The Return of Color Vision Secondary to
Macular Degeneration After
Chiropractic CareThis section is compiled by Frank M. Painter, D.C.
Send all comments or additions to: Frankp@chiro.org
FROM: Chiropractic Journal of Australia 2017; 45 (1): 38–43 ~ FULL TEXT
OPEN ACCESS Thomas A. Brozovich D.C
Palmer College of Chiropractic,
1000 Brady St,
Davenport, IA 52803, USA
Objective: To discuss the chiropractic management of a patient whose unilateral color vision loss associated with macular degeneration resolved after treatment.
Clinical Features: A 66-year-old female with a history of cervical, thoracic and lumbar pain and a four-year history of macular degeneration of the left eye resulting in a loss of color vision sought chiropractic care for primarily her spinal pain. Initially she was not requesting care for her loss of color vision. She reported having multiple recent traumas (falls) injuring her cervical, thoracic and lumbar region.
Intervention and Outcome: The patient was adjusted based on location of her subluxations (intersegmental joint dysfunction). She had 17 treatments over 8 month. A thermography study was performed of the face before and after treatment and a more symmetrical thermal pattern was obtained. Her spinal pain reduced. She also unexpectedly had a return of color vision in her left eye.
Conclusion: The patient responded favorably to chiropractic care, which resulted in a decrease in spinal pain and improvement in left eye color vision.
Keywords Macular Degeneration; Color Blindness
From the FULL TEXT Article:
INTRODUCTION
A patient seeking care for musculoskeletal symptoms following trauma is common in chiropractic practice. Patients may concomitantly have other health problems identified during the history and physical examination. The chiropractor’s treatment is typically intended to reestablish joint function and reduce inflammation. On occasion, symptoms and conditions other than musculoskeletal may respond to chiropractic care.
Macular degeneration has a number of causes: age, genetics, mutation, Drusen bodies, hypertension, cholesterol, oxidative stress, race, and exposure to sunlight, vitamin D deficiency, and smoking. Symptoms include visual distortion, blind spots, photostress, photophobia, better night vision, peripheral vision sensitivity, and color vision loss. [1] Macular degeneration also causes color vision loss and is not directly associated with age and is not well understood. [2] It rarely causes total blindness. [3] The macula covers about 2% of the retina, and the receptors most concentrated in the macula are the cones, which are color receptors. The visual loss seen with macular degeneration is better described as a loss of contrast sensitivity, with the contour of objects, shadows and color vision being diminished. [4] Drusen bodies are similar to plaques and can deprive the photoreceptors of the retina of blood and oxygen. This can explain the progressive loss of vision; however; clinically it’s common to see Drusen bodies in patients with normal visual acuity. Therefore, there must be another factor that accounts for loss of vision with macular degeneration.
Thermography is a method for recording the temperature of the skin. This can be visualized using non-contact high resolution infrared thermography. Interpretation of a thermogram, according to the American Chiropractic College of Thermology, is based on relative symmetry between like points on the body and based on the research by Uematsu. [5, 6] There is normally less than .4°C difference between sides in a normal individual. The forehead has less than 0.2°C difference between right and left side. [6] The skin area is for heat transfer. The loss of heat through the skin is in the form of infrared radiation and can be documented with thermography. The vascularity of the skin is controlled by the autonomic nervous system. When there is a sympathetic nerve fiber injury which is part of the autonomic nervous system due to compression as in tumors or disc herniation, or in irritation as in local autoimmune response from trauma, there will be asymmetry of skin temperature noted on the thermogram. [6]
Compression/irritation at the nerve root will appear on the thermogram in a very specific thermal pattern noted as thermatomes, which closely resemble dermatomes. [5] Spinal nerve roots do not contain postganglionic sympathetic fibers and are joined by postganglionic sympathetic nerve fibers outside the canal. Changes in the thermal emission are caused from irritation of corresponding sensory nerves which result in an increase in sympathetic outflow resulting in a vasoconstriction of the supplied area. [6] A study utilizing stimulation of the chest produced pupillary dilation concluded that sympathetic activity rather than parasympathetic inhibition was responsible. [7]
CASE REPORT
A 66-year-old female sought care for musculoskeletal symptoms and concomitantly had loss of color vision in her left eye. She had a history of multiple injuries. Several of her injuries were a result of falling off horses, leading to moderate to severe sprains/strains, grade 2, in the thoracic spine. She also suffered multiple concussions in some of her falls. She commented that the loss of color vision of the left eye was worsening. She also had a history of TIAs.
Examination revealed a coherent, alert, 6 ‘2”, 160-pound female. Vital signs were normal. Review of systems revealed dry skin, headaches, corrective lenses, macular degeneration with color blindness, TIAs, hiatal hernia, and depression. Cranial nerve exam revealed macular degeneration and color vision loss in the left eye. Her visual acuity was 20/25 in the right eye and 20/80 in the left eye. She also had episodes of nausea and dizziness. The vertebral basilar artery insufficiency exam was negative. Shoulder depressor, Kemp’s test. Schepelmann’s test, and bilateral leg raising and lowering tests all produced mid-thoracic pain. The Soto-Hall test produced mild cervical tenderness. Chiropractic exam using static and motion palpation, instrumentation and leg checks revealed subluxations at C2, C6, T1, T6, and L5. The remainder of the examination was negative.
She was referred to a neurologist. A visual evoked-response test revealed dysfunction in her left optic nerve. Brain MRI revealed microangiopathic ischemic vascular disease (accounting for her TIA’s). A fluorescein angiogram revealed abnormalities in her left eye. Several months into treatment, a repeat fluorescein angiogram was performed and it was noted that her left eye had shown improvement in its vascularity and visual acuity.
Management and Outcomes
She had 17 treatments over 8 months. Treatment consisted of chiropractic manipulation to the cervical, thoracic and lumbar region based on location of subluxations (intersegmental joint dysfunction). We adjusted the subluxations located at C2, C6, T1, T6, and L5. During the first few adjustments she experienced seeing a brilliant flash of green light in her left eye during a thoracic adjustment. Following the adjustment, she noticed that her color vision returned to normal. She indicated that she could see color through her left eye as well as her right eye.
Table 1 Two facial thermograms were performed according to the protocol of the American Board of Clinical Thermology. [8] Five standard views were taken, consisting of frontal view, right side view, left side view, right oblique view, left oblique view, focusing particular attention to the temperature in the supraorbital region. [7] Following equilibration, the first thermography examination was performed prior to any adjustment procedures. She was then adjusted. Following a second equilibration, the second thermography examination was performed. Table 1 shows the results of the thermograms.
Ten standard photographs were taken of the patient’s face during the thermography procedure to monitor for any possible ptosis, cormiosis, or enophthalmos. No abnormalities were noted on the photographs throughout the entire procedure, indicating no signs of Horner’s syndrome.
DISCUSSION
The patient’s history, physical exam findings confirmed macular degeneration of the left eye. These findings were confirmed with a visual evoked-response test, internal ophthalmoscopic exam, and a fluorescein angiogram and explained why she had been experiencing left eye visual deficits.
This case raises questions related to the underlying etiology of her macular degeneration. There are multiple causes for macular degeneration. The question arises, why, with chiropractic treatment and the removal of subluxations (intersegmental joint dysfunction), was there a change in her left eye symptomatology and what was the mechanism? The mechanism of the disease caused from Drusen bodies is primarily a hypoxia response of the retina and macular region. [1]
It is possible that there was a decrease in blood flow to the retina with this patient. To determine if this was a possibility, a thermographic study of the face could be performed and would reveal the measurement of skin temperature and provide information about alterations in local flow. [6, 8] The primary arteries involved would be the supraorbital and supratrochlear arteries, which arise from the internal carotid artery via the ophthalmic artery supplying the frontal region of the face. [9] These arteries supplying the frontal area of the face are the terminal ends of the internal carotid artery. Just proximal to the supraorbital artery is the ophthalmic artery supplying blood to the retina. Therefore, monitoring the blood supply on the frontal region of the face would confirm if there was a deficit of blood supply to the ophthalmic artery and reveal a decrease in blood supply to the retina and indicate a state of hypoxia to the retina. [9, 12]
CONCLUSION
Macular degeneration of the left eye with deficits of thermal emission noted in the supraorbital region would give indication of decreased blood supply through the ophthalmic artery to the retina. The result would be a decrease in macular function and a loss of color vision. [1, 2, 6, 8, 9] Following treatment, increased vascular flow noted on the thermogram would indicate that subluxation could cause the hypoxia to the retina. The decreased blood flow arises from different mechanisms than in peripheral nerve injuries. Spinal nerve roots do not contain postganglionic sympathetic fibers in the spinal canal and IVF region. The spinal nerve is joined by postganglionic sympathetic nerves outside the canal some distance from the compression/irritation at the IVF region secondary to subluxation. This compression/irritation causes an increase of the sensory nerves, (nociceptive pain C fibers) signal. The sensory nerve synapses in the cord and stimulates the preganglionic sympathetic nerve.
The preganglionic sympathetic nerve travels to the sympathetic ganglion and synapses with the postganglionic sympathetic nerve. The postganglionic sympathetic nerve then exits the sympathetic ganglion and radiates into the periphery and innervates the peripheral vascularity causing vasoconstriction. [10] This neural activity will result in a temperature change noticeable on a thermogram and will show a cold area in the area of the nerve root distribution. [11]
Thermogram studies revealed an increase in frontal temperature indicating a favorable response to chiropractic manipulative therapy and the removal of the subluxations. This occurs by reducing irritation to the sensory nerve and decreasing the postganglionic outflow. This re-established normal blood supply to the retina, allowing proper function of the cones of the macula region and improving the patient’s color vision. Further investigation is warranted.
References:
Windsor RL, Windsor LK.
The many visual problems of macular degeneration.
http://www.eyeassociates.com/many-visual-problems-of-macular/
accessed December 16, 2016Downie LE, Cheng AS, Vingrys AJ.
Color vision deficits in intermediate age-related macular degeneration.
Optom Vision Sci 2014; 9 (8):32–38De Jong PT.
Age-related macular degeneration.
N Engl J Med 2006;355(14):1474–1485Horton JC.
Harrison's principles of internal medicine.
McGraw Hill. Ch. 25:16th ed.Keegan JJ, Garrett FD.
The segmental distribution of the cutaneous nerves in the limbs in man.
Anat Record 1948;102:409-437Uematsu S.
Thermographic imaging of cutaneous sensory segment in patients
with peripheral nerve injury.
J.Neurosurgery 1985;62:716-720Arieff AJ, Pyzik SW.
The ciliospinal reflex in injury of the cervical spinal cord and management.
Arch.Neurol Psychiat 1953:70:621-629Prithvi R.
Practical Management of Pain.
Chicago, IL; Mosby.11:168-183,1992Netter FH.
Atlas of human anatomy.
Summit, NJ; CIBA-Geigy Corporation, 1990Guyton AC, Hall JE.
Textbook of medical physiology, 12th Ed.
Philadelphia, PA; Saunders2011;60:731-740Bralsford K, Uematsu S.
Thermographic presentation of cutaneous sensory and vasomotor activity
in the injured peripheral nerve.
J Neurosurgery 1985;62:711-715Wexler CE.
Lumber, thoracic, and cervical thermography.
Prog Clin Biol 1982:107:377-388
Return to BLINDNESS
Since 5-02-2017
| Home Page | Visit Our Sponsors | Become a Sponsor |
Please read our DISCLAIMER |