Do You See What Do You See What I See?I See?Denise A. JohnDenise A. John

VEIVEI

10/20/200610/20/2006

CaseCase HPI: 35 y/o HPI: 35 y/o ♀♀ c/o’s of “seeing shapes, c/o’s of “seeing shapes,

colors & partially-formed images.” colors & partially-formed images.” ROS: (+) Mild headache/weight ROS: (+) Mild headache/weight

loss/poor energy/constipationloss/poor energy/constipation

Questions???Questions???

Differential DiagnosisDifferential Diagnosis Classic Classic MigraineMigraine

PsychosisPsychosis Psychiatric illnessPsychiatric illness

SchizophreniaSchizophrenia Affective disordersAffective disorders Conversion Conversion

disordersdisorders Metabolic/toxicMetabolic/toxic

Electrolyte Electrolyte imbalanceimbalance

UremicUremic Liver dzLiver dz InfectionInfection

Alcohol/drug effects Alcohol/drug effects

Neurodegenerative Neurodegenerative disorderdisorder

Diffuse Lewy BodyDiffuse Lewy Body Parkinson’sParkinson’s Alzheimer’sAlzheimer’s

Sleep-related Sleep-related hallucinationshallucinations “ “ Hypnopompic “ Hypnopompic “

Peduncular Peduncular hallucinationshallucinations

SeizuresSeizures

Release Release hallucinationshallucinations

Fortification Spectrum

CaseCase FHX: FHX:

GlaucomaGlaucoma Heart & liver dz; HTN; cancer; strokeHeart & liver dz; HTN; cancer; stroke

SHX: ø Tobacco/IVDA/ETOHSHX: ø Tobacco/IVDA/ETOH

NKDANKDA

MEDS: ASA; prednisone; pepcid; MEDS: ASA; prednisone; pepcid; metoclopramide; anzemet; synthroid; metoclopramide; anzemet; synthroid; colace; lexapro; zyprexa; morphine; colace; lexapro; zyprexa; morphine; lortab lortab

CaseCase PMHX: PMHX:

Migraines Migraines Pituitary GH-producing adenomaPituitary GH-producing adenoma

Pituitary apoplexy Pituitary apoplexy Subarachnoid hemorrhageSubarachnoid hemorrhage S/p trans-sphenoidal hypophysectomy x S/p trans-sphenoidal hypophysectomy x

2; CSF leak x 2 s/p repair 2; CSF leak x 2 s/p repair PanhypopituitarismPanhypopituitarism SIADH SIADH

DepressionDepression Polycystic ovarian syndromePolycystic ovarian syndrome Psoriatic arthritisPsoriatic arthritis

CaseCase Alert & oriented x 3Alert & oriented x 3

Normal affectNormal affect

NLPNLP VVA A NLPNLP

CVF: Unable OUCVF: Unable OU

Motility: Full OUMotility: Full OU

1111 IOPIOP 1212

55

PupilsPupils 55

NR to lightNR to light Partial reaction to Partial reaction to

nearnear

External/PLE exam External/PLE exam unremarkableunremarkable

DFE: DFE: Mild disc pallor OUMild disc pallor OU Macula/vessels/Macula/vessels/

periphery periphery unremarkable OUunremarkable OU

Patient

Patient

Visual Visual HallucinationsHallucinations

Visual HallucinationsVisual Hallucinations Visual perceptions not associated Visual perceptions not associated

with external visual with external visual

stimulistimuli

Visual HallucinationsVisual Hallucinations

Simple (non-Simple (non-formed):formed): DotsDots ColorsColors Flashing lights Flashing lights Geometric Geometric

patterns patterns

Visual HallucinationsVisual Hallucinations

Complex Complex (formed):(formed): ObjectsObjects AnimalsAnimals PeoplePeople Scenery Scenery

Visual IllusionsVisual Illusions

Distortion or modification of a Distortion or modification of a real visual imagereal visual image

Visual HallucinationsVisual Hallucinations Most are NOT due to psychiatric dzMost are NOT due to psychiatric dz

Related to ocular, optic nerve or brain Related to ocular, optic nerve or brain pathologypathology

Treatment involves managing underlying Treatment involves managing underlying disorderdisorder

Insight into the reality of the hallucinations Insight into the reality of the hallucinations varies with the associated etiologyvaries with the associated etiology

May interfere with daily functioning & May interfere with daily functioning & cause significant anxiety cause significant anxiety

Visual Visual Hallucinations:Hallucinations:

EtiologiesEtiologies

PhosphenesPhosphenes ““Seeing light”Seeing light”

Insight preservedInsight preserved

Visual hallucinations:Visual hallucinations: ““Scintillating blue spots Scintillating blue spots

on a black backgroundon a black background Rubbing closed eyesRubbing closed eyes

““Seeing stars”Seeing stars” Sneeze, head Sneeze, head

trauma, low blood trauma, low blood pressurepressure

““Flashes of light” Flashes of light” (photopsias)(photopsias)

Dim lightening or total Dim lightening or total darkness darkness

Light twinkles to bright Light twinkles to bright flashesflashes

Irritation of Irritation of photoreceptors photoreceptors

Vitreous tractionVitreous traction Retinal detachment/ Retinal detachment/

inflammationinflammation Optic neuritisOptic neuritis

Esp. with EOM/soundEsp. with EOM/sound

PsychosisPsychosis Visual Hallucinations:Visual Hallucinations:

ComplexComplex Duration: VariableDuration: Variable

+/- Other hallucinations+/- Other hallucinations Esp. auditoryEsp. auditory

+/- Insight preservation+/- Insight preservation

Release HallucinationsRelease Hallucinations Complete or partial visual acuity/field loss Complete or partial visual acuity/field loss

from any causefrom any cause Commonly seen in AMDCommonly seen in AMD

Charles Bonnet Syndrome (CBS)Charles Bonnet Syndrome (CBS) Described in 1769 Described in 1769

Swiss naturalist & philosopherSwiss naturalist & philosopher ~ 14% prevalence in U.S. eye clinics~ 14% prevalence in U.S. eye clinics

with age with age Ø Gender predilectionØ Gender predilection

Release HallucinationsRelease Hallucinations Theory of CBS:Theory of CBS:

Sensory deprivationSensory deprivation Visual cortex Visual cortex “release phenomenon” “release phenomenon”

Input from other cortical areas (esp. memory) Input from other cortical areas (esp. memory) “fill-in” the sensory deficit“fill-in” the sensory deficit

Risk factors:Risk factors: Bilateral visual lossBilateral visual loss ageage SolitudeSolitude CognitionCognition

Release HallucinationsRelease Hallucinations Visual hallucinations:Visual hallucinations:

65%: Weekly/monthly; 27%: Daily65%: Weekly/monthly; 27%: Daily People: 80%; animals: 38%; plants/trees: People: 80%; animals: 38%; plants/trees:

25%; buildings/other scenery: 15%25%; buildings/other scenery: 15% Color: 63% Color: 63% Movement: 47%Movement: 47% Duration:Duration:

53%: 1-60 mins; 13% < 5 secs53%: 1-60 mins; 13% < 5 secs Eyes open: 67%Eyes open: 67%

Teurisse et al. Visual hallucinations in psychologically Teurisse et al. Visual hallucinations in psychologically normal patients: CBS. Lancet, 1996normal patients: CBS. Lancet, 1996

Release HallucinationsRelease Hallucinations Insight preserved Insight preserved

Setting:Setting: FatigueFatigue StressStress Early mornings/late eveningEarly mornings/late evening Poor lighteningPoor lightening

Often spontaneously resolve Often spontaneously resolve Worsening/improvement of visual loss Worsening/improvement of visual loss

Release HallucinationsRelease Hallucinations Management:Management:

Reassurance of sanityReassurance of sanity Keep eyes closedKeep eyes closed Look away from visionsLook away from visions Improve lighteningImprove lightening social interactionssocial interactions Antipsychotic/antiepileptic Antipsychotic/antiepileptic

medicationsmedications

Back to our patient…Back to our patient… AssessmentAssessment:: Visual - deprivation Visual - deprivation

hallucinations hallucinations

(Charles Bonnet Syndrome)(Charles Bonnet Syndrome)

Plan:Plan: Psychiatry consultedPsychiatry consulted

Olanzapine 5mg QHSOlanzapine 5mg QHS

ReferencesReferences BCSC. Neuro-Ophthalmology. AAO. 2004-05BCSC. Neuro-Ophthalmology. AAO. 2004-05 Kanski. Clinical Ophthalmology, 5Kanski. Clinical Ophthalmology, 5thth Ed. Butterworth Heinemann. Ed. Butterworth Heinemann.

20032003 Teurisse et al. Visual hallucinations in psychologically normal Teurisse et al. Visual hallucinations in psychologically normal

patients: CBS. Lancet, 1996patients: CBS. Lancet, 1996 Manford et al. Complex visual hallucinations. Brain. 1998Manford et al. Complex visual hallucinations. Brain. 1998 Visual hallucinations caused by vision impairment. Geriatrics. Visual hallucinations caused by vision impairment. Geriatrics.

2002. 57 (6): 45-62002. 57 (6): 45-6 Charles Bonnet syndrome. Psychology of medicine. 1982;12: Charles Bonnet syndrome. Psychology of medicine. 1982;12:

251-61251-61 Charles Bonner syndrome: A review. Journal of Mental Charles Bonner syndrome: A review. Journal of Mental

Disorders. 1997; 185 (3): 195-200Disorders. 1997; 185 (3): 195-200 Pelak et al. Visual Hallucinations. Current Science. 2006Pelak et al. Visual Hallucinations. Current Science. 2006