Abstract
The investigation of the human oculomotor system by eye movement recordings provides an approach to behavior and its alterations in disease. The neurodegenerative process underlying parkinsonian syndromes, including Parkinson’s disease (PD), progressive supranuclear palsy (PSP), and multisystem atrophy (MSA) changes structural and functional brain organization, and thus affects eye movement control in a characteristic manner. Video-oculography has been established as a non-invasive recording device for eye movements, and systematic investigations of eye movement control in a clinical framework have emerged as a functional diagnostic tool in neurodegenerative parkinsonism. Disease-specific brain atrophy in parkinsonian syndromes has been reported for decades, these findings were refined by studies utilizing diffusion tensor imaging (DTI) and task-based/task-free functional MRI—both MRI techniques revealed disease-specific patterns of altered structural and functional brain organization. Here, characteristic disturbances of eye movement control in parkinsonian syndromes and their correlations with the structural and functional brain network alterations are reviewed. On this basis, we discuss the growing field of graph-based network analysis of the structural and functional connectome as a promising candidate for explaining abnormal phenotypes of eye movement control at the network level, both in health and in disease.
Introduction
More than half a century ago, Carl F. List concluded in his essay that abnormal oculomotor function frequently gives valuable information of both the localization and the pathoanatomy of an underlying disease process (). Although eye movements in the diseased brain have been extensively studied since then, it has been only recently that several multimodal studies support an increasingly coherent understanding of the structural and functional brain organization correlates. Characteristic disturbances of eye movement control accompany ongoing pathology () and include saccade disturbances, e.g., gaze palsy (), saccadized smooth pursuit (), or executive oculomotor dysfunctions, e.g., increased anti-saccade errors ().
This narrative review links current experimental evidence of human behavior as observed from eye movement recordings in parkinsonian syndromes, including Parkinson’s disease (PD), progressive supranuclear palsy (PSP), and multisystem atrophy (MSA) to what is known from neuroimaging studies in structural and functional brain architecture. Moreover, we discuss how the growing field of graph theory-based investigations of the structural and functional connectome might provide a more elaborated approach to the principles of functional architecture underlying human behavior.
The Oculomotor System and its Relation to Higher Cognitive Processes
Human cognition is related to sensorimotor activation including oculomotion—a position that nowadays makes many researchers term eye movements as a window to complex forms of human behavior () and cognitive processes (, ). Subjects facing a choice between multiple stimuli tend to repeatedly look at them and more toward the option they are going to choose (), presumably implementing a comparison process between different items (). Brain structures and neural pathways which are involved in the control of eye movements have been reported in a multitude of studies (, ), as depicted in Figure 1. Brain mapping of eye movement control has been extensively studied in healthy human subjects including evidence from structural imaging (), diffusion tensor imaging (DTI) (), “task-evoked” (), and “task-free” functional magnetic resonance imaging (fMRI) (). These studies revealed that the control of eye movements involves multiple networks spanning the brainstem to the neocortex (, ). It is well known that parkinsonian syndromes present with progressive impairment of structural and functional brain networks (), and it is a growing field of neuroimaging research how these brain alterations are linked with the respective oculomotor phenotype. In this context, getting subtle clues from abnormal eye movement control often requires standardized eye movement recordings with dedicated techniques, e.g., by means of video-oculography ().
Figure 1
Brain Mapping of Oculomotor Phenotypes in Neurodegenerative Parkinsonism
Video-Oculographic Recordings of Eye Movements
Tracking eye movements with state-of-the-art video-based techniques is non-invasive and allows for precise and quantifiable measures of horizontal and vertical movements of the eye (
Characteristic but Non-Specific Eye Movement Patterns
Figure 2 illustrates a possible concept of mapping patterns of eye movement disturbances to brain structure and function. Oculomotor control examination is ideally performed at the time of MRI investigations in a dedicated oculomotor laboratory which allows a detailed investigation of eye movement control using state-of-the-art video-oculographically based tracing of eye movements in an acoustically shielded atmosphere (
Figure 2

Concept of the bimodal study design. Structural and functional brain mapping of eye movement control by combining video-oculographically eye movements recordings (left upper panel) with structural and functional MR imaging data (right) in order to define disease-specific patterns.
Brain Structural Correlates of Eye Movement Control
A multitude of widely distributed brain regions, including the brainstem (
Brain Functional Correlates of Eye Movement Control
Functional magnetic resonance imaging has enabled researchers to investigate functionally activated regions when performing a task as compared to a baseline (“rest”) condition (
Functionally involved brain regions in eye movement control can be accurately captured by “task-free” or “resting-state” fMRI experiments, where subjects quietly “rest” in the scanner (53, 54). Resting-state (rs)-fMRI has gained substantial insights into the organization of intrinsic activity patterns of the human brain (54–56), after the discovery of temporally coherent patterns of ongoing low-frequency BOLD fluctuations under “resting” conditions (53). These patterns, i.e., intrinsic functional connectivity networks, remarkably resemble the maps of task-evoked coactive brain regions (57) and reveal a more general picture of the functional brain organization (58). Some substantial advances in understanding brain architecture have emerged from the observation of spontaneous “ongoing” brain activity as measured indirectly via the rs-fMRI signal while subjects lying quietly in the scanner (56). Understanding eye movement control on the basis of functionally interacting brain regions topologically organized as functional connectivity networks put forward the understanding of underlying pathology of impaired eye movement control and behavioral interpretations of these intrinsic connectivity networks (59).
Brain Networks and Oculomotor Disturbances in Parkinsonian Syndromes
Parkinson’s Disease
Parkinson’s disease is now recognized as an age-related multisystem disorder with cardinal motor symptoms that manifest years after the initial onset of pathogenesis—a process that is virtually self-promoting in a well predictable distribution pattern and not subject to remission (60, 61). A broad spectrum of oculomotor disturbances comprising impaired smooth pursuit, hypometric saccades, prolonged latencies, increased anti-saccade errors that accompany the cardinal motor symptoms (
These findings raised the question whether functional connectivity between interconnected gray matter regions is correlated with oculomotor deficits. In a network-based rs-fMRI study in PD, a pronounced pattern of increased functional connectivity in cognitively unimpaired patients and a pattern of decreased functional connectivity in demented patients could be demonstrated (67). The pattern of abnormal functional connectivity is, in addition, related to abnormal oculomotor performance as revealed by a study of rs-fMRI and video-oculography in PD patients ranging from mild cognitive impairment to dementia (63). In particular, impaired executive oculomotor functions are correlated with a functional connectivity loss in the cognition-related default mode functional network. Taken together, these results allow for the development of a hypothetical model that links oculomotor performance and macro- and microstructural brain changes. Here, oculomotor performance markedly declined in the course of PD and functional connectivity appears to decrease after a critical cell loss has been reached; Figure 3 illustrates a hypothetical model of PD-associated alterations of functional connectivity together with executive eye movement control changes. The suggested course of functional connectivity is somewhat speculative, but many studies in the field of functional brain mapping try to establish a connection between neurodegeneration and adaptive mechanisms in relation to clinical phenotypes (68). We did not find any correlation between oculomotor parameters and volumetric, structural, and functional measures in ponto-cerebellar structures, midbrain or brainstem in PD—this may indicate that oculomotor deficits are not associated with disturbed ponto-cerebellar circuits or impaired oculomotor brainstem nuclei.
Figure 3

Hypothetical model of functional connectivity alterations in association with executive eye movement control in Parkinson’s disease (PD). The model results from correlations between functional connectivity data and eye movement impairment in early and advanced patients with PD (63). Neural damage due to the ongoing PD-associated pathological process from (A) healthy or premotor to (B) clinically manifest disease status paradoxically results in increased functionally connectivity early in the course of the disease upon a critical cell loss is reached. During this phase, executive oculomotor function gradually worsens as evidenced from visually guided reactive saccade performance (lower row)—remarkably, neuropsychological assessment in these patients revealed cognitively unimpaired “normal” performance (67). (C) In the final stages of PD, patients most patients met the criteria of PD-associated dementia and have developed a function disconnection syndrome (decreased functional connectivity) that is associated with a pattern of severely impaired eye movement control (right lower panel).
Previous studies supported the notion of a possible cerebellar involvement in PD (69) which has been recently strengthened by reports of α-synuclein aggregation in precerebellar structures (70). Connectivity studies in macaques (71) and DTI studies in humans (72) indicated that the cerebellum is part of a cerebello-cortico-basal ganglia network that is affected in PD. However, the role of this network and its alterations due to possibly impaired connectivity with respect to oculomotor function has not been systematically disentangled yet. Our oculomotor experience revealed a tendency toward a pattern of a “pontocerebellar type” of smooth pursuit disturbance in PD patients in an advanced disease state, most frequently accompanied by dementia. This observation leads to the speculative conclusion that the cerebellum, if ever, becomes involved later in the course of the disease as proposed by Braak and Del Tredici (60).
Given that, in PD, pathology progresses in different disease stages (60, 73) and eye movement performance worsen over time (
Antiparkinsonian treatment including deep brain stimulation of the subthalamic nucleus was reported to improve oculomotor inhibition control and to facilitate saccade initiation (80), most likely due to compensatory mechanisms (81), whereas other groups reported no significantly improved oculomotor performance (62). Apparently, improvement of oculomotor performance due to antiparkinsonian treatment depends on the disease state, i.e., patients early in the course are more likely to improve eye movement performance (
Other Neurodegenerative Parkinsonism
Progressive supranuclear palsy and MSA are other parkinsonian syndromes (82–85) which comprise a characteristic spectrum of oculomotor dysfunctions (65). In contrast to PD patients who predominantly show oculomotor dysfunctions that are attributable to executive dysfunctions, PSP and MSA patients were shown to present predominantly “genuine” oculomotor dysfunctions (
Progressive supranuclear palsy is considered a neuropathologically defined disease presenting with a broad spectrum of clinical phenotypes besides the “classical” phenotype Richardson syndrome [PSP-RS (88)], including the Parkinsonian subtype (PSP-P), corticobasal syndrome subtype, and frontotemporal dementia subtypes (89) besides further variants which are of limited importance for oculomotor control. Slowed saccades in all subtypes of PSP are due to the paucity in burst generation at the excitatory burst (90). The PSP-RS and PSP-P subtypes show an almost identical oculomotor phenotype, hence, eye movement recordings do not allow to distinguish between PSP-PS and PSP-P (91). There are no systematic data for eye movement alterations associated with the other variants yet. It might be of note in that context that, in patients with frontal lobe degeneration, saccadic and smooth pursuit eye movements are impaired (92), and multimodal morphological studies revealed a link between atrophy in frontal brain regions and executive oculomotor performance (93). In the search of an imaging correlate of slowed saccades in PSP (including both PSP-RS and PSP-P patients), it could be demonstrated that the characteristic deficits in eye movement control were associated with regional macrostructural (
Figure 4

Disease-specific correlations of eye movement alterations in progressive supranuclear palsy (PSP) and multisystem atrophy (MSA). Specific correlations (red area) between microstructural impairment and gaze palsy in patients with PSP showing midbrain and brainstem regions typically associated with eye velocity (left). Specific correlations (red area) between microstructural impairment in ponto-cerebellar structures and the shape of saccadized smooth pursuit in patients with MSA (right).
Multisystem atrophy can be distinguished in a cerebellar subtype (MSA-C) and a MSA-P. The oculomotor phenotype in MSA-C and MSA-P is almost identical (
Smooth pursuit eye movement is the ability to perfectly stabilizing the image of a continuously moving object onto the fovea (
Lesion studies in animals that targeted vital elements of the smooth pursuit pathways including the cerebellar vermis and precerebellar nuclei, indicate that these structures are responsible for catch-up saccades (
These findings, at a broader scope, may allow to generally speculate about brain structure and function in association with oculomotor phenotyping in parkinsonian syndromes. Disease-characteristic patterns of impaired oculomotor control gradually worsen over time and are apparently closely related with ongoing region-specific macrostructural and microstructural damage. The pattern of network-dependent functional connectivity alterations is more complex. As suggested, the pattern of functional connectivity increases and then gradually declines toward a disconnection syndrome. The development of functional connectivity in the course of the disease is well explained by the concept of adaptive changes (i.e., hyperconnectivity) that aims to compensate for ongoing cell loss in the sense of cortical network reorganization up to a point in time where a critical cell loss is reached (68, 98). From this point in time, compensation is no longer possible and the cognitive reserve is exhausted (99, 100). A limitation of the suggested model is the lack of information from longitudinal studies.
A Perspective on Connectomics and Eye Movement Control
The brain is an efficient representation of a complex system (101, 102) which consists of spatially distributed and functionally specialized regions that continuously share information with each other (103). Graph-theoretical approaches for the analysis of both structural and functional networks enable to quantify properties of the brain’s functional system together with the underlying wiring (104). A network is defined in graph-theory as a set of nodes, i.e., anatomically segregated brain regions, and edges, i.e., a connectivity measure, between two nodes (105). Many measures of useful properties that characterize the network organization can be computed, including basic concepts, measures of segregation, integration, motifs, resilience, and other concepts such as “network small-worldness” (106). These measures are to be correlated with behavioral parameters including quantitative measures of eye movement control. For instance, the saccadic reaction times are prolonged in parkinsonian syndromes, but there is no report about any specific regions of the brain which are structurally or functionally correlated with reaction times (
Concluding Remarks
The oculomotor analysis of a patient using gaze-tracking technology might help clinicians to gain insights into the brain function and disease status. In addition, the reviewed studies pave the way toward the development of a standardized protocol for video-oculographic assessment in the differential diagnostic frame aiming at establishing a technical surrogate marker. In neurodegenerative parkinsonism, worse oculomotor performance in the disease-specific domain was shown to be associated with more severely impaired regional macro- and microstructure and altered regional functional connectivity in disease-specific brain structures. These findings increase our pathophysiological knowledge of the underlying parkinsonism-associated network pathology. Finally, brain mapping of impaired eye movement control as shown for parkinsonian syndromes should be investigated in a broader context of brain diseases in order to find out whether the demonstrated findings could be generalized to neurodegenerative diseases beyond parkinsonism.
Statements
Author contributions
MG and JK drafted the manuscript. H-PM revised the manuscript for intellectual content. All authors performed literature search, agreed to be accountable for the content of the work, and finally approved the manuscript.
Acknowledgments
Mrs. Sonja Fuchs is thankfully acknowledged for her great help in the acquisition of MRI data. The authors would like to thank the Ulm University Center for Translational Imaging MoMAN for its support.
Conflict of interest
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
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Summary
Keywords
magnetic resonance imaging, diffusion tensor imaging, “resting-state” functional magnetic resonance imaging, neurodegenerative movement disorder, video-oculography, Parkinson’s disease, progressive supranuclear palsy, multisystem atrophy
Citation
Gorges M, Müller H-P and Kassubek J (2018) Structural and Functional Brain Mapping Correlates of Impaired Eye Movement Control in Parkinsonian Syndromes: A Systems-Based Concept. Front. Neurol. 9:319. doi: 10.3389/fneur.2018.00319
Received
15 January 2018
Accepted
23 April 2018
Published
07 May 2018
Volume
9 - 2018
Edited by
Peter Sörös, University of Oldenburg, Germany
Reviewed by
Tino Prell, Friedrich Schiller Universität Jena, Germany; Norbert Brüggemann, Universität zu Lübeck, Germany
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Copyright
© 2018 Gorges, Müller and Kassubek.
This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Martin Gorges, martin.gorges@uni-ulm.de
Specialty section: This article was submitted to Applied Neuroimaging, a section of the journal Frontiers in Neurology
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