Pediatric phantom vision (Charles Bonnet) syndrome

Visual hallucinations and sight loss in children and young adults: a retrospective case series of Charles Bonnet syndrome

BACKGROUND/AIMS

Charles Bonnet syndrome (CBS) is a complication of sight loss affecting all ages; yet, few childhood cases have been reported. Our aim is to raise awareness of this under-reported association occurring in children and young adults in order to prevent psychological harm in this age group.

METHODS

A retrospective case series reviewing medical notes of patients <25 years of age with sight loss and reported CBS at a single centre hospital eye service in London, United Kingdom. Search of electronic patient records identified 13 patients experiencing hallucinatory events over a 9-year period. Outcomes were patient demographics including ocular diagnosis, visual acuity at time of onset, characteristics of hallucinations, clinical management strategies and patient-reported affliction.

RESULTS

Eight patients were diagnosed with progressive inherited retinal diseases, primarily Stargardt disease (N=5). Clinical history indicated patients had significantly reduced best-corrected visual acuity (BCVA) in at least one eye at onset; median (IQR) worse eye BCVA was 1.0 (0.86-1.6) logarithm of minimum angle of resolution(LogMAR). CBS significantly affected patients' personal lives including education, diet and sleep. Clinical management was varied, mostly relating to reassurance at the point of contact.

CONCLUSION

We describe the clinical features of young patients with CBS, with management strategies and aspects of negative outcomes. High potential caseload and risk of psychological harm merit further research. Increased awareness among healthcare professionals and patient education to forewarn susceptible individuals may reduce the overall impact and improve coping with symptoms.

An overview of psychological and social factors in Charles Bonnet syndrome

Charles Bonnet syndrome (CBS) is a condition where cognitively normal individuals with sight impairment experience simple and/or complex visual hallucinations. The exact pathogenesis of CBS is unknown; however, deafferentation is often recognised as a causal mechanism. Studies have provided insight into the multifaceted impact of CBS on wellbeing. Onset of CBS may cause distress among those believing visual hallucinations are indicative of a neurological condition. Hallucinatory content is often congruent with the emotional response. For example, hallucinations of a macabre nature typically result in a fearful response. Visual hallucinations may be highly disruptive, causing everyday tasks to become challenging. Clinical management relies on forewarning and pre-emptive questioning. Yet, knowledge and awareness of CBS is typically low. In this review, we provide a summary of the social and psychological implications of CBS and explore recent developments aimed at raising awareness and improving patient management.

Cosmetic results of enucleation and/or external beam radiation therapy in 195 retinoblastoma survivors

PURPOSE

To report the cosmetic outcome and late effects of enucleation and/or irradiation for retinoblastoma and to evaluate the role of orbital implants.

METHODS

Patients (age >4 years) enucleated and/or irradiated for retinoblastoma, visiting the hospital for routine follow-up (April 2013 to May 2015), were included in our cross-sectional study. Data were obtained via clinical records, questionnaires, physical measurements and standardized photographs. Two independent observers scored the cosmetic features: upper eyelid position, lower eyelid position, volume deficiency, and prosthesis motility and overall cosmetic appearance.

RESULTS

A total of 195 patients participated. Ptosis was seen in 45 (28.3%) patients, lower lid sagging in 45 (28.3%). Both complications were associated with the orbital implant; ptosis being more common with increasing implant size (5.6% without implant, 16.7% with small implant, 37.1% with medium implant and 76.9% with large implant) and lower lid sagging being more common in patients without implant (20% with implant versus 37.5% without). Volume loss of the superior sulcus was seen in 107 sockets (66.9%), most frequent in additionally irradiated patients (χ² (2) = 42.7, p < 0.001) and in patients without implant (χ² (2) = 11.92, p = 0.003). Prosthesis motility was better in patients with orbital implant, regardless of the size.

CONCLUSION

Minor late and potentially treatable effects were seen in patients with implant. Larger sized implants were associated with a higher incidence of ptosis; implant size did not affect subjective outcome with respect to volume or prosthetic motility. Treatment with EBRT had a less favourable outcome.

Charles Bonnet syndrome in a child with congenital glaucoma

CASE REPORT

The case is presented of a 12 year-old boy with congenital glaucoma and low visual acuity diagnosed with Charles Bonnet syndrome. This consisted of the acute onset of complex, repetitive, persistent, and with visual hallucinations (people, brooms and coffeemakers) of self-limited evolution without treatment. The patient was diagnosed with congenital glaucoma at 3 years of age, and subjected to a trabeculectomy in right eye, and trabeculectomy and keratoplasty in his left eye.

DISCUSSION

Charles Bonnet syndrome symptoms have been described in adults, but their presence in children is poorly reflected in literature, with unknown characteristics and prevalence.

The Prevalence and Characteristics of Charles Bonnet Syndrome in Turkish Patients with Retinal Disease

Purpose: The aim of this study is to investigate the prevalence and clinical characteristics of Charles Bonnet syndrome (CBS) in a group of Turkish patients with various retinal diseases. Methods: Two hundred and sixty-four patients with a best-corrected visual acuity of ≤20/40 in the better-seeing eye were asked with a standardized question whether they had symptoms of CBS. If they responded positively, a questionnaire was verbally administered to learn more about the details of the symptoms. Results: There were 125 (47.3%) females and 139 (52.7%) males with a mean age of 72.1 years (range 31-90). Seventeen (6.4%) patients were diagnosed with CBS. Three (17.7%) patients had noncomplex hallucinations and 14 (82.3%) had complex hallucinations. Conclusion: CBS is not uncommon in visually impaired patients with retinal disease. Clinicians who care for visually impaired patients should be aware of CBS.

Prevalence and Clinical Characteristics of Charles Bonnet Syndrome in Madrid, Spain

Purpose

Charles Bonnet syndrome (CBS) is a condition characterized by development of visual hallucinations in patients with no cognitive impairment and significant loss of vision mainly caused by age-related macular degeneration (AMD) or glaucoma.

Methods

This was a study of prevalence and characteristics of CBS diagnosed at the Neuroophthalmic Unit within the Ophthalmology Department of Hospital Clínico San Carlos (HCSC), Madrid, Spain.

Results

The CBS prevalence in patients from HCSC Madrid is 0.47%, rising to 15% in patients with low vision. Women over 80 years of age comprised 58.3% of the patients, who mainly had AMD (58.3%). Main characteristics of hallucinations included animals (50%), color (58.3%), moving (75%), 6- to 12-month evolution (50%), three times a day frequency (75%), and 3- to 5-minute duration (50%).

Conclusions

Charles Bonnet syndrome is a complex process that must be treated jointly by ophthalmologists, neurologists, and psychiatrists in order to ensure accurate diagnosis and adequate management. New studies are needed in order to improve awareness of clinical manifestation of this condition, the incidence of which is underestimated due to patients' fear of being branded mentally ill, as well as physicians' lack of knowledge about CBS.

Clinical phenomenology and mortality in Charles Bonnet syndrome

BACKGROUND/AIM

Despite existing diagnostic criteria for Charles Bonnet syndrome (CBS), clinical manifestations vary greatly. We examined the clinical course and mortality of patients diagnosed with CBS.

METHODS

We conducted a retrospective chart review of patients with CBS. We collected demographic and clinical information and medical burden scores. Kaplan-Meier mortality curves were compared using log-rank test. Cox proportional hazard model was used for multivariate analysis and hazard ratio (HR). Mortality was compared to expected mortality from Minnesota population.

RESULTS

Seventy-seven patients with CBS had a mean age of 79.5 (standard deviation ± 13.0) and were predominantly Caucasian (97%) and female (73%). In all, 20 (26%) subsequently developed a dementia syndrome, most often Lewy body. A total of 46 (60%) deaths occurred with an average follow-up time of 33.0 months. Characteristics associated with mortality included older age (75-84 [HR 3.34, P = .029], >85 [HR 4.58, P = .007]) and renal disease (HR 3.39 with 95% confidence interval 1.31-8.80, P = .012). Medical burden scores were not associated with overall mortality. Mortality was high compared to Minnesota population (P < .0001).

CONCLUSIONS

A large proportion of patients with CBS developed dementia, and there was a high mortality rate associated with older age and renal disease. Medical burden was not associated with mortality.

Charles Bonnet syndrome: two case reports and review of the literature

Visual hallucinations (VHs) can be associated with a variety of clinical conditions, and are also experienced by healthy people due to visual impairment. The condition is known as Charles Bonnet Syndrome (CBS). The circumstances favoring VHs support the hypothesis that sensory deprivation enhances the ongoing activity of the visual system after sensory loss. Clinician should be aware that a significant proportion of visually impaired patients experience complex VHs, which are sometimes distressing. Herein, we report two cases of CBS. Case 1 is a 60-year-old man with visual impairment due to orbit pseudotumor in autoimmune hypothyroidism. Case 2 is an 87-year-old woman with Parkinson's disease and a 15-year history of intermittent complex VHs due to age-related macular degeneration in both eyes. In both cases investigations for alternative pathological causes of VHs were negative and, therefore, the aetiology of hallucinations was attributed to CBS. The course and treatment of CBS patients vary according to the nature of the visual dysfunction. Drug treatments remain partially satisfactory, with individual cases successfully treated with atypical antipsychotics. Nonpharmacological interventions aimed to reduce the visual pathway deprivation. Reassurance of the benign nature of CBS is essential to support patients and reduce caregiver's burden.

Charles Bonnet syndrome after herpes simplex encephalitis

Visual impairment associated with Charles Bonnet syndrome is rarely reported in childhood. We describe a child who presented with visual hallucinations and postinfectious bilateral retrobulbar optic neuritis. The patient had undergone acyclovir therapy for 3 weeks because of herpes encephalitis. Four days after therapy was completed, he experienced visual impairment in both eyes. He manifested a bilateral decrease in visual acuity, with normal funduscopic findings. The patient experienced visual hallucinations for about 1 week, and then experienced total loss of vision. During his hallucinations, the patient did not exhibit behavioral changes or cognitive impairment. The visual hallucinations included unfamiliar children hiding under his bed, and he spoke to someone whom he did not know. Magnetic resonance imaging indicated bilateral optic nerve hyperintensity on T(2)-weighted and contrast-enhanced images. The patient received corticosteroid therapy for his retrobulbar optic neuritis, and his vision returned to normal after 1 month. Although rare, visual impairment can be associated with complex visual hallucinations indicative of Charles Bonnet syndrome.

[Psychiatric, psychological comorbidities of typical and atypical Charles-Bonnet syndrome]

OBJECTIVES

Charles-Bonnet syndrome (CBS) is conventionally defined by the presence of visual hallucinations in patients suffering from lowered visual acuity without having psychosis or dementia. Actually, it is a syndrome that interests many specialties, especially ophthalmology, geriatrics, neurology and psychiatry. "Atypical CBS" or "CBS plus" was introduced to designate any kind of visual hallucinations that could be considered as a CBS but accompanied by a low level of insight, a possible cognitive decline, other hallucinatory modalities etc. Since all patients suffering from CBS have to be psychiatrically evaluated, psychological and psychiatric implications of their syndrome have to be well understood in order to better manage them. These psychiatric and psychological implications are: the relationship between the CBS and dementia, the psychological reaction of the patients towards their hallucinations and psychiatric comorbidities that could be developed during the course of the syndrome.

METHODS

A research via MEDLINE for all the articles published in French or in English between January 1999 and December 2009 was done using the following keywords Charles-Bonnet, psychiatric comorbidities and Charles-Bonnet syndrome, Charles-Bonnet syndrome and dementia, psychological reaction and Charles-Bonnet syndrome.

RESULTS

Although some studies report an association between the CBS and dementia, the majority of these studies do not confirm this association and point towards an atypical initial presentation of the syndrome. The psychological reaction accompanying the visual hallucinations of the typical CBS is variable (mild distress, indifference, pleasure). Patients suffering from a typical CBS conserve a full insight during the course of the syndrome. A positive personal psychiatric history or a concomitant psychiatric disorder changes the clinical presentation of the syndrome.

DISCUSSION

Our research allowed us to define the following diagnostic criteria for the atypical CBS: 1) diminished level or absence of insight towards the visual hallucinations; 2) presence of a mild cognitive decline; 3) presence of an atypical psychological reaction towards the visual hallucinations as in the case of a severe and prolonged stressful reaction; 4) presence of other hallucinatory modalities; 5) presence of a positive personal psychiatric history or a concomitant psychiatric disorder. Each patient suffering from CBS should be initially evaluated psychiatrically and neurologically in order to confirm or to eliminate the presence of the most common causes of visual hallucinations. In the presence of a lowered visual acuity and a conserved cognitive functioning, the typical CBS is diagnosed after eliminating more common disorders. Once this diagnosis is established, patients should be evaluated in order to rule out the presence of an atypical clinical presentation.

CONCLUSION

Atypical CBS is a syndrome that could be eventually associated with dementia, accompanied with a major depressive disorder or another psychiatric disorder, or with vulnerability towards psychiatric disorders. Patients suffering from atypical CBS should be closely followed psychiatrically and neurologically. Patients suffering from the typical CBS should also benefit from a psychiatric follow-up, due to their multiple psychiatric vulnerability factors and their possible management with psychotropic drugs.

Charles Bonnet syndrome in Asian patients in a tertiary ophthalmic centre

AIMS

To describe the epidemiology of Charles Bonnet syndrome (CBS) among patients in an Asian tertiary ophthalmic centre and to describe the characteristics of the hallucinations experienced.

METHODS

1077 consecutive patients aged 50 years and above were asked a standardised question to determine if they had ever experienced formed visual hallucinations. All patients who experienced these symptoms were further interviewed using a detailed, standardised questionnaire to ascertain if they met the diagnostic criteria established for CBS.

RESULTS

There were 491 men (45.6%) and 586 women (54.4%). The best corrected visual acuity ranged from 20/20 to light perception in the better seeing eye and from 20/20 to no light perception in the worse seeing eye. Four patients (0.4%) were diagnosed with CBS; two men and two women. There were two Chinese and two Indians. The average age of the CBS patients was 76.3 years (range 65-90 years). Two patients had cataracts, one had glaucoma, and one had both cataracts and glaucoma. A wide variety of visual hallucinations were reported. Three out of four patients experienced a negative reaction to their hallucinations. Only one patient had discussed his symptoms with a doctor.

CONCLUSIONS

This is the first report on the epidemiology of CBS in Asian patients. The prevalence rate of CBS (0.4%) is slightly lower than in comparable studies in non-Asian populations. The nature of the hallucinations experienced were similar to those previously reported.

Phantom Vision: A Graphic Description

An 80-year-old man, who is an experienced artist, underwent orbital exenteration for invasive squamous cell carcinoma. After exenteration, the patient noted a persistent, colored visual phenomenon. The phantom vision continued unchanged to 9 months after surgery (the time of writing), when the patient presented a graphic and written description of phantom vision.

Auras and other hallucinations: windows on the visual brain

Hallucinations in psychologically normal individuals provide a valuable route to studying the neural mechanisms of visual awareness. Migraine auras, epileptic auras and the hallucinations of Charles Bonnet Syndrome are examined in this context. Both similarities and striking differences in content are noted and the extent to which we are currently able to localize the source of these forms of endogenously driven visual awareness is discussed.