Therapeutic options in Charles Bonnet syndrome

Review of Risk Factors, Pathophysiology, Management Principles, and Role of Medications

This is a case report of one patient experiencing psychotic symptoms in the setting of Charles Bonnet syndrome (CBS). Case description is included, and patient has been deidentified. Patient's consent could not be obtained for the submission of the report. The case report focuses on understanding and formulating key psychological issues addressed in this case. It is important to identify that the absence of psychotic illness is classical in patients presenting with psychotic symptoms in CBS and the role of antipsychotic medication is uncertain. A literature review on the management of CBS guidelines published across the world and summarization of the management approach applicable to this case. Visual hallucination is a perception of a visual stimuli when none exists. CBS is characterized by the presence of complex visual hallucinations experienced by the visually impaired, i.e., in an individual with ocular pathology causing vision loss without having true psychosis or dementia. Furthermore, the person having these experiences has a preserved insight into the unreal nature of the perceptions and the absence of mental disorders. An introduction to the terminology "atypical CBS" or "CBS plus" was done to consider visual hallucinations in individuals with low level of insight in a setting of possible cognitive deficits or other hallucinatory modalities.

Evaluation of the Clinical Features, Management, and Prognoses of Patients With Charles Bonnet Syndrome

Charles Bonnet syndrome (CBS) is characterized by visual hallucinations with preservation of cognitive abilities. The hallucinations consist mostly of vivid (realistic) objects and tend to reoccur. Here, we evaluate the etiologies, symptoms, treatments, and prognoses of 13 CBS cases. All patients had visual hallucinations but were normal on cognitive and psychiatric assessments. Patient demographic and clinical characteristics, treatment options, and 3-month follow-up data were retrospectively reviewed. The possible causes of CBS and what the patients perceived during their hallucinations were recorded. Antipsychotic agents, such as risperidone and quetiapine, and anticonvulsants, such as levetiracetam, may be effective in some cases.

Charles Bonnet Syndrome: A Review of the Literature

Charles Bonnet syndrome (CBS) commonly occurs in older adults with visual impairments, particularly those with age-related macular degeneration. It is characterized by complex visual hallucinations in individuals without mental disorders. The authors explore diagnostic criteria, demographic characteristics, clinical features, theories of pathogenesis, and management options for people who are diagnosed with CBS.

Low vision rehabilitation: An update

This article provides information concerning issues related to the care of individuals who are visually impaired. Issues reviewed include determining who should be referred for vision rehabilitation services, Charles Bonnet syndrome, visual acuity, contrast sensitivity and visual field testing along with Useful Field of View testing. This article also discusses technology advances that can enhance the visual functioning of individuals who are visually impaired, including how these advances can help drivers with visual impairments to continue to safely operate motor vehicles, at least on a limited basis. Finally, resources that are available to both encourage and motivate patients to take advantages of vision rehabilitation services are reviewed.

Visual Hallucination in Craniometaphyseal Dysplasia Successfully Treated with Olanzapine

Objective:

To report the successful treatment of visual hallucinations in a patient with craniometaphyseal dysplasia (CMD) with olanzapine.

Case Summary:

A 15-year-old girl with CMD presenting with transient episodes of total blindness and complex visual hallucinations was successfully treated with olanzapine.

Discussion:

The co-occurrence of visual hallucination and blindness in this patient suggests a variety of the Charles Bonnet syndrome, a diagnosis made almost exclusively in the older population. Compared with traditional antipsychotics, the reduced propensity of olanzapine to produce extrapyramidal side effects may make it more favorable in specific situations.

Conclusions:

More experience with olanzapine in treating visual hallucinations is needed to determine whether it is more effective than typical antipsychotics in treating visual hallucinations associated with CMD or Charles Bonnet syndrome.

Charles Bonnet's syndrome: not only a condition of the elderly

PURPOSE

To investigate whether the experience of visual hallucinations, namely Charles Bonnet's syndrome, in psychologically healthy people is a phenomenon solely of elderly, visually impaired people.

METHODS

In a prospective controlled study, four groups of subjects (total 324) were formed: age ≤40 years, no visual impairment; age ≤40 years, visually impaired; age >40 years, no visual impairment; age >40 years, visually impaired. Visual impairment was defined as best-corrected visual acuity ≤0.3 (Snellen) in the better-seeing eye. Each group consisted of 81 subjects. Visual hallucinations were defined as complex visual perceptions. After ruling out psychiatric causes for visual hallucinations or medication related to the experience of visual hallucinations, affected subjects underwent a detailed interview about their visual hallucinations.

RESULTS

The prevalence of visual hallucinations among young subjects with visual impairment was 4.9 %; among the elderly visually impaired subjects, it was 6.2 %. The difference was not statistically significant. No subject without visual impairment experienced visual hallucinations.

CONCLUSIONS

Charles Bonnet's syndrome is not limited to elderly people suffering from visual impairment, though there tends to be a higher prevalence of visual hallucinations in this group.

Escitalopram for antipsychotic nonresponsive visual hallucinosis: eight patients suffering from Charles Bonnet syndrome

BACKGROUND

The Charles Bonnet syndrome (CBS) is characterized by distinct visual hallucinations and ocularpathology causing visual impairment in patients with insight and the absence of psychiatric comorbidity. The number of reported cases of CBS is expanding as the population ages and the prevalence of vision disorders increases. Antipsychotic medications are often prescribed. However, their efficacy in CBS has been based on sketchy evidence. The use of serotonin selective reuptake inhibitor (SSRI) for CBS was anecdotally reported. We herein describe effectiveness of escitalopram in a series of patients suffering from CBS who were unresponsive to antipsychotic treatment.

METHODS

Eight consecutive patients suffering from CBS who did not respond to standard antipsychotic treatment were switched to escitalopram. CBS severity prior to escitalopram treatment was quantified using the Clinical Global Impression (CGI) scale and again after eight weeks of treatment. All had undergone brain CT and cognitive assessment. Brain CT imaging was normal except for an incidental finding of a small frontal meningioma in one patient. All had Mini-Mental Status Examination scores of ≥ 27/30.

RESULTS

There were four men and four women, with a mean age of 81.7 ± 7.3 years. Previous antipsychotic treatment was mostly with risperidone, 1.0 to 3.0 mg/daily. Mean CGI-severity upon switching to escitalopram treatment was 5.7. This was significantly reduced to 1.8 (p < 0.001) after eight weeks of escitalopram treatment (mean dose: 11.8 mg/daily). There were no side effects, nor any adverse events were reported.

CONCLUSIONS

This is the first case-series to show that SSRI is an effective and well-tolerated treatment for visual hallucinations associated with vision impairment such as in CBS.

Recognizing Charles Bonnet syndrome in the elderly

Charles Bonnet syndrome (CBS) is an under-recognized and commonly misdiagnosed condition characterized by the presence of visual hallucinations that psychologically normal people acknowledge as being unreal. It is commonly associated with ocular pathology and usually observed in elderly individuals with visual impairment. The exact etiology of CBS is unknown; however, the presentation of hallucinations is believed to be a result of functional deterioration of the central and peripheral nervous systems. Eradication of hallucinations and recurrent episodes has been seen with the use of neuroleptic and anticonvulsant agents. Correction of underlying ocular disorders and low-vision rehabilitation may also help in the resolution of visions. Careful patient assessment is necessary to appropriately diagnose CBS and determine the best approach to management.

Complex visual hallucinations (Charles Bonnet syndrome) in the hemianopic visual field following occipital infarction

Charles Bonnet syndrome is characterised by the occurrence of complex visual hallucinations in the presence of normal cognition in elderly individuals. It commonly happens following conditions where there has been a profound loss of vision or interruption of visual input into the occipital cortex. It is important to distinguish this largely innocuous condition from psychiatric conditions that exist in the same age group. This article describes a rare variant of this condition where such hallucinations occur in the hemianopic visual field of a patient with an occipital infarct whose visual acuity is largely unimpaired. The article details the various conditions where this phenomenon has been experienced; the theories that have been postulated for its aetiology and the treatment options. The variations of this case from the commonly observed scenarios are highlighted questioning previously held convictions as well as providing an insight into the widening spectrum of the phenomenon as more cases are described. The article hopes to raise awareness of this condition, which is much commoner than perceived by healthcare practitioners, as most patients in that age group are reluctant to be forthcoming with their symptoms for fear of being diagnosed with a psychiatric disorder.

Treatment of typical Charles Bonnet syndrome with donepezil

Charles Bonnet syndrome (CBS) is characterized by the presence of complex visual hallucinations in psychologically normal people. Although visual hallucinations in the elderly are often associated with dementia with Lewy body (DLB), Alzheimer's disease and delirium, they are excluded from the diagnosis of typical CBS, as are cognitive or psychiatric disturbances, sleep disorders and focal neurological lesions. Here, we describe a patient with typical CBS, who responded to donepezil, a cholinesterase inhibitor, and has not shown any symptoms suggestive of Alzheimer's disease or DLB for approximately the past 40 months. However, follow-up examination of her clinical symptoms is necessary for a definite exclusion of Alzheimer's disease and DLB. The effectiveness of donepezil indicates that the patient's visual hallucinations might be related to dysfunction of cholinergic neurones, although she did not exhibit any cognitive decline, or morphological and physiological brain pathology. Because donepezil has fewer adverse effects than anticonvulsants and neuroleptic drugs, it may be a safer option for the treatment of CBS in the elderly.

Rehabilitation in Charles Bonnet syndrome: a review of treatment options

People with vision loss sometimes experience visual hallucinations associated with Charles Bonnet syndrome. The appearance of these hallucinations often causes anxiety for the sufferer and can be difficult for the attending eye care professional to manage. A review of the literature highlighted a range of visual, pharmacological and social management regimes that may alleviate these hallucinations, albeit using small samples in uncontrolled trials. Eye care practitioners should be aware of methods of rehabilitation in Charles Bonnet syndrome that may lead to resolution of the visual hallucinations.

Charles Bonnet syndrome: visual hallucination and multiple sclerosis

Multiple sclerosis (MS) is a fairly common condition that affects approximately 350,000 people in the United States. It is associated with various neuropsychiatric symptoms including cognitive and behavioral symptoms. However, visual hallucinations are rare in multiple sclerosis without the presence of cognitive deficits. We are describing the case of a 40-year-old married white female with isolated complex visual hallucinations compatible with the Charles Bonnet syndrome (CBS). The patient was successfully treated with the atypical antipsychotic olanzapine.

Complex visual hallucinations in the visually impaired: the Charles Bonnet Syndrome

Visually impaired patients may experience complex visual hallucinations, a condition known as the Charles Bonnet Syndrome. Patients usually possess insight into the unreality of their visual experiences, which are commonly pleasant but may sometimes cause distress. The hallucinations consist of well-defined, organized, and clear images over which the subject has little control. It is believed that they represent release phenomena due to de-afferentation of the visual association areas of the cerebral cortex, leading to a form of phantom vision. Cognitive defects, social isolation, and sensory deprivation have also been implicated in the etiology of this condition. This condition, which is most common in the elderly, frequently goes unrecognized in clinical practice, due to both lack of awareness among doctors and patients' reluctance to admit to hallucinatory experiences, for fear of being labeled mentally unstable. Furthermore, patients who comprehend the unreality of their hallucinations may be distressed by the real fear of imminent insanity. Sensitive and sympathetic history taking is essential to ascertain the existence of hallucinations. Reassurance and explanation that the visions are benign and do not signify mental illness have a powerful therapeutic effect. Hallucinatory activity may terminate spontaneously, on improving visual function or on addressing social isolation. There is no universally effective drug treatment but anticonvulsants may play a limited role in aborting the hallucinations. Physician awareness and empathy are the cornerstones of management.

Melperone in the treatment of neuroleptic-resistant schizophrenia

Melperone is an effective antipsychotic drug that has been reported to have atypical properties, i.e. low extrapyramidal side effect liability at clinically effective doses. It also does not increase serum prolactin levels. Its effectiveness for patients with neuroleptic (treatment)-resistant schizophrenia has not been evaluated. In this study, melperone was administered, in an open trial design of 6 weeks' duration, to 44 patients with chronic neuroleptic-resistant schizophrenia. The Global Assessment Scale (GAS), Brief Psychiatric Rating Scale (BPRS) and measures of extrapyramidal symptoms and other clinical variables were assessed at baseline and 6 weeks. Thirty-seven patients completed the 6-week trial. Melperone significantly improved overall psychiatric status as measured by GAS score for all evaluable subjects [last value carried forward (LVCF) and a completers analysis]. No significant effects on BPRS measures of psychopathology scores were found in the LVCF or completers analysis. Patients who showed > or = 20% decrease in the BPRS Total score (N=7) were more likely to have high baseline psychopathology, as measured by BPRS Total and Anxiety-Depression subscales, than those who showed > or = 20% increase in the BPRS Total score (N=8). Non-responders to melperone generally did not respond to subsequent treatment with clozapine, indicating that this group of patients was very treatment resistant. Melperone was not associated with worsening of extrapyramidal symptoms, elevation in plasma prolactin levels, or an increase in body mass index (BMI). The results suggest that a proportion of neuroleptic-resistant patients with schizophrenia respond to melperone, which requires further controlled study.

Charles Bonnet syndrome in glaucoma patients with low vision

PURPOSE

To characterize the nature and frequency of Charles Bonnet syndrome in glaucoma patients with low vision.

PATIENTS AND METHODS

All patients attending the glaucoma clinic during a period of 10 months who had visual acuity of 20/80 or less in both eyes were included in this study. Each patient was questioned about the occurrence of visual hallucinations. Those who responded positively had a thorough interview relating to the characteristics of the hallucinations. Medical history and social history were taken, followed by a complete ocular examination.

RESULTS

Eighty-nine patients met the inclusion criteria. Eleven patients (12.3%), eight men and three women, admitted to having experienced visual hallucinations. Except for one case, the patients did not disclose this experience previously. Eight patients had one repeatable hallucination, and three patients experienced more than one sight. The visions were usually sharp, and the figures were occasionally incomplete. Most hallucinations were chromatic. Frequency of hallucinations varied between daily and weekly, and duration was mostly a few minutes. In addition to glaucoma, nine of the eleven patients had other ocular findings that could have contributed to the reduction of vision.

CONCLUSION

Visual hallucinations are not rare in glaucoma patients with low vision. Patients tend to conceal their experience of visual hallucinations, but a discussion of these phenomena with the patient and assurance of their harmless nature will reduce his or her anxiety and concerns.