#1a What Your Eye Doctor Should Know

What Your Eye Doctor Should Know

About FMS and CMP

by Devin J. Starlanyl

This information may be freely copied and distributed only if unaltered, with complete original content including: © Devin Starlanyl, 2003.

Please read “What Everyone on Your Health Care Team Should Know.”

Fibromyalgia (FMS) may affect eyesight, and many myofascial TrPs can cause optical symptoms. This can confuse diagnosis and treatment, especially if there is body-wide chronic myofascial pain (CMP) in addition to FMS. Fibromyalgia tends to amplify symptoms of co-existing conditions, as the central nervous system is in a state of central sensitization. Not only hyperalgesia but also allodynia may occur.

Normally nonpainful stimuli, such as light, can evoke pain. Since the hypothalmicpituitary- adrenal axis may be one of the first to unbalance in FMS, part of this sensitivity may be due to a connection between the hypothalamus and light sensitivity.

 Many people with FMS and CMP have difficulty driving at night. The lights of the oncoming cars are painful or distracting. Beta-carotene seems to help this in some cases. It may be due to altered reactivity of the pupils, which is under neurotransmitter control.

FMS patients often have sicca syndrome, or symptoms that mimic Sjogren’s syndrome (Price, Venables 2002). Coupled with the FMS sensitivity to and amplification of pain, this may cause intolerance of contact lenses. The dryness, irritation, sensitivity, and the allergies often prove too much to handle. Yet the weight of glasses can aggravate myofascial trigger points (TrPs) in the head and neck area. After a regimen of eye exercises and medication (especially

guaifenesin), some people with both FMS and CMP have been able to wear contact lenses for the first time. Thick secretions in the eyes, with accretions at the corner of the eye, may occur in patients with fibromyalgia. Myofascial TrPs may constrict tear ducts as well as nerves and blood vessels. There is a study indicating eye motility dysfunction in FMS (Rosenhall, Johannson and Orndahl 1996). This all needs to be taken into consideration in differential diagnosis.

Fibromyalgia is not homogeneous (Sorensen, Bengtsson, Ahlner et al. 1997;

Eisinger, Starlanyl, Blotman et al 2000). The flickering of fluorescent lights as they wear out can be difficult for some FMS patients to tolerate. Patients have reported varying responses ranging from very mild irritation and disquiet to near seizure and petit-mal-type fugue states. This may be similar to “video-game epilepsy”, which is not unique to FMS. FMS sensations are simply amplified. One study found that 50% of photosensitive patients are also sensitive to a 50-Hz television flicker (Kasteleijn-Nolst Trenite, da Silva, Ricci et al. 1999). Some people with this sort of sensitivity may do well on Neurontin and other centrally-acting medications.

Sternocleidomastoid (SCM) TrPs can cause redness and tearing of the eye (Simons, Travell and Simons, 1999). Artificial tears may be a big help temporarily, but the patient must have the TrPs treated and the perpetuating factors identified and brought under control. An artificial tears formula that can be safely stored in the refrigerator allows the patient to enjoy the mechanical effect of the cold to help constrict swollen red vessels. Some people with FMS may develop sensitivity to some anesthetic eye drops.

Myofascial TrPs in the SCM muscle may cause sensitivity to patterns of light and dark, such as stripes, checks, or even shadows on the road. Some patients have reported becoming dizzy to the point of falling, just from looking at patterns of light and dark. Some patients even vomit. This can happen in fabric stores, around escalators, or even around conveyor belts. Even certain floor patterns can cause dizziness, or watching airport carousels.

Some of this is due to the proprioception disturbances which are well documented (Simons, Travell and Simons 1999). There may also be a proprioceptive component in many or most cases of FMS. Proprioceptor dysfunction may be associated with any TrP. Clumsiness is often due to a combination of internal eye muscle TrPs, FMS lack of optical accommodation, and SCM TrPs. Look for the patterns. SCM TrPs can cause any (or all) of the following problems: dizziness, imbalance, neck soreness, a swollen glands feeling, runny nose, maxillary sinus congestion, tension headaches, eye problems (tearing, bug-eyes, blurred or double vision, inability to raise the upper eyelid, dimming of perceived light intensity), spatial disorientation, postural dizziness, vertigo, sudden falls while bending, unintentional veering while you walk, staggering walk, impaired sleep, nerve impingement, and disturbed weight perception. This last symptom can result in spilling food and drink, and throwing an object across the room when you are just trying to pick it up. These symptoms can include a feeling of continued movement in a car after stopping, and the feeling of tilted “banking” as the car turns corners.

Any of the muscles that hold the eyeballs in place can develop TrPs, causing double vision, blurry vision, or changing vision. They may profoundly influence

proprioception (Buttner-Ennever, Horn 2002). The TrPs cause the muscles to contract. If these muscles are being contracted asymmetrically by TrPs, vision irregularities result. The culprits may be TrPs in the extrinsic eye muscles, the SCM, trapezius, temporalis, or cutaneous facial muscles. Simple eye exercises can help relieve this problem. Warn your patients that the eye exercises should be started gently and only done once a day. Repetitive exercises should not be done for TrPs. They will only make the TrPs worse, because the muscle is already contracted physiologically. They must be stretched gently and lengthened before they can be strengthened. The first time your patient tries to roll the eyes upward, looking into each “corner” of the eye and stretching the muscles, s/he may experience pain or headache. That is a sign that the TrPs are present, and must be approached carefully.

Tell your patient to do this: To check the inner eye muscles, stretch them. Put one hand on your head, above your forehead. Then try to look at that hand. This shouldn’t hurt. If it does hurt, the TrPs are telling you they are there.With your eyes still looking upward at your hand, look from one upper corner of your eye to the other. If this hurts, the TrPs are there, and that’s at least part of what is causing your eye problem. The eye exercises stretch out eye muscle TrPs.

Once your patient does this simple eye exercise regularly, the mysterious changing vision problem often disappears. TrPs in the splenius cervices muscles can cause blurring of near vision, as well as pain in the side of the head to the eye on same side, and in the eye orbit. It is helpful to discuss your patient’s reading habits.

Incorrect lighting can give rise to TrPs (Simons, Travell and Simons 1999).

Cutaneous facial TrPs can cause pain in your ears, eyes, nose, and teeth. These TrPs are shallow, and can occur anywhere on the face. Teach your patient some gentle pressure-point work for the face. If the TrPs are there, the patient will let you know.

The orbicularis oculi cutaneous facial TrPs refer pain to the nose and cheek and above the eye, and cause jittery letters when you try to read. The words seem to jump off the page or disappear when you stare at them. Putting clear plastic over the page to decrease print contrast may help with this problem.

Asymmetry is a common perpetrator of TrPs. Check to see if your patient’s ears are misaligned. Ensure that glasses fit well. Asymmetry may also be caused by myofascial TrPs. Check all of your patients medications.Recent research indicates that the combination of melatonin, Zoloft and a high protein diet may cause optic neuropathy (Lehman, Johnson. 1999). Many patients with these conditions have metabolic syndrome or insulin resistance, and may be eating more protein. They also may be on melatonin for sleep and Zoloft for FMS.

References

Buttner-Ennever J.A., Horn A.K. 2002. The neuroanatomical basis of oculomotor disorders: the dual motor control of extraocular muscles and its possible role in proprioception. Curr Opin Neurol 15(1):35-43.

Eisinger J., Starlanyl D., Blotman F. et al 2000. [Protocole d’informations snonyme sur les fibromyalgiques.] Medicine du sud-est Lyon Mediterranee Medical. 1:9-11. [French] Kasteleijn-Nolst Trenite, D.G., da Silva A.M., Ricci S., Binnie C.D., Rubboli G.,

Tassinari C.A., and Segers J.P. 1999. Video-game epilepsy: a European study. Epilepsia 40 (Suppl 4):70-4.

Lehman N.L., Johnson L.N. 1999.Toxic optic neuropathy after concomitant use of melatonin, zoloft, and a high protein diet. J Neuroopthalmol 19(4):232-234.

Price E.J., Venables P.J. 2002. Dry eyes and mouth syndrome — a subgroup of patients presenting with sicca syndrome. Rheumatology (Oxford) 41(4):416-22.

Rosenhall, U., Johannson G., and Orndahl G. 1996. Otoneurologic and audiologic findings in fibromyalgia. Scand J Rehabil Med 28(4):225–232.

Simons, D.G., Travell J.G., Simons L.S. 1999. Myofascial Pain and Dysfunction:

The Trigger Point Manual, Volume 1, edition II: The Upper Body. Baltimore: Williams and Wilkins.

Sorensen J., Bengtsson A., Ahlner J. et al. 1997. Fibromyalgia — are there different mechanisms in the processing of pain? A double blind crossover comparison of analgesic drugs. J Rheumatol 24(8):1615-1621.

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Information for Eye Care Professionals

©Devin Starlanyl, MD 1995-1998

Two excellent medical texts are available on MPS, "Myofascial Pain and Dysfunction: The Trigger Point Manual Vol. I and II" by Janet G.Travell M.D. and David G Simons M.D. The first volume is important to you, as it deals with upper body TrPs. This is but an introduction to them. The manuals show the referred patterns, tell what causes them, and how to relieve them. You can find specific information in regards to focal length and TrPs. 

Common Vision-Related FMS&MPS Complex Symptoms

• Night driving problems: We often have a real problem driving at night. The lights of the on-coming cars bother us more than most people. Beta-carotene seems to help this somewhat.
• Sensitivity to light: Some FMS people can't go anywhere unless they wear dark glasses. Some of us have Seasonal Affective Disorder (SAD), and need light to prevent depression. Part of this problem in FMS may be due to the hypothalamic-light connection.
• People with FMS often have too little of the neurotransmitter melatonin, which helps to regulate sleep. This may be also connected to light. People with SAD have too much melatonin, and they don't always have a night/day fluctuation of melatonin production.
• Dry eyes, nose and mouth: This is called sicca syndrome, which simply means that you have dry eyes, nose and mouth. All the mucous membranes can dry, including the lining of the vagina, and the GI tract. It is very hard for us to wear contact lenses. The dryness, the irritation and sensitivity, and the allergies prove too much for most of us. After a regimen of eye exercises and medication (especially guaifenesin), some people with FMS&MPS Complex have been able to wear contact lenses for the first time.
• Red eyes, tearing eyes: These symptoms can be caused by the sternocleidomastoid (SCM)TrPs, along with hearing impairment, and a disturbed sense of weight perception.
• Eye pain: Cutaneous facial TrPs can cause pain in ear, eyes, nose and teeth. These TrPs are shallow, and can occur in many places on the face. Try some pressure-point work on the face. If the TrPs are there, they will let you know. At times, deposits form in the corners of the eyes. This is fairly common in FMS&MPS Complex.
• Double vision, blurry vision, changing vision: In order for vision to be clear, both eyes must take the same picture at the same time. When this doesn't happen, vision problems result. I believe that misalignment of eyes can be caused by TrPs contracting the muscles that hold the eyeballs in place. If these muscles are being contracted to different tensions, that could cause all of the vision irregularities mentioned. Muscle fatigue and lack of sleep would make things worse. 

Check the internal eye muscles, temporalis, SCM, trapezius, cutaneous facial muscles for TrPs. To check the inner eye muscles, stretch them. Put one hand on your head, above your forehead. Then try to look at your hand. This shouldn't hurt. If it does, it's the TrPs in the muscles telling you they are there.  With your eyes still looking upward at your hand, look from one upper corner of your eye to the other. This will probably hurt too, which is a good sign. The TrPs are there, and that's at least part of what is causing your eye problem. The eye-exercises stretch out those TrPs. Once your patient does this simple eye exercise regularly, the mysterious changing vision problem usually disappears.

Splenius cervices TrPs can also cause blurring of near vision. This will also cause pain inside of the head to the eye on the same side, and in the eye orbit. Floaters are common, and may go along with the overgrowth or dysregulation of connective tissue growth so common in FMS&MPS Complex.

Words jump off the page or disappear when you stare at them: Orbicularis oculi TrPs will refer pain to your nose, cheek, above your eye, and cause "jumpy pages" when you try to read. Try putting clear plastic over the page to decrease print contrast.

Asymmetry is a common perpetrator of TrPs. Check to see if your patients have ears that are misaligned. Ensure the glasses fit well.

Motor coordination problems: The sternocleidomastoid is much of the problem here. SCM TrPs can cause dizziness, imbalance, neck soreness, swollen gland feeling, runny nose, maxillary sinus congestion, "tension" headaches, eye problems (tearing, ptosis, blurred or double vision, inability to raise the upper lid, and a dimming of perceived light intensity), spatial disorientation, postural dizziness, vertigo, sudden falls while bending, staggering walk, impaired sleep, nerve impingement, and disturbed weight perception. People with SCM TrPs often have trouble glancing downward -- they can fall forward. They can get so disoriented that there is nausea and vomiting. Chronic dry cough, pain deep in the ear canal, pain to the throat and back of the tongue and to a small round area at the tip of the chin can be part of the SCM TrP package. Localized sweating and vasoconstriction can be a problem, as well as pain in a "skull cap" area of the head. What SCM TrPs don't cause is a pain in the neck, although they figuratively become one due to their wide-ranging symptoms.

A feeling of continued movement in car after you've stopped, and feeling of tilted "banking" as your car corners are also part of the SCM TrP gifts to us. The perceptual changes can be very hard to explain to a doctor. Ask your patient.

Bump into doorjambs, walls and other stationary objects, knock things over often, clumsiness: If "klutziness" were an Olympic event, my closet would be filled with gold medals. They'd have to bar people with SCM TrPs from entering -- they'd have an unfair advantage . All of us go tripping through life, cleaning up one mess after another. We learn to keep our sense of humor and a good supply of absorbent paper towels. The combination of SCM TrPs and extrinsic eye muscle TrPs seem to be chiefly responsible for visual perception problems.

"Fibromyalgia and Chronic Myofascial Pain Syndrome: A Survival Manual" by Devin Starlanyl and Mary Ellen Copeland M.S., M.A., New Harbinger Publications Oakland CA 1996 800-748-6273 $19.95 400 pages