per day in March 2019 (before two months of the reported diplopia). She also found that the episodes of complete diplopia were associated with selective diplopia, visual hallucinations, and somnolence. She decided to reduce the Pramipexole dose to 0.54 mg and to add Amantadine 200 mg. We prescribed an inferior sector in the left spectacle glass as well as an optometric rehabilitation for the convergence. Although the sessions were tiring for the patient, they allowed, with the decrease of Pramipexole doses and the inferior sector to reduce the patient's symptoms.

Diplopia is frequent in Parkinson's disease (PD) patients; it can occur in all stages of the disease (30% in PD patients without dementia and 58% in those with dementia).PD patients may, however, not complain about diplopia spontaneously, that is why we aimed through this case, to raise awareness for this heterogeneous symptom in clinical practice. A high prevalence of oculomotor abnormalities, impaired vision, and visual hallucinations in PD patients with diplopia was also reported.There are two subtypes of binocular diplopia: selective diplopia (diplopia of single objects) and complete diplopia (diplopia of the entire visual field). Selective diplopia is not the result of oculomotor abnormalities, it may represent a type of visual illusion, and may reflect the mild end of the psychosis spectrum in PD. 

Oculomotor related diplopia in PD patients is frequent and recognizing it in clinical practice can significantly improve the patient’s quality of life.