Selective effects of low doses of apomorphine on spatiotemporal contrast sensitivity in healthy volunteers: a double-blind placebo-controlled study

Parkinson's disease, visual hallucinations and apomorphine: A review of the available evidence

BACKGROUND

Visual hallucinations (VH) occur in the clinical course of Parkinson's disease (PD) and are predictive for PD dementia. The genesis of VH is related to impaired bottom-up and/or top-down visual processing which can be linked to cholinergic dysfunction and mono-amine imbalance. The risk of developing VH with oral dopamine agonists seems to increase with advancing disease, while in contrast some clinical studies suggest that apomorphine does not worsen VH, or might even improve VH.

METHODS

The aim of this study is to review the current evidence of apomorphine and its effects on VH in PD patients.

RESULTS

Apomorphine is well-tolerated in PD patients with VH, also in long-term follow-up studies. Apomorphine is also suggested to have the potential to alleviate VH. Some data suggest that the positive effect of apomorphine on VH is related to its piperidine moiety, part of many anti-psychotics. Irrespective this piperidine moiety, apomorphine has a high D1-like receptor affinity, and acts as a serotonin 5-HT2A receptor antagonist, which might explain the potential anti-hallucinogenic properties as well.

CONCLUSION

The anecdotal evidence suggesting that apomorphine has a relatively low proclivity to induce VH in PD may be due to its capacity to reduce serotonergic activity in particular. Therefore apomorphine is still an option to consider in fluctuating PD patients with VH, if they are treated properly with respect to their cholinergic deficits and existing VH.

Schizophrenia and the eye

Although visual processing impairments are common in schizophrenia, it is not clear to what extent these originate in the eye vs. the brain. This review highlights potential contributions, from the retina and other structures of the eye, to visual processing impairments in schizophrenia and high-risk states. A second goal is to evaluate the status of retinal abnormalities as biomarkers for schizophrenia. The review was motivated by known retinal changes in other disorders (e.g., Parkinson’s disease, multiple sclerosis), and their relationships to perceptual and cognitive impairments, and disease progression therein. The evidence reviewed suggests two major conclusions. One is that there are multiple structural and functional disturbances of the eye in schizophrenia, all of which could be factors in the visual disturbances of patients. These include retinal venule widening, retinal nerve fiber layer thinning, dopaminergic abnormalities, abnormal ouput of retinal cells as measured by electroretinography (ERG), maculopathies and retinopathies, cataracts, poor acuity, and strabismus. Some of these are likely to be illness-related, whereas others may be due to medication or comorbid conditions. The second conclusion is that certain retinal findings can serve as biomarkers of neural pathology, and disease progression, in schizophrenia. The strongest evidence for this to date involves findings of widened retinal venules, thinning of the retinal nerve fiber layer, and abnormal ERG amplitudes. These data suggest that a greater understanding of the contribution of retinal and other ocular pathology to the visual and cognitive disturbances of schizophrenia is warranted, and that retinal changes have untapped clinical utility.

The possible role of retinal dopaminergic system in visual performance

It is a well-known fact that the retina is one of the tissues in the body, which is richest in dopamine (DA), yet the role of this system in various visual functions remains unclear. We have identified 13 types of DA retinal pathologies, and 15 visual functions. The pathologies were arranged in this review on a net grid, where one axis was "age" (i.e., from infancy to old age) and the other axis the level of retinal DA (i.e., from DA deficiency to DA excess, from Parkinson disorder to Schizophrenia). The available data on visual dysfunction(s) is critically presented for each of the DA pathologies. Special effort was made to evaluate whether the site of DA malfunction in the different DA pathologies and visual function is at retinal level or in higher brain centers. The mapping of DA and visual pathologies demonstrate the pivot role of retinal DA in mediating visual functions and also indicate the "missing links" in our understanding of the mechanisms underlying these relationships.

Repeated visual hallucinations in Parkinson's disease as disturbed external/internal perceptions: Focused review and a new integrative model

Visual hallucinations (VH) in Parkinson's disease (PD) are a chronic complication in 30 to 60% of treated patients and have a multifaceted phenomenology. Flickering, faultive impressions, and illusionary misperceptions precede the core syndrome of stereotyped, colorful images. The patient variably recognizes these images as hallucinations, being rarely irritated or frightened and more often amused as a bystander. Although studies on VH in PD focus on several research domains, no comprehensive, unified theory has been developed to study their pathophysiology. We have adapted Hobson's work on the states of consciousness and propose a model integrating seemingly disparate data on VH. We suggest that VH should be considered as a dysregulation of the gating and filtering of external perception and internal image production. Contributive elements and anatomical links for the model include poor primary vision, reduced activation of primary visual cortex, aberrant activation of associative visual and frontal cortex, lack of suppression or spontaneous emergence of internally generated imagery through the ponto-geniculo-occipital system, intrusion of rapid eye movement dreaming imagery into wakefulness, errative changes of the brainstem filtering capacities through fluctuating vigilance, and medication-related overactivation of mesolimbic systems. Different etiologies likely produce different phenomenologies and the prognosis may not be uniform. This new conceptual framework permits an anatomical view of VH and suggests new, testable hypotheses regarding their pathophysiology and therapy.

Decreased color discrimination and contrast sensitivity in Parkinson's disease

Patients with Parkinson's disease (PD) often complain of blurred vision or even of distinctive visual disturbances like hallucinations and illusions. Recent studies have emphasized the potential influence of primary visual deficits of color and contrast discrimination. To study primary visual function, we studied color discrimination (CD) and contrast sensitivity (CS) during 'on' medication in PD patients and compared them to non-PD subjects. Twenty one PD patients were compared to 30 age-matched controls using CD tested by the D-15 Lanthony test (D15) and the Farnsworth-Munsell 100 Hue test (FM) and CS tested by the Pelli-Robson (PL) and the Vis-Tech tables (VT). We excluded subjects with a visual acuity </=0.6 Snellen fraction or known ophthalmological diseases. PD patients showed greater impairment on all visual tests than controls. This difference was significant for the FM test (P<0.001), the spatial frequencies 12 and 18 cpd (cycles per degree) of the VT test (P<0.05) and both the monocular and binocular PR tests (P<0.05). Most tests for CS and CD showed statistical independency. CS deficits, but not CD deficits, correlated with age in both patients and controls. This study documents major and independent impairment of both color and contrast discrimination in PD patients. Further studies should elucidate possible clinical implications and correlations, such as the frequency of falls or visual hallucinations.

Contrast sensitivity improvement with sulfamethoxazole and trimethoprim in a patient with Machado-Joseph disease without spasticity

A double-blind, placebo controlled, cross-over trial of sulfamethoxazole and trimethoprim was performed in a 62-year-old male patient who suffered from Machado-Joseph disease for 25 years. The patient, with cerebellar ataxia, akinetic-rigid syndrome and motor weakness but without any pyramidal features, had been chair-bound for 3 years before the trial. Bactrim therapy markedly improved performance on a physical examination which tested standing and gait, as compared to placebo session. Walker-assisted gait was possible again. For the first time, evaluation of spatio-temporal contrast sensitivity was performed and also revealed an improvement after Bactrim therapy as compared to placebo. These results suggest that Bactrim may be effective in degenerative neurological diseases and that Bactrim may have an overall effect on neurotransmission rather than solely possessing antispastic properties.

Dopaminergic modulation of visual sensitivity in man

A large body of experimental evidence supports the hypothesis that dopamine is a functional neuromodulator at many levels of the visual system. Intrinsic dopaminergic neurons were characterized in most mammalian retina, including man. These neurons give rise to a dendritic plexus covering the retina. Thus, dopamine seems to be involved in the organization of the ganglion cell and the bipolar cell receptive fields and modulates physiological activity of photoreceptors, both processes which underlie sensitivity and spatial selectivity of visual processing in the early stage of the visual system. Moreover, few data are now available concerning the functional significance of dopaminergic modulation of visual sensitivity in man. Parkinson's disease is a specific disorder of central dopaminergic systems. Abnormalities in the pattern-evoked potentials and electroretinogram have been found in parkinsonian patients. Contrast sensitivity, a useful tool for measuring visual spatio-temporal sensitivity in man, has also been shown to be modified due to this affection. Dynamic contrast sensitivity is primarily decreased in these patients, distinguishing them from the normal aging process. Because these modifications in shape of the contrast sensitivity function are reversed by L-Dopa, and that neuroleptic administration could reproduce them in schizophrenia patients, it was suggested that dopamine might tune the contrast sensitivity function in man. We have recently shown that subcutaneous apomorphine induces changes in contrast sensitivity in healthy volunteers, which preferentially affect motion sensitivity. These dopaminergic sensitive modifications in the shape of the contrast sensitivity function might reflect a change in the range of sensitivity of the visual system, both in dynamic and spatial properties. This could be explained by a modification in the spatial and dynamic properties of the ganglion cell responses in the retina. Moreover, we suggest both from our results and from the review of the literature that human psychophysical data confirm the hypothesis that dopamine may be involved in light retinal adaptation, as light-induced and dopamine-induced modifications in the shape in the contrast sensitivity function are quite similar.

GABA-ergic control of visual perception in healthy volunteers: effects of midazolam, a benzodiazepine, on spatio-temporal contrast sensitivity

1. We studied the effects of midazolam (MDZ), a benzodiazepine, on spatio-temporal contrast sensitivity, choice reaction time, and mood visual analogue scales in healthy volunteers. 2. Eight extensively trained, healthy volunteers were included in a placebo-controlled cross-over double-blind trial of MDZ (0.15 mg kg-1). Treatments were injected intramuscularly and evaluations were performed before and 0.5, 1, 2, 3 and 4 h after drug administration. Spatio-temporal contrast sensitivity was measured using a micro-computer with appropriate software. Stimuli were vertical gratings with adjustable contrast, with spatial frequencies of 0.25, 1 and 4 cpd. Four conditions of temporal modulation were used: the grating was either static or drifting laterally with temporal frequencies of 1, 3 and 9 Hz. 3. An analysis of variance was performed on the data. As compared with placebo, MDZ induced an increase in choice reaction time and sedation (as assessed on visual analogue scales). From 0.5-4 h after the injection, MDZ produced an overall decrease in visual sensitivity, as compared with placebo. More specifically, MDZ preferentially affected medium to high spatial frequencies and low temporal frequencies. Several non-exclusive hypotheses may account for the results: 1) an increase in the size of the receptive fields, 2) a preferential effect on the visual parvocellular pathways which mediate the sensitivity to high spatial and low temporal frequencies.