William V. Padula OD, SFNAP, FAAO, FNORA Guest Blog

image_pdfimage_print

 

May Awareness LDA Guest Blogger

Padula.Headshot.2019.Square

William V. Padula, OD is Director of the Padula Institute of Vision Rehabilitation in Guilford, CT.  He is a Fellow of the American Academy of Optometry and the Founding President of the Neuro-Optometric Rehabilitation Association (NORA).  Dr. Padula is on the faculty for Western University of Health Sciences College of Optometry and Salus University of Health Sciences College of Optometry. 

Dr. Padula has conducted research discovering Post Trauma Vision Syndrome (PTVS) and Visual Midline Shift Syndrome (VMSS).  Dr. Padula has written numerous publications including a book titled: Neuro-Optometric Rehabilitation and Neuro Visual Processing: An Integrated Model of Rehabilitation. He is the primary author of a chapter on vision in Brain Injury Medicine: Principles and Practice.  He has also been awarded six U.S. Patents.

The Visual Consequences of Lyme Disease: Early Diagnosis and Treatment

Vision is often affected by Lyme disease yet the symptoms are often mistaken for other problems associated with functional ocular disorders, balance, movement and cognition as described by Padula.(1) When a child is infected often they experience symptoms of blurring, double vision (diplopia), photophobia, distortion of space, visual strain and headaches when performing near vision activities, difficulty with balance, dizziness, difficulty with convergence and focusing, to name several (see Figure 1).

Standard eye exams may show difficulties with convergence and accommodation (focus of the eyes). These characteristics can occur without Lyme disease so doctors may recommend glasses and vision therapy without ruling out Lyme related disease. A Lyme blood titer is not always positive because the spirochetes may not be active in the blood causing the disease to not be identified.

Recent research (Padula, et.al. submitted for publication)(2) has found a biomarker using visual evoked potentials (VEP). This demonstrates that the Lyme related disease causes dysfunction with the spatial visual process in the brain (see Figure 2). This dysfunction of the spatial visual process causes interference in the balance between two visual processes in the brain. This imbalance is what causes the functional vision difficulties such as convergence and accommodative insufficiency. A compromise to the spatial visual process causes the child’s vision to isolate on detail. Reading is no longer is fluent. Instead of the spatial visual process seeing the shape of several words before the higher process sees the letters, the child begins to see the words as isolated details of letters. This is termed ‘focal binding’. It produces intensity within the visual process that interferes with comprehension, memory and produces fatigue, headaches and visual fatigue. This condition also affects the children when in busy moving environments. The world becomes over-whelming and this produces anxiety and in some cases even panic attacks.

For those who haven’t had this visual compromise it is like driving at night in a snowstorm. With your headlights on low beam you can still see the road. If you have made the mistake and hit your high beams all that you will see is a meteor barrage of snowflakes and it becomes very difficult to see the road. The experience is very stressful. This is what it is like for the child with Lyme related disease. Except they can’t turn off the high beams or seek relief by going home out of the storm. The environment is a constant barrage of stimulus that becomes over-whelming.

Treatment requires an inter-professional team. This includes the treating physician who should refer the child to a vision specialist such as an optometrist or ophthalmologist, practicing Neuro-Visual Processing Rehabilitation (NVPR). The examination is more involved than a routine eye exam and may include a thorough sensorimotor evaluation, comprehensive refraction, dynamic testing of accommodation and convergence, a VEP as well as vision-balance gait analysis. The doctor will often recommend special prescriptive glasses for distance and near vision with prisms that re-balance the spatial visual process. In addition, a neuro-psychologist specializing in Lyme disease together with a social worker and counselor may be part of the team provided for the child. The team will establish recommendations to the school concerning adaptations needed to enable the child to continue to go to school or recommendations for home schooling may be necessary depending upon the level of functioning of the child.

Treating the child as soon as possible with the appropriate medications requires early diagnosis. If the spatial visual process is compromised the child may have a successful outcome for resolving the disease, however, the affect of the visual dysfunction will often interfere with development and cause compensations visually that will cause the visual symptoms to persist even after medical treatment is discontinued. Therefore, seeking a vision specialist to work with the child to rehabilitate the visual processing dysfunction can maximize the potentials of the child and reduce the interference to learning and development.

Figure 1. Checklist of symptoms often presented with early Lyme disease.

Figure 2. The figure on the left demonstrates a normal VEP while the figure on the right show a dysfunction of the spatial visual process caused by Lyme disease.

References

  1. Padula W. Neuro-Visual Processing Rehabilitation: An Intergrated Model of Service. Santa Ana, CA: Optometric Extension Program Foundation Press; 2012.
  2. Padula WV, Padula W, Frid E, Jeness J, Spurling, A, Sayyed A. Visual Evoked Potential N-75 Biomarker to Predict Lyme Disease and Visual Processing Dysfunction: An Experimental Design, (Submitted for publication).
  3. Crowder LA, Yedlin VA, Weinstein ER, Kortte KB, Aucott JN. Lyme disease and post-treatment Lyme disease syndrome: the neglected disease in our own backyard. Public Health. 2014;128(9):784-91.
  4. Borchers AT, Keen CL, Huntley AC, Gershwin ME. Lyme disease: a rigorous review of diagnostic criteria and treatment. J Autoimmun. 2015;57:82-115.