Do You See What
I See?
Denise A. John
VEI
10/20/2006
Case

HPI: 35 y/o ♀ c/o’s of “seeing shapes, colors &
partially-formed images.”
 ROS: (+) Mild headache/weight loss/poor
energy/constipation
Questions???
Differential Diagnosis

Classic Migraine

Psychosis
 Psychiatric illness
 Schizophrenia
 Affective disorders
 Conversion disorders
 Metabolic/toxic
 Electrolyte imbalance
 Uremic
 Liver dz
 Infection
 Alcohol/drug effects
Neurodegenerative disorder
 Diffuse Lewy Body
 Parkinson’s
 Alzheimer’s
Sleep-related hallucinations
 “ Hypnopompic “



Peduncular hallucinations

Seizures

Release hallucinations
Fortification Spectrum
Case

FHX:
 Glaucoma
 Heart & liver dz; HTN; cancer; stroke

SHX: ø Tobacco/IVDA/ETOH

NKDA

MEDS: ASA; prednisone; pepcid; metoclopramide;
anzemet; synthroid; colace; lexapro; zyprexa;
morphine; lortab
Case

PMHX:
 Migraines
 Pituitary GH-producing adenoma
 Pituitary apoplexy
 Subarachnoid hemorrhage
 S/p trans-sphenoidal hypophysectomy x 2; CSF leak x 2
s/p repair
 Panhypopituitarism
 SIADH
 Depression
 Polycystic ovarian syndrome
 Psoriatic arthritis
Case

Alert & oriented x 3
 Normal affect

Pupils


VA

CVF: Unable OU

5
NR to light
Partial reaction to near
NLP


5
NLP
Motility: Full OU
IOP
11
12

External/PLE exam
unremarkable

DFE:
 Mild disc pallor OU
 Macula/vessels/periphery
unremarkable OU
Patient
Patient
Visual
Hallucinations
Visual Hallucinations
Visual perceptions not associated with external visual
stimuli
Visual Hallucinations

Simple (non-formed):
 Dots
 Colors
 Flashing lights
 Geometric patterns
Visual Hallucinations

Complex (formed):
 Objects
 Animals
 People
 Scenery
Visual Illusions

Distortion or modification of a real visual
image
Visual Hallucinations

Most are NOT due to psychiatric dz

Related to ocular, optic nerve or brain pathology
 Treatment involves managing underlying disorder

Insight into the reality of the hallucinations varies with the
associated etiology

May interfere with daily functioning & cause significant
anxiety
Visual
Hallucinations:
Etiologies
Phosphenes

“Seeing light”

Insight preserved

Visual hallucinations:
 “Scintillating blue spots on a
black background
 Rubbing closed eyes

“Seeing stars”
 Sneeze, head trauma,
low blood pressure

“Flashes of light” (photopsias)
 Dim lightening or total
darkness
 Light twinkles to bright flashes
 Irritation of
photoreceptors
 Vitreous traction
 Retinal detachment/
inflammation
 Optic neuritis
 Esp. with
EOM/sound
Psychosis

Visual Hallucinations:
 Complex
 Duration: Variable

+/- Other hallucinations


Esp. auditory
+/- Insight preservation
Release Hallucinations

Complete or partial visual acuity/field loss
from any cause


Commonly seen in AMD
Charles Bonnet Syndrome (CBS)
 Described in 1769
 Swiss naturalist & philosopher
 ~ 14% prevalence in U.S. eye clinics
  with age
 Ø Gender predilection
Release Hallucinations

Theory of CBS:
 Sensory deprivation
 Visual cortex  “release phenomenon”
 Input from other cortical areas (esp. memory) “fill-in” the
sensory deficit

Risk factors:
 Bilateral visual loss
  age
 Solitude
  Cognition
Release Hallucinations

Visual hallucinations:
65%: Weekly/monthly; 27%: Daily
 People: 80%; animals: 38%; plants/trees: 25%;
buildings/other scenery: 15%
 Color: 63%
 Movement: 47%
 Duration:
 53%: 1-60 mins; 13% < 5 secs
 Eyes open: 67%


Teurisse et al. Visual hallucinations in psychologically normal patients: CBS. Lancet, 1996
Release Hallucinations

Insight preserved

Setting:
 Fatigue
 Stress
 Early mornings/late evening
 Poor lightening

Often spontaneously resolve

Worsening/improvement of visual loss
Release Hallucinations

Management:
 Reassurance of sanity
 Keep eyes closed
 Look away from visions
 Improve lightening
  social interactions
 Antipsychotic/antiepileptic medications
Back to our patient…

Assessment: Visual - deprivation hallucinations
(Charles Bonnet Syndrome)

Plan:
 Psychiatry consulted
 Olanzapine 5mg QHS
References
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BCSC. Neuro-Ophthalmology. AAO. 2004-05
Kanski. Clinical Ophthalmology, 5th Ed. Butterworth Heinemann. 2003
Teurisse et al. Visual hallucinations in psychologically normal patients: CBS. Lancet,
1996
Manford et al. Complex visual hallucinations. Brain. 1998
Visual hallucinations caused by vision impairment. Geriatrics. 2002. 57 (6): 45-6
Charles Bonnet syndrome. Psychology of medicine. 1982;12: 251-61
Charles Bonner syndrome: A review. Journal of Mental Disorders. 1997; 185 (3):
195-200
Pelak et al. Visual Hallucinations. Current Science. 2006