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Romozzi M, Trigila V, Tosto F, Cuffaro G, García-Azorín D, Iannone LF, Romozzi P, Savino G, Calabresi P, Puledda F, Vollono C. Prevalence and characteristics of visual snow syndrome in a cohort of young Italian adults. Eur J Neurol 2024:e16472. [PMID: 39318133 DOI: 10.1111/ene.16472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2024] [Revised: 08/19/2024] [Accepted: 08/26/2024] [Indexed: 09/26/2024]
Abstract
BACKGROUND Visual snow (VS) and visual snow syndrome (VSS) are becoming increasingly recognized. However, their prevalence worldwide is unknown. This study aimed to investigate lifetime prevalence and describe the clinical characteristics of VS and VSS in a representative population sample from Italy. METHODS This cross-sectional study was conducted among students attending different faculties in three universities in the central and southern regions of Italy. Eligible participants completed a self-administered questionnaire. In patients fulfilling possible criteria for VS/VSS, the diagnosis was validated by an on-site visit conducted by experienced neurologists and neuro-ophthalmologists that included optical coherence tomography angiography (OCTA). RESULTS A total of 750 participants completed the study. Seven (0.9%) reported symptoms compatible with VS (mean age 24.8 ± 3.85 years). Among the seven patients, five (0.7%) also met the phenomenological and temporal criteria for VSS. Neuroimaging and ophthalmological examinations showed normal results upon review or during the on-site visit including OCTA. For the five patients with full VSS, the other visual symptoms reported were enhanced entoptic phenomenon (n = 5), photophobia (n = 5), palinopsia (n = 1), and nyctalopia (n = 4). In four of the seven patients (57%) reporting VS symptoms, there was a concomitant diagnosis of migraine with aura, and in one (14%) migraine without aura. All patients (n = 7) reported tinnitus. Six of the seven (85.7%) patients with VS/VSS had never used specific treatments for the condition. None of the seven patients had received a previous diagnosis of VS/VSS. CONCLUSIONS The prevalence in Italy of VSS is around 1%. However, there is a limited tendency for affected individuals to seek medical attention, leading to a low rate of diagnosis and treatment.
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Affiliation(s)
- Marina Romozzi
- Dipartimento Universitario di Neuroscienze, Università Cattolica del Sacro Cuore, Rome, Italy
- Neurologia, Dipartimento di Neuroscienze, Organi di Senso e Torace, Fondazione Policlinico, Universitario A. Gemelli IRCCS, Rome, Italy
| | - Vincenzo Trigila
- Dipartimento Universitario di Neuroscienze, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Federico Tosto
- Department of Neuroscience, "Giovanni Paolo II" Hospital, Lamezia Terme, Italy
| | - Giovanni Cuffaro
- Oculistica, Fondazione Policlinico, Universitario A. Gemelli IRCCS, Rome, Italy
| | - David García-Azorín
- Hospital Universitario Rio Hortega, Valladolid, Spain
- Department of Medicine, Toxicology and Dermatology, Faculty of Medicine, University of Valladolid, Valladolid, Spain
| | - Luigi Francesco Iannone
- Section of Clinical Pharmacology and Oncology, Department of Health Sciences, University of Florence, Florence, Italy
| | - Pietro Romozzi
- Dipartimento di Scienze Farmaceutiche, Università degli Studi di Perugia, Perugia, Italy
| | - Gustavo Savino
- Oculistica, Fondazione Policlinico, Universitario A. Gemelli IRCCS, Rome, Italy
| | - Paolo Calabresi
- Dipartimento Universitario di Neuroscienze, Università Cattolica del Sacro Cuore, Rome, Italy
- Neurologia, Dipartimento di Neuroscienze, Organi di Senso e Torace, Fondazione Policlinico, Universitario A. Gemelli IRCCS, Rome, Italy
| | - Francesca Puledda
- Headache Group, Wolfson SPaRRC, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Catello Vollono
- Dipartimento Universitario di Neuroscienze, Università Cattolica del Sacro Cuore, Rome, Italy
- Neurologia, Dipartimento di Neuroscienze, Organi di Senso e Torace, Fondazione Policlinico, Universitario A. Gemelli IRCCS, Rome, Italy
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2
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González-Ávila C, García-Azorín D, Mínguez-Olaondo A, Rubio-Flores L, Lamas R, Nieves-Castellanos C, López-Bravo A, Muñoz-Vendrell A, Campoy S, Sebastian-Valles F, Quintas S. Visual snow syndrome in patients with migraine: widening the clinical spectrum of the syndrome with permanent and episodic manifestations. Neurol Sci 2024; 45:4437-4444. [PMID: 38536549 DOI: 10.1007/s10072-024-07483-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 03/19/2024] [Indexed: 08/09/2024]
Abstract
PURPOSE Migraine is the comorbidity most frequently associated with visual snow syndrome (VSS), but the prevalence of VSS in patients with migraine (PWM) has not been studied. Our objective was to evaluate the frequency of VSS in PWM and to analyze if symptoms of VSS happened in a permanent or episodic manner (eVSS) in this population. METHODS We conducted a multicenter observational cross-sectional study. PWM was recruited from headache units, and a survey about the presence of visual snow symptoms was administered. The frequency and characteristics of patients that met current VSS criteria were analyzed. Demographic and clinical features of patients with VSS, eVSS, and PWM with no visual snow were compared. RESULTS A total of 217 PWM were included. Seventeen patients (7.8%) met the VSS criteria. VSS patients had visual aura more frequently (58.8% vs. 31%; p = 0.019) and a higher MIDAS score (96.6 vs. 47.7; p = 0.014). Fifty-eight PWM (26.7%) showed visual snow and associated features in an episodic way and were classified as eVSS. Patients with VSS showed a tendency towards a higher frequency of visual symptoms than patients with eVSS (p > 0.05). No statistically significant differences in sociodemographic characteristics and comorbid conditions were found between VSS and eVSS. CONCLUSION The prevalence of VSS in PWM may be higher than that described for the general population. Some PWM may present similar visual symptoms to patients with VSS but in an episodic manner. Our study reinforces the observation that the clinical spectrum of visual snow is likely to be broader than previously described.
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Affiliation(s)
- Carmen González-Ávila
- Headache Unit, Neurology Department, Hospital Universitario de La Princesa, Madrid, Spain.
| | - David García-Azorín
- Headache Unit, Neurology Department, Hospital Clínico Universitario, Valladolid, Spain
| | - Ane Mínguez-Olaondo
- Neurology Department, Hospital Universitario Donostia, San Sebastián, Spain
- Athenea Neuroclinics (Donostia), San Sebastián, Spain
- Neuroscience Area, Biodonostia Research Institute (Donostia), San Sebastián, Spain
- Departamento de Medicina, Facultad de Ciencias de La Salud, Universidad de Deusto (Bilbao), San Sebastián, Spain
| | - Laura Rubio-Flores
- Neurology Department, Hospital Universitario General de Villalba, Madrid, Spain
- Neuroscience Institute, La Milagrosa University Hospital and Vithas Madrid, Aravaca University Hospital, Vithas Hospital Group, Madrid, Spain
| | - Raquel Lamas
- Headache Unit, Neurology Department, Hospital Virgen del Rocío, Seville, Spain
| | | | - Alba López-Bravo
- Headache Unit, Department of Neurology, Hospital Reina Sofía, Tudela, Navarra, Spain
- Instituto de Investigación Sanitaria de Aragón, Zaragoza, Spain
| | - Albert Muñoz-Vendrell
- Headache Unit, Neurology Department, Hospital Universitari de Bellvitge-IDIBELL, Universitat de Barcelona, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Sergio Campoy
- Headache Unit, Neurology Department, Hospital Universitari de Bellvitge-IDIBELL, Universitat de Barcelona, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Fernando Sebastian-Valles
- Endocrinology and Nutrition Department, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria de La Princesa, Madrid, Spain
| | - Sonia Quintas
- Headache Unit, Neurology Department, Hospital Universitario de La Princesa, Madrid, Spain
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3
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Fraser CL. How do I recognise and manage visual snow syndrome? Eye (Lond) 2024; 38:2253-2256. [PMID: 38627546 PMCID: PMC11306332 DOI: 10.1038/s41433-024-03059-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 02/26/2024] [Accepted: 04/02/2024] [Indexed: 08/09/2024] Open
Abstract
Visual snow syndrome (VSS) is becoming increasingly recognised by clinicians and self-diagnosed by our patients thanks to online search tools. Previously this phenomenon was overlooked or dismissed leading to increased patient anxiety. Now, however, we need to be careful with that we are not making what would seem to be an easy diagnosis of VSS when actually we are missing any underlying or mimic conditions.
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Affiliation(s)
- Clare L Fraser
- Save Sight Institute, Faculty of Health and Medicine, The University of Sydney, 8 Macquarie Street, Sydney, NSW, 2000, Australia.
- Macquarie Ophthalmology, School of Clinical Medicine, Macquarie University, Sydney, NSW, Australia.
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Montoya SA, Mulder CB, Allison KD, Lee MS, Engel SA, Schallmo MP. What does visual snow look like? Quantification by matching a simulation. J Vis 2024; 24:3. [PMID: 38837169 PMCID: PMC11160957 DOI: 10.1167/jov.24.6.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 04/26/2024] [Indexed: 06/06/2024] Open
Abstract
The primary symptom of visual snow syndrome (VSS) is the unremitting perception of small, flickering dots covering the visual field. VSS is a serious but poorly understood condition that can interfere with daily tasks. Several studies have provided qualitative data about the appearance of visual snow, but methods to quantify the symptom are lacking. Here, we developed a task in which participants with VSS adjusted parameters of simulated visual snow on a computer monitor until the simulation matched their internal visual snow. On each trial, participants (n = 31 with VSS) modified the size, density, update speed, and contrast of the simulation. Participants' settings were highly reliable across trials (intraclass correlation coefficients > 0.89), and they reported that the task was effective at stimulating their visual snow. On average, visual snow was very small (less than 2 arcmin in diameter), updated quickly (mean temporal frequency = 18.2 Hz), had low density (mean snow elements vs. background = 2.87%), and had low contrast (average root mean square contrast = 2.56%). Our task provided a quantitative assessment of visual snow percepts, which may help individuals with VSS communicate their experience to others, facilitate assessment of treatment efficacy, and further our understanding of the trajectory of symptoms, as well as the neural origins of VSS.
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Affiliation(s)
- Samantha A Montoya
- Graduate Program in Neuroscience, University of Minnesota, Minneapolis, MN, USA
| | - Carter B Mulder
- Department of Psychiatry and Behavioral Sciences, University of Minnesota, Minneapolis, MN, USA
| | - Karly D Allison
- Department of Psychology, University of Minnesota, Minneapolis, MN, USA
| | - Michael S Lee
- Department of Ophthalmology and Visual Neurosciences, University of Minnesota, Minneapolis, MN, USA
| | - Stephen A Engel
- Department of Psychology, University of Minnesota, Minneapolis, MN, USA
| | - Michael-Paul Schallmo
- Department of Psychiatry and Behavioral Sciences, University of Minnesota, Minneapolis, MN, USA
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5
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Aeschlimann SA, Klein A, Schankin CJ. Visual snow syndrome: recent advances in understanding the pathophysiology and potential treatment approaches. Curr Opin Neurol 2024; 37:283-288. [PMID: 38465699 PMCID: PMC11064904 DOI: 10.1097/wco.0000000000001258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
PURPOSE OF REVIEW Visual snow syndrome (VSS) is a disorder characterized by persistent visual disturbances, including the visual snow phenomenon, palinopsia, heightened perception of entoptic phenomena, impaired night vision, and photophobia. The purpose of this review is to provide an update on recent findings over the past 18 months in VSS research and to summarize the current state of treatment approaches. RECENT FINDINGS Electrophysiological studies have revealed cortical hyperresponsivity in visual brain areas, imaging studies demonstrated microstructural and functional connectivity alterations in multiple cortical and thalamic regions and investigated glutamatergic and serotoninergic neurotransmission. These findings suggest that VSS might be a network disorder.Only few treatment studies are currently available demonstrating limited response to medication and even worsening or triggering of visual symptoms by certain antidepressants. Promising nonpharmacological treatments include mindfulness-based cognitive therapy, the use of chromatic filters, and research on visual noise adaption and neuro-optometric visual rehabilitation therapy (NORT). However, the level of evidence is still low and further research is needed including larger trials and involving objective measures of individual dysfunction. SUMMARY Although there has been recent progress, we still have not fully understood the nature of VSS. Further research is needed on a clinical and pathophysiological level to successfully treat the condition.
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Affiliation(s)
- Sarah A Aeschlimann
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Brooks CJ, Chan YM, Fielding J, White OB, Badcock DR, McKendrick AM. Improving Understanding of Visual Snow by Quantifying its Appearance and Effect on Vision. Invest Ophthalmol Vis Sci 2024; 65:38. [PMID: 38787547 PMCID: PMC11129720 DOI: 10.1167/iovs.65.5.38] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 04/27/2024] [Indexed: 05/25/2024] Open
Abstract
Purpose Visual snow is the hallmark of the neurological condition visual snow syndrome (VSS) but the characteristics of the visual snow percept remain poorly defined. This study aimed to quantify its appearance, interobserver variability, and effect on measured visual performance and self-reported visual quality. Methods Twenty-three participants with VSS estimated their visual snow dot size, separation, luminance, and flicker rate by matching to a simulation. To assess whether visual snow masks vision, we compared pattern discrimination thresholds for textures that were similar in spatial scale to visual snow as well as more coarse than visual snow, in participants with VSS, and with and without external noise simulating visual snow in 23 controls. Results Mean and 95% confidence intervals for visual snow appearance were: size (6.0, 5.8-6.3 arcseconds), separation (2.0, 1.7-2.3 arcmin), luminance (72.4, 58.1-86.8 cd/m2), and flicker rate (25.8, 18.9-32.8 frames per image at 120 hertz [Hz]). Participants with finer dot spacing estimates also reported greater visibility of their visual snow (τb = -0.41, 95% confidence interval [CI] = -0.62 to -0.13, P = 0.01). In controls, adding simulated fine-scale visual snow to textures increased thresholds for fine but not coarse textures (F(1, 22) = 4.98, P = 0.036, ηp2 = 0.19). In VSS, thresholds for fine and coarse textures were similar (t(22) = 0.54, P = 0.60), suggesting that inherent visual snow does not act like external noise in controls. Conclusions Our quantitative estimates of visual snow constrain its likely neural origins, may aid differential diagnosis, and inform future investigations of how it affects vision. Methods to quantify visual snow are needed for evaluation of potential treatments.
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Affiliation(s)
- Cassandra J. Brooks
- Department of Optometry and Vision Sciences, University of Melbourne, Victoria, Australia
| | - Yu Man Chan
- Department of Optometry and Vision Sciences, University of Melbourne, Victoria, Australia
| | - Joanne Fielding
- Department of Neurosciences, Central Clinical School, Monash University, Melbourne, Australia
| | - Owen B. White
- Department of Neurosciences, Central Clinical School, Monash University, Melbourne, Australia
| | - David R. Badcock
- School of Psychological Science, The University of Western Australia, Crawley, Australia
| | - Allison M. McKendrick
- Department of Optometry and Vision Sciences, University of Melbourne, Victoria, Australia
- Lions Eye Institute, Nedlands, Australia
- School of Allied Health, The University of Western Australia, Crawley, Australia
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Klein A, Aeschlimann SA, Zubler F, Scutelnic A, Riederer F, Ertl M, Schankin CJ. Alterations of the alpha rhythm in visual snow syndrome: a case-control study. J Headache Pain 2024; 25:53. [PMID: 38584260 PMCID: PMC11000394 DOI: 10.1186/s10194-024-01754-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Accepted: 03/19/2024] [Indexed: 04/09/2024] Open
Abstract
BACKGROUND Visual snow syndrome is a disorder characterized by the combination of typical perceptual disturbances. The clinical picture suggests an impairment of visual filtering mechanisms and might involve primary and secondary visual brain areas, as well as higher-order attentional networks. On the level of cortical oscillations, the alpha rhythm is a prominent EEG pattern that is involved in the prioritisation of visual information. It can be regarded as a correlate of inhibitory modulation within the visual network. METHODS Twenty-one patients with visual snow syndrome were compared to 21 controls matched for age, sex, and migraine. We analysed the resting-state alpha rhythm by identifying the individual alpha peak frequency using a Fast Fourier Transform and then calculating the power spectral density around the individual alpha peak (+/- 1 Hz). We anticipated a reduced power spectral density in the alpha band over the primary visual cortex in participants with visual snow syndrome. RESULTS There were no significant differences in the power spectral density in the alpha band over the occipital electrodes (O1 and O2), leading to the rejection of our primary hypothesis. However, the power spectral density in the alpha band was significantly reduced over temporal and parietal electrodes. There was also a trend towards increased individual alpha peak frequency in the subgroup of participants without comorbid migraine. CONCLUSIONS Our main finding was a decreased power spectral density in the alpha band over parietal and temporal brain regions corresponding to areas of the secondary visual cortex. These findings complement previous functional and structural imaging data at a electrophysiological level. They underscore the involvement of higher-order visual brain areas, and potentially reflect a disturbance in inhibitory top-down modulation. The alpha rhythm alterations might represent a novel target for specific neuromodulation. TRIAL REGISTRATION we preregistered the study before preprocessing and data analysis on the platform osf.org (DOI: https://doi.org/10.17605/OSF.IO/XPQHF , date of registration: November 19th 2022).
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Affiliation(s)
- Antonia Klein
- Department of Neurology Inselspital, Bern University Hospital, University of Bern, Rosenbühlgasse 25, Bern, CH-3010, Switzerland
| | - Sarah A Aeschlimann
- Department of Neurology Inselspital, Bern University Hospital, University of Bern, Rosenbühlgasse 25, Bern, CH-3010, Switzerland
| | - Frederic Zubler
- Department of Neurology Inselspital, Bern University Hospital, University of Bern, Rosenbühlgasse 25, Bern, CH-3010, Switzerland
| | - Adrian Scutelnic
- Department of Neurology Inselspital, Bern University Hospital, University of Bern, Rosenbühlgasse 25, Bern, CH-3010, Switzerland
| | - Franz Riederer
- Department of Neurology Inselspital, Bern University Hospital, University of Bern, Rosenbühlgasse 25, Bern, CH-3010, Switzerland
| | - Matthias Ertl
- Department of Psychology, University of Bern, Bern, CH 3010, Switzerland
- Neurocenter, Luzerner Kantonsspital, Lucerne, 6000, Switzerland
| | - Christoph J Schankin
- Department of Neurology Inselspital, Bern University Hospital, University of Bern, Rosenbühlgasse 25, Bern, CH-3010, Switzerland.
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Barrachina-Esteve O, Hidalgo-Torrico I, Acero C, Aranceta S, Cánovas-Vergé D, Ribera G. Visual snow syndrome and its relationship with migraine. Neurologia 2024; 39:190-195. [PMID: 37442427 DOI: 10.1016/j.nrleng.2021.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 05/01/2021] [Indexed: 07/15/2023] Open
Abstract
INTRODUCTION Visual snow syndrome (VSS) is a central nervous system disorder that consists of the constant perception of small black and white dots throughout the entire visual field. DEVELOPMENT VSS can present from infancy to old age, with greater prevalence in the young population, and shows no difference between sexes. The diagnostic criteria include the presence of visual snow and such other visual phenomena as palinopsia, photophobia, nyctalopia, and other persistent visual phenomena. The pathophysiology of VSS is unknown, but hyperexcitability of the visual cortex and a dysfunction in higher-order visual processing are postulated as potential mechanisms. The prevalence of migraine among patients with VSS is high, compared to the general population, and symptoms are more severe in patients presenting both conditions. No effective treatment is available, but the drug with the best results is lamotrigine, which is recommended only in selected cases with severe functional limitation. CONCLUSIONS VSS is a little-known and underdiagnosed entity, but the increasing number of studies in recent years has made it possible to establish diagnostic criteria and begin studying its pathophysiology. This entity is closely related to migraine, with overlapping symptoms and probably shared pathophysiological mechanisms.
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Affiliation(s)
- O Barrachina-Esteve
- Servicio de Neurología, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, Spain.
| | - I Hidalgo-Torrico
- Servicio de Cirugía Cardiaca, Hospital Universitario Son Espases, Palma de Mallorca, Spain
| | - C Acero
- Servicio de Oftalmología, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, Spain
| | - S Aranceta
- Servicio de Neurología, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, Spain
| | - D Cánovas-Vergé
- Servicio de Neurología, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, Spain
| | - G Ribera
- Servicio de Neurología, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, Spain
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Stern JI, Robertson CE. Visual Snow: Updates and Narrative Review. Curr Pain Headache Rep 2024; 28:55-63. [PMID: 38079073 DOI: 10.1007/s11916-023-01186-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/25/2023] [Indexed: 02/22/2024]
Abstract
PURPOSE OF REVIEW Visual snow (VS) involves visualization of innumerable dots throughout the visual field, sometimes resembling "TV static." Patients who experience this symptom may also have additional visual symptoms (e.g., photophobia, palinopsia, floaters, and nyctalopia) with a pattern now defined as visual snow syndrome (VSS). This manuscript describes both VS and VSS in detail and provides an updated review on the clinical features, pathophysiology, and optimal management strategies for these symptoms. RECENT FINDINGS VS/VSS may be primary or secondary to a variety of etiologies, including ophthalmologic or brain disorders, systemic disease, and medication/hallucinogen exposure. Evaluation involves ruling out secondary causes and mimics of VS. Increasing evidence suggests that VSS is a widespread process extending beyond the visual system. Pathophysiology may involve cortical hyperexcitability or dysfunctional connectivity of thalamocortical or attention/salience networks. VSS is typically a benign, non-progressive syndrome and can be managed with non-medicine strategies. Though no medication provides complete relief, some may provide partial improvement in severity of VS.
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Affiliation(s)
- Jennifer I Stern
- Neurology Department, Mayo Clinic College of Medicine and Science, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Carrie E Robertson
- Neurology Department, Mayo Clinic College of Medicine and Science, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA.
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10
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Satgunam P, Kannan K, Hathibelagal AR. Understanding visual snow syndrome: A retrospective study from a tertiary eye care center. Indian J Ophthalmol 2024; 72:211-216. [PMID: 38099384 PMCID: PMC10941942 DOI: 10.4103/ijo.ijo_2180_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 05/02/2023] [Accepted: 05/16/2023] [Indexed: 12/19/2023] Open
Abstract
PURPOSE Visual snow syndrome is a debilitating neurological condition. A comprehensive eye examination may not detect any abnormalities in this condition. Presently the condition is recognized only through the history elicited. Hence, it becomes important to understand the presenting complaints and profile of these patients. A retrospective study at a tertiary eye care center was undertaken to achieve this goal. METHODS Electronic medical records of patients presenting to a Binocular Vision and Orthoptics clinic were reviewed. Records of the patients containing keywords such as "light sensitivity, shadowing, visual snow, multiple images, and night vision" were retrieved and inspected. Those matching the diagnostic criteria of visual snow syndrome were included in the study. RESULTS A total of 33 patients (average age ± standard deviation: 29.7 ± 9.8 years) were identified. Majority of the patients were males (69%). All the patients had logMAR visual acuity 0 or better in each eye. The most prominent (84.4%) presenting symptom was palinopsia (or afterimage or trailing). About 34.4% complained of floaters (including snow-like appearance). More than half (54.6%) of the patients also had binocular dysfunction. CONCLUSION Visual snow syndrome is a relatively new condition on the rise, with unclear pathology. The symptoms of this condition can easily be confused with regular floaters or black spots seen in vitreous and retinal pathologies. In the absence of such pathology, an elaborate history should be elicited, and the distress of the patient should be acknowledged. The patient should also be reassured that this is not a blinding condition.
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Affiliation(s)
- PremNandhini Satgunam
- Brien Holden Institute of Optometry and Vision Sciences, Hyderabad Eye Research Foundation, Hyderabad, Telangana, India
| | - Kiruthika Kannan
- Srimati Kanuri Santhamma Centre for Vitreoretinal Diseases, Anant Bajaj Retina Institute, L. V. Prasad Eye Institute, Hyderabad, Telangana, India
| | - Amithavikram R Hathibelagal
- Brien Holden Institute of Optometry and Vision Sciences, Hyderabad Eye Research Foundation, Hyderabad, Telangana, India
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11
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Vaphiades MS. Delta-8 gummies causing visual snow: a case report. FRONTIERS IN OPHTHALMOLOGY 2024; 3:1349525. [PMID: 38983002 PMCID: PMC11182212 DOI: 10.3389/fopht.2023.1349525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 12/27/2023] [Indexed: 07/11/2024]
Abstract
A 26-year-old man developed visual snow syndrome (VSS) after consuming a little less than half of a delta-8 gummy (estimated at 4 mg of delta-8 tetrahydrocannabinol). Secondary VSS and hallucinogen-persisting perception disorder (HPPD) are discussed, and clinicians who evaluate patients with VS and VSS should ask about delta-8 gummies as an etiology of secondary VSS.
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Affiliation(s)
- Michael S Vaphiades
- Department of Ophthalmology, University of Alabama, Birmingham, AL, United States
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12
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Thompson AC, Goodbourn PT, Forte JD. Elucidating the Visual Snow Spectrum: A Latent Class Analysis Study. Behav Neurol 2024; 2024:5517169. [PMID: 38282623 PMCID: PMC10817806 DOI: 10.1155/2024/5517169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 12/21/2023] [Accepted: 12/28/2023] [Indexed: 01/30/2024] Open
Abstract
Objective People with visual snow syndrome (VSS) experience a range of perceptual phenomena, in addition to visual snow (VS; flickering pinpricks of light throughout the visual field). We investigated the patterns of perceptual phenomena associated with VSS in a large sample of people without prior knowledge of VSS or its associated symptoms. Methods and Measures. Two thousand participants completed a screening questionnaire assessing the frequency and severity of perceptual phenomena associated with VSS. We used latent class analysis (LCA), a clustering technique which identifies qualitatively different subgroups within a given population, to investigate whether the presence (or absence) of VS impacted class structure. Results Of 1,846 participants included for analysis, 41.92% experienced VS some of the time, including 4.49% who had VSS without prior knowledge. The mean number of perceptual phenomena experienced was 2.03. Optimal four-class LCA solutions did not substantially differ whether VS was included in the model; instead, classes differed in the frequency and total number of symptoms experienced. Discussion. Our results suggest that the perceptual phenomena associated with VSS are likely to be common in the general population and do not necessarily indicate an underlying pathology. We also showed that visual snow itself does not explain the presence of other perceptual phenomena.
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Affiliation(s)
- Amy Claire Thompson
- Melbourne School of Psychological Sciences, University of Melbourne, Parkville, Australia
| | - Patrick T. Goodbourn
- Melbourne School of Psychological Sciences, University of Melbourne, Parkville, Australia
| | - Jason D. Forte
- Melbourne School of Psychological Sciences, University of Melbourne, Parkville, Australia
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Balas M, Micieli JA. Visual Snow Syndrome: Use of Text-To-Image Artificial Intelligence Models to Improve the Patient Perspective. Can J Neurol Sci 2023; 50:946-947. [PMID: 36352764 DOI: 10.1017/cjn.2022.317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Michael Balas
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jonathan A Micieli
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario, Canada
- Division of Neurology, Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
- Kensington Vision and Research Centre, Toronto, Ontario, Canada
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14
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Puledda F, Dipasquale O, Gooddy BJM, Karsan N, Bose R, Mehta MA, Williams SCR, Goadsby PJ. Abnormal Glutamatergic and Serotonergic Connectivity in Visual Snow Syndrome and Migraine with Aura. Ann Neurol 2023; 94:873-884. [PMID: 37466404 DOI: 10.1002/ana.26745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 06/22/2023] [Accepted: 07/15/2023] [Indexed: 07/20/2023]
Abstract
OBJECTIVE Neuropharmacological changes in visual snow syndrome (VSS) are poorly understood. We aimed to use receptor target maps combined with resting functional magnetic resonance imaging (fMRI) data to identify which neurotransmitters might modulate brain circuits involved in VSS. METHODS We used Receptor-Enriched Analysis of Functional Connectivity by Targets (REACT) to estimate and compare the molecular-enriched functional networks related to 5 neurotransmitter systems of patients with VSS (n = 24), healthy controls (HCs; n = 24), and migraine patients ([MIG], n = 25, 15 of whom had migraine with aura [MwA]). For REACT we used receptor density templates for the transporters of noradrenaline, dopamine, and serotonin, GABA-A and NMDA receptors, as well as 5HT1B and 5HT2A receptors, and estimated the subject-specific voxel-wise maps of functional connectivity (FC). We then performed voxel-wise comparisons of these maps among HCs, MIG, and VSS. RESULTS Patients with VSS had reduced FC in glutamatergic networks localized in the anterior cingulate cortex (ACC) compared to HCs and patients with migraine, and reduced FC in serotoninergic networks localized in the insula, temporal pole, and orbitofrontal cortex compared to controls, similar to patients with migraine with aura. Patients with VSS also showed reduced FC in 5HT2A -enriched networks, largely localized in occipito-temporo-parietal association cortices. As revealed by subgroup analyses, these changes were independent of, and analogous to, those found in patients with migraine with aura. INTERPRETATION Our results show that glutamate and serotonin are involved in brain connectivity alterations in areas of the visual, salience, and limbic systems in VSS. Importantly, altered serotonergic connectivity is independent of migraine in VSS, and simultaneously comparable to that of migraine with aura, highlighting a shared biology between the disorders. ANN NEUROL 2023;94:873-884.
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Affiliation(s)
- Francesca Puledda
- Headache Group, Wolfson SPaRRC, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
- National Institute for Health Research (NIHR) King's Clinical Research Facility, King's College London, London, UK
| | - Ottavia Dipasquale
- National Institute for Health Research (NIHR) King's Clinical Research Facility, King's College London, London, UK
| | - Benjamin J M Gooddy
- Department of Neuroimaging, Centre for Neuroimaging Sciences, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Nazia Karsan
- Headache Group, Wolfson SPaRRC, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
- National Institute for Health Research (NIHR) King's Clinical Research Facility, King's College London, London, UK
| | - Ray Bose
- Headache Group, Wolfson SPaRRC, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
- National Institute for Health Research (NIHR) King's Clinical Research Facility, King's College London, London, UK
| | - Mitul A Mehta
- Department of Neuroimaging, Centre for Neuroimaging Sciences, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Steven C R Williams
- Department of Neuroimaging, Centre for Neuroimaging Sciences, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Peter J Goadsby
- Headache Group, Wolfson SPaRRC, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
- National Institute for Health Research (NIHR) King's Clinical Research Facility, King's College London, London, UK
- Department of Neurology, University of California, Los Angeles, Los Angeles, CA
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15
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Marek A. [Psychosomatic aspects in otorhinolaryngology-historical milestones]. HNO 2023; 71:622-631. [PMID: 37626261 DOI: 10.1007/s00106-023-01349-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/04/2023] [Indexed: 08/27/2023]
Abstract
BACKGROUND This investigation examined the development of psychosomatics in the field of otolaryngology in Germany using the examples of psychogenic deafness and chronic tinnitus by means of literature research. The focus of the study was on the period 1948-2022. METHODS A literature search was carried out in the PubMed database from 1948 and antiquarian ENT textbooks were evaluated. The search terms used were "ENT and psychosomatics," "tinnitus," "retraining therapy," "analytical psychology," "behavioral therapy," and "sensory systems." RESULTS Psychosomatic phenomena were mentioned in the treatment of nasal diseases and ear ailments in writings of Byzantine and medieval medicine. Even older are references to tinnitus in ancient Egyptian and Indian scripts. From the nineteenth to the mid-twentieth century, psychological abnormalities in ENT symptoms were assigned to the term hysteria. From the middle of the twentieth century, a paradigm shift in the assessment of psychosomatic disorders in otolaryngology became apparent. In the 1950s, a broad psychosomatic discussion was opened in individual lectures and book contributions on mental abnormalities in ENT diseases. With the implementation of the Psychosomatics Working Group of the German Society of Otorhinolaryngology, Head and Neck Surgery, psychosomatics in the field of ENT received the framework for scientific and clinical activity at the turn of the millennium. Psychosomatics is scientifically represented and part of the continuing education regulations for otolaryngology in Germany and at European level. It shows high standards in research, qualification of otolaryngologists, and patient care. CONCLUSION As of 2022, psychosomatics in otolaryngology has been steadily developing for over 70 years. The standards achieved are to be further expanded and research on cognition, affectivity, and sensory analogies intensified.
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Affiliation(s)
- Astrid Marek
- Abteilung für Psychosomatik in der HNO-Heilkunde, Klinik für Hals‑, Nasen- und Ohrenheilkunde, Kopf- und Hals-Chirurgie, Ruhr-Universität Bochum, St. Elisabeth-Hospital Bochum, Bleichstr. 15, 44787, Bochum, Deutschland.
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16
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Puledda F, Viganò A, Sebastianelli G, Parisi V, Hsiao FJ, Wang SJ, Chen WT, Massimini M, Coppola G. Electrophysiological findings in migraine may reflect abnormal synaptic plasticity mechanisms: A narrative review. Cephalalgia 2023; 43:3331024231195780. [PMID: 37622421 DOI: 10.1177/03331024231195780] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/26/2023]
Abstract
BACKGROUND The cyclical brain disorder of sensory processing accompanying migraine phases lacks an explanatory unified theory. METHODS We searched Pubmed for non-invasive neurophysiological studies on migraine and related conditions using transcranial magnetic stimulation, electroencephalography, visual and somatosensory evoked potentials. We summarized the literature, reviewed methods, and proposed a unified theory for the pathophysiology of electrophysiological abnormalities underlying migraine recurrence. RESULTS All electrophysiological modalities have determined specific changes in brain dynamics across the different phases of the migraine cycle. Transcranial magnetic stimulation studies show unbalanced recruitment of inhibitory and excitatory circuits, more consistently in aura, which ultimately results in a substantially distorted response to neuromodulation protocols. Electroencephalography investigations highlight a steady pattern of reduced alpha and increased slow rhythms, largely located in posterior brain regions, which tends to normalize closer to the attacks. Finally, non-painful evoked potentials suggest dysfunctions in habituation mechanisms of sensory cortices that revert during ictal phases. CONCLUSION Electrophysiology shows dynamic and recurrent functional alterations within the brainstem-thalamus-cortex loop varies continuously and recurrently in migraineurs. Given the central role of these structures in the selection, elaboration, and learning of sensory information, these functional alterations suggest chronic, probably genetically determined dysfunctions of the synaptic short- and long-term learning mechanisms.
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Affiliation(s)
- Francesca Puledda
- Headache Group, Wolfson CARD, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom
| | | | - Gabriele Sebastianelli
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome Polo Pontino ICOT, Latina, Italy
| | | | - Fu-Jung Hsiao
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Shuu-Jiun Wang
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Wei-Ta Chen
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Marcello Massimini
- Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
| | - Gianluca Coppola
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome Polo Pontino ICOT, Latina, Italy
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Silva EM, Puledda F. Visual snow syndrome and migraine: a review. Eye (Lond) 2023; 37:2374-2378. [PMID: 36788360 PMCID: PMC10397188 DOI: 10.1038/s41433-023-02435-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Revised: 01/19/2023] [Accepted: 01/30/2023] [Indexed: 02/16/2023] Open
Abstract
Visual snow syndrome is a neurological condition characterized by ongoing prominent phenomena described consistently as tiny dots moving across the entire visual field, often associated with complex visual symptoms. These can take the form of afterimages, entoptic phenomena, nyctalopia and light sensitivity. Although some of these symptoms can be benign, they can nonetheless become significantly impactful for many who experience them, particularly in cases that have a sudden and abrupt start. As visual snow syndrome becomes increasingly recognized in clinical practice we begin to learn about its typical presentation and underlying pathophysiology. Treatment of visual snow, however, still proves quite challenging, and efforts need to be focused on unravelling the biological mechanisms of the syndrome. This endeavour has characterized the most recent research on visual snow, mostly involving neuroimaging, neurophysiological and neurobehavioral studies aimed at understanding its underlying neural signature. Another important aspect of the syndrome, which will likely prove critical in deepening our understanding of visual snow, is represented by the intricate biological and historical connexion with migraine. This narrative review focused on visual snow syndrome will explore its clinical, pathophysiological and treatment aspects in detail.
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Affiliation(s)
| | - Francesca Puledda
- Headache Group, Wolfson CARD, Institute of Psychiatry, Psychology and Neuroscience, King's College, London, UK.
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18
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Zaroban NJ, Kedar S, Anderson D, Vuppala AAD. Analysis of Retinal Structure and Electrophysiological Function in Visual Snow Syndrome: An Exploratory Case Series. J Neuroophthalmol 2023; 43:227-231. [PMID: 36503963 DOI: 10.1097/wno.0000000000001757] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Visual snow (VS) is a rare but distressing phenomenon of persistent granular or pixelated visual distortions that may occur in isolation or as a component of visual snow syndrome (VSS). The current understanding of VS pathogenesis, including the role of retinal involvement structurally and functionally, is limited. The objective of this study is to investigate retinal structural and electrophysiological abnormalities in VS. METHODS This retrospective case series included 8 subjects (7 with VSS and 1 with isolated VS). Patients with other ocular and neurologic diseases were excluded. Data were assessed from automated perimetry, optical coherence tomography (OCT), visual evoked potential (VEP), and full-field electroretinography (ffERG) testing. The VEP and ffERG data of visual snow subjects were compared with age- and sex-matched control subjects for statistical significance. RESULTS The mean age of the cohort was 29.4 years (SD = ±5.3) with 50% gender split. The mean age of VS onset was 24.2 years (SD = ±3.8). All subjects had normal visual acuity, color vision, brain MRI, automated perimetry, OCT parameters (peripapillary retinal nerve fiber layer and macular ganglion cell layer thickness), and P100 and N135 wave pattern on VEP. Compared with controls, VS subjects had a greater mean b-wave amplitude in response to light-adapted 3.0 stimuli ( t test; P = 0.035 right eye and P = 0.072 left eye), greater mean light-adapted 3.0 flicker amplitude ( t test; P = 0.028 right eye P = 0.166 left eye) and greater b-wave amplitude in response to dark-adapted 10.0 stimuli ( t test; P = 0.102 right eye; P = 0.017 left eye) on ERG. CONCLUSIONS Patients with VS and VSS have normal retinal structure, but abnormal electrophysiology compared with control subjects. The increased b-wave and flicker amplitudes observed with ffERG suggest increased responsiveness of the rod and cone photoreceptors and may contribute to VS pathophysiology.
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Affiliation(s)
- Nathaniel J Zaroban
- University of Nebraska Medical Center (NZ), University of Nebraska College of Medicine, Omaha, Nebraska; Department of Ophthalmology (SK), Emory University School of Medicine, Atlanta, Georgia; University of Nebraska Medical Center (DA), Truhlsen Eye Institute, Omaha, Nebraska; and Department of Ophthalmology and Visual Sciences (A-AV), Medical College of Wisconsin, Milwaukee, Wisconsin
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19
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Han MHE, Ciuffreda KJ, Rutner D. Historical, Diagnostic, and Chromatic Treatment in Visual Snow Syndrome: A Retrospective Analysis. Optom Vis Sci 2023; 100:328-333. [PMID: 37071109 DOI: 10.1097/opx.0000000000002019] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2023] Open
Abstract
PURPOSE This study aimed to determine the historical, diagnostic, and treatment aspects in patients with documented visual snow syndrome/visual snow in an academic, optometric setting. METHODS A retrospective analysis was performed in patients (N = 40, aged 12 to 55 years) with documented visual snow syndrome/visual snow examined over a 4-year period. Information was collected by a detailed case history and the Visual Snow Syndrome Symptom Survey. Treatment assessment was performed using the Intuitive Colorimeter, and a wide selection of chromatic tints was assessed under the most provocative/exacerbating and other conditions. RESULTS Visual snow was typically constant and monochromatic, with it being present on average 6.43 years. Bright and dark surfaces were the most provocative/exacerbating/revealing conditions, along with the viewing of computer screens. The most common etiology was mild traumatic brain injury. The most common primary and secondary symptoms were photosensitivity and tinnitus, respectively. There was a high frequency of occurrence of oculomotor deficits, especially accommodative and vergence insufficiency (~40 to 50%). Eighty percent of the patients were prescribed a chromatic tint with subjective visual reduction of visual snow ranging from 15 to 100% (mean, 45%). CONCLUSIONS The present information will help in understanding this unusual medicoperceptual condition, especially with respect to simple treatment frequently using readily available chromatic tints.
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Affiliation(s)
| | - Kenneth J Ciuffreda
- Vision Rehabilitation Service, SUNY/College of Optometry, New York, New York
| | - Daniella Rutner
- Vision Rehabilitation Service, SUNY/College of Optometry, New York, New York
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20
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Eren OE, Straube A. [Temporary and persistent visual phenomena in neurology]. DER NERVENARZT 2023; 94:344-352. [PMID: 37039876 DOI: 10.1007/s00115-023-01466-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Accepted: 02/21/2023] [Indexed: 04/12/2023]
Abstract
Temporary and persistent visual phenomena are a frequent reason for a neurological presentation. The diagnosis can usually be made with the help of a structured anamnesis with determination of the time of onset, the course and symptoms as well as the monocular vs. binocular manifestation. The visual aura in migraine is certainly the most frequent entity to be differentiated. In particular, persistent visual phenomena such as visual snow syndrome, hallucinogen persisting perception disorder and the Charles Bonnet syndrome (CBS) seem to be underdiagnosed in clinical practice for various reasons and are probably not that rare. Instrumental diagnostics are mostly used for exclusion diagnostics and are a component of a complete patient education, but can be indicative for certain questions (CBS, epilepsy). This article presents the most frequent visual phenomena from the neurological practice and their differential diagnoses, guided by a case history.
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Affiliation(s)
- Ozan E Eren
- Neurologie, München Klinik Bogenhausen, München, Deutschland
- Neurologie, Klinikum der Universität München, Marchioninistraße 15, 81377, München, Deutschland
| | - Andreas Straube
- Neurologie, Klinikum der Universität München, Marchioninistraße 15, 81377, München, Deutschland.
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21
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Frattale I, Papetti L, Ursitti F, Sforza G, Monte G, Voci A, Proietti Checchi M, Mazzone L, Valeriani M. Visual Disturbances Spectrum in Pediatric Migraine. J Clin Med 2023; 12:jcm12082780. [PMID: 37109116 PMCID: PMC10143789 DOI: 10.3390/jcm12082780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 04/04/2023] [Accepted: 04/07/2023] [Indexed: 04/29/2023] Open
Abstract
Migraine is a complex neurological disorder with partially unknown pathophysiological mechanisms. The prevalence in childhood ranges from 7.7% to 17.8%, thus representing the most frequent primary headache. In half of the cases, migraine is accompanied or preceded by various neurological disturbances, among which the visual aura is the best known. In literature, other conditions, such as Alice in Wonderland Syndrome and Visual Snow syndrome, are characterized by visual manifestations and are often associated with migraine. The aim of this narrative review is to describe the spectrum of visual disturbances in pediatric migraine and their pathophysiological mechanisms.
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Affiliation(s)
- Ilaria Frattale
- Child Neurology and Psychiatry Unit, Systems Medicine Department, Hospital of Rome, Tor Vergata University, 00165 Rome, Italy
| | - Laura Papetti
- Developmental Neurology, Bambino Gesù Children Hospital, IRCCS, 00165 Rome, Italy
| | - Fabiana Ursitti
- Developmental Neurology, Bambino Gesù Children Hospital, IRCCS, 00165 Rome, Italy
| | - Giorgia Sforza
- Developmental Neurology, Bambino Gesù Children Hospital, IRCCS, 00165 Rome, Italy
| | - Gabriele Monte
- Developmental Neurology, Bambino Gesù Children Hospital, IRCCS, 00165 Rome, Italy
| | - Alessandra Voci
- Developmental Neurology, Bambino Gesù Children Hospital, IRCCS, 00165 Rome, Italy
| | | | - Luigi Mazzone
- Child Neurology and Psychiatry Unit, Systems Medicine Department, Hospital of Rome, Tor Vergata University, 00165 Rome, Italy
| | - Massimiliano Valeriani
- Developmental Neurology, Bambino Gesù Children Hospital, IRCCS, 00165 Rome, Italy
- Center for Sensory Motor Interaction, Aalborg University, 9220 Aalborg, Denmark
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22
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Differential Diagnosis of Visual Phenomena Associated with Migraine: Spotlight on Aura and Visual Snow Syndrome. Diagnostics (Basel) 2023; 13:diagnostics13020252. [PMID: 36673062 PMCID: PMC9857878 DOI: 10.3390/diagnostics13020252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 12/30/2022] [Accepted: 12/30/2022] [Indexed: 01/11/2023] Open
Abstract
Migraine is a severe and common primary headache disorder, characterized by pain as well as a plethora of non-painful symptoms. Among these, visual phenomena have long been known to be associated with migraine, to the point where they can constitute a hallmark of the disease itself. In this review we focus on two key visual disorders that are directly or indirectly connected to migraine: visual aura and visual snow syndrome (VSS). Visual aura is characterized by the transient presence of positive and negative visual symptoms, before, during or outside of a migraine attack. VSS is a novel stand-alone phenomenon which has been shown to be comorbid with migraine. We discuss key clinical features of the two disorders, including pathophysiological mechanisms, their differential diagnoses and best treatment practices. Our aim is to provide an aid for clinicians and researchers in recognizing these common visual phenomena, which can even appear simultaneously in patients with an underlying migraine biology.
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23
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Van Laere K, Ceccarini J, Gebruers J, Goffin K, Boon E. Simultaneous 18F-FDG PET/MR metabolic and structural changes in visual snow syndrome and diagnostic use. EJNMMI Res 2022; 12:77. [PMID: 36583806 PMCID: PMC9803799 DOI: 10.1186/s13550-022-00949-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 12/21/2022] [Indexed: 12/31/2022] Open
Abstract
PURPOSE Visual snow syndrome (VSS) is a recently recognized chronic neurologic condition characterized by the constant perceiving of tiny flickering dots throughout the entire visual field. Metabolic overactivity and grey matter volume increase in the lingual gyrus has been reported. We investigated this by 18F-FDG PET/MR in comparison to healthy controls. Aside from voxel-based characterization, the classification accuracy of volume-of-interest (VOI)-based multimodal assessment was evaluated, also in comparison with visual analysis. METHODS Simultaneous 18F-FDG PET and MR imaging was performed in 7 patients with VSS (24.6 ± 5.7 years; 5 M/2F) and 15 age-matched healthy controls (CON) (28.0 ± 5.3 years; 8 M/7F). SPM12 and voxel-based morphometric analysis was performed. A VOI-based discriminant analysis was performed with relative 18F-FDG uptake, MR grey matter (GM) volumes and their combination. A visual analysis was done by two blinded experienced readers. RESULTS Relative increased hypermetabolism was found in VSS patients in the lingual gyrus and cuneus (pFWE < 0.05, peak change + 24%), and hypometabolism in the mesiotemporal cortex (pheight,uncorr < 0.001, peak change - 14%). VSS patients also had increased GM volume in the limbic system and frontotemporal cortex bilaterally (pFWE < 0.05), and in the left secondary and associative visual cortex and in the left lingual gyrus (pheight,uncorr < 0.001). Discriminant analysis resulted in 100% correct classification accuracy for 18F-FDG with lingual gyrus, cuneus and lateral occipital lobe (BA 17 and BA 18) as main discriminators. Unimodal MR- and combined 18F-FDG + MR classification resulted in an accuracy of 91% and 95%, respectively. Visual analysis of 18F-FDG was highly observer dependent. CONCLUSION Patients with VSS have highly significant structural and metabolic abnormalities in the visual and limbic system. VOI-based discriminant analysis of 18F-FDG PET allows reliable individual classification versus controls, whereas visual analysis of experienced observers was highly variable. Further investigation in larger series, also in comparison to VSS mimicking disorders such as migraine, is warranted. TRAIL REGISTRATION Retrospectively registered at clinicaltrials.gov under NCT05569733 on Oct 5, 2022.
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Affiliation(s)
- Koen Van Laere
- grid.410569.f0000 0004 0626 3338Nuclear Medicine, University Hospitals Leuven, UZ Leuven, Campus Gasthuisberg, Nucleaire Geneeskunde, E901, Herestraat 49, 3000 Leuven, Belgium ,grid.5596.f0000 0001 0668 7884Nuclear Medicine and Molecular Imaging, Department of Imaging and Pathology, KU Leuven, Leuven, Belgium ,grid.5596.f0000 0001 0668 7884Leuven Brain Institute (LBI), KU Leuven, Leuven, Belgium
| | - Jenny Ceccarini
- grid.5596.f0000 0001 0668 7884Nuclear Medicine and Molecular Imaging, Department of Imaging and Pathology, KU Leuven, Leuven, Belgium ,grid.5596.f0000 0001 0668 7884Leuven Brain Institute (LBI), KU Leuven, Leuven, Belgium
| | - Juanito Gebruers
- grid.410569.f0000 0004 0626 3338Nuclear Medicine, University Hospitals Leuven, UZ Leuven, Campus Gasthuisberg, Nucleaire Geneeskunde, E901, Herestraat 49, 3000 Leuven, Belgium
| | - Karolien Goffin
- grid.410569.f0000 0004 0626 3338Nuclear Medicine, University Hospitals Leuven, UZ Leuven, Campus Gasthuisberg, Nucleaire Geneeskunde, E901, Herestraat 49, 3000 Leuven, Belgium ,grid.5596.f0000 0001 0668 7884Nuclear Medicine and Molecular Imaging, Department of Imaging and Pathology, KU Leuven, Leuven, Belgium
| | - Elizabet Boon
- grid.410569.f0000 0004 0626 3338Division of Neurology and Psychiatry, University Hospitals Leuven and UPC Kortenberg, Leuven, Belgium
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24
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Costa RM, Campos P, Wiborg M, Rebôlo C, Wittmann M, Kornmeier J. Prevalence of visual snow and relation to attentional absorption. PLoS One 2022; 17:e0276971. [PMID: 36342911 PMCID: PMC9639836 DOI: 10.1371/journal.pone.0276971] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 10/18/2022] [Indexed: 11/09/2022] Open
Abstract
Visual snow is a condition of unclear prevalence characterized by tiny flickering dots throughout the entire visual field. It appears to result from visual cortex hyperactivity and possibly correlates with propensity to be engrossed in sensory and imaginary experiences (absorption). The prevalence and correlates of visual snow, and emotional reactions to it, were explored in the general Portuguese population with three studies with online surveys. In Study 1, 564 participants were shown an animated graphic simulation of visual snow and asked to rate how frequently they have similar percepts on a scale anchored by 0% and 100% of their waking time. They also reported their degree of distress and fascination resulting from visual snow. Absorption was measured with the Modified Tellegen Absorption Scale. 44% of respondents reported they see visual snow at least 10% of the time, and 20% reported seeing it between 80% and 100% of the time. Similar to findings in clinical samples, the frequency of visual snow correlated with tinnitus frequency and entoptic phenomena, but not with ophthalmologic problems. It was confirmed that visual snow is related to absorption. Although distress caused by visual snow was generally absent or minimal in our samples, a substantial minority (28%) reported moderate to high levels of distress. High fascination with visual snow was reported by 9%. In Studies 2 and 3, visual snow was measured by means of verbal descriptions without graphic simulation (“visual field full of tiny dots of light” and “world seen with many dots of light”, respectively). The results were similar to those in Study 1, but seeing visual snow 80%-100% of the time was less frequent (6.5% in Study 2 and 3.6% in Study 3). Visual snow has been insufficiently investigated. More research is needed to uncover underlying neurophysiological mechanisms and psychological and behavioral correlates.
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Affiliation(s)
- Rui Miguel Costa
- William James Center for Research, Ispa–Instituto Universitário, Lisbon, Portugal
- * E-mail:
| | | | | | | | - Marc Wittmann
- Institute for Frontier Areas of Psychology and Mental Health, Freiburg, Germany
| | - Jürgen Kornmeier
- Institute for Frontier Areas of Psychology and Mental Health, Freiburg, Germany
- Faculty of Medicine, Department of Psychiatry and Psychotherapy, Medical Center—University of Freiburg, Freiburg, Germany
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Irvine A, Luke D. Apophenia, absorption and anxiety: Evidence for individual differences in positive and negative experiences of Hallucinogen Persisting Perceptual Disorder. JOURNAL OF PSYCHEDELIC STUDIES 2022. [DOI: 10.1556/2054.2022.00195] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Abstract
Background and Aims
Little is known about individual differences in Hallucinogen Persisting Perceptual Disorder (HPPD). This study investigated visual processing style and personality across two HPPD types (HPPD I and HPPD II) and a Non-HPPD group.
Methods
An online survey was delivered to participants sourced from online HPPD and psychedelic user groups and forums (N = 117). Using one-way ANOVA, respondents were compared across four measures of individual difference. Using logistic regression, a range of visual symptoms and experiences were investigated as potential predictors of group categorisation.
Results
The HPPD I group had higher absorption and visual apophenia scores than the other groups and was predicted by higher drug use. The HPPD II group showed significantly higher trait anxiety than both other groups. Across the HPPD groups, HPPD II categorisation was also predicted by increased negative precipitating experiences, lack of prior knowledge and pre-existing anxiety diagnoses.
Conclusions
Anxiety, negative precipitating experiences and lack of prior knowledge are associated with negative experiences of persistent visual symptoms following hallucinogen use, whilst higher absorption and visual apophenia are associated with positive or neutral experiences. Together these findings indicate that differences in personality may play a role in determining an individual's experience of HPPD, highlighting the role of individual difference research in expanding knowledge around HPPD.
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Affiliation(s)
| | - David Luke
- University of Greenwich, Greenwich, London
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Graber M, Scutelnic A, Klein A, Puledda F, Goadsby PJ, Schankin CJ. Natural course of visual snow syndrome: a long-term follow-up study. Brain Commun 2022; 4:fcac230. [PMID: 36147453 PMCID: PMC9487631 DOI: 10.1093/braincomms/fcac230] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 07/18/2022] [Accepted: 09/08/2022] [Indexed: 11/13/2022] Open
Abstract
Visual snow syndrome is characterized by a continuous visual disturbance resembling a badly tuned analogue television and additional visual and non-visual symptoms causing significant disability. The natural course of visual snow syndrome has not hitherto been studied. In this prospective longitudinal study, 78 patients with the diagnosis of visual snow syndrome made in 2011 were re-contacted in 2019 to assess symptom evolution using a semi-structured questionnaire. Forty patients (51% of 78) were interviewed after 84 ± 5 months (mean ± SD). In all patients, symptoms had persisted. Visual snow itself was less frequently rated as the most disturbing symptom (72 versus 42%, P = 0.007), whereas a higher proportion of patients suffered primarily from entopic phenomena (2 versus 17%, P = 0.024). New treatment was commenced in 14 (35%) patients, of whom in seven, visual snow syndrome was ameliorated somewhat. Three (7%) experienced new visual migraine aura without headache, and one (2%) had new migraine headache. There were no differences in the levels of anxiety and depression measured by the Patient Health Questionnaire 8 and the Generalized Anxiety Disorder Scale 7. Thirty-eight patients (49%) were lost to follow-up. In visual snow syndrome, symptoms can persist over 8 years without spontaneous resolution, although visual snow itself might become less bothersome.
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Affiliation(s)
- Michael Graber
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern 3010, Switzerland
| | - Adrian Scutelnic
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern 3010, Switzerland
| | - Antonia Klein
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern 3010, Switzerland
| | - Francesca Puledda
- Headache Group, Wolfson CARD, Institute of Psychiatry, Psychology and Neuroscience, King’s College LondonSE1 1YR, London, UK
- NIHR-Wellcome Trust King’s Clinical Research Facility, SLaM Biomedical Research Center, King’s College LondonSE5 9PJ, London, UK
| | - Peter J Goadsby
- Headache Group, Wolfson CARD, Institute of Psychiatry, Psychology and Neuroscience, King’s College LondonSE1 1YR, London, UK
- NIHR-Wellcome Trust King’s Clinical Research Facility, SLaM Biomedical Research Center, King’s College LondonSE5 9PJ, London, UK
| | - Christoph J Schankin
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern 3010, Switzerland
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Tsao YC, Wang YF, Fuh JL, Chen WT, Lai KL, Liu HY, Wang SJ, Chen SP. Non-aura visual disturbance with high visual aura rating scale scores has stronger association with migraine chronification than typical aura. Cephalalgia 2022; 42:1487-1497. [PMID: 36068697 DOI: 10.1177/03331024221123074] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To investigate the clinical correlates of visual symptoms in patients with migraine. METHOD Patients with migraine that attended our headache clinics were enrolled. Headache profiles, disability, and comorbidities were acquired with structured questionnaires. A semi-structured visual phenomenon questionnaire was also used to assess the characteristics of visual symptoms, including visual aura in patients with migraine with aura and transient visual disturbance in patients with migraine without aura. Headache specialists interviewed with the participants for the ascertainment of diagnosis and verification of the questionnaires. RESULT Migraine with aura patients with visual aura (n = 743, female/male = 2.3, mean age: 34.7 ± 12.2 years) and migraine without aura patients with non-aura transient visual disturbance (n = 1,808, female/male = 4.4, mean age: 39.4 ± 12.6 years) were enrolled. Patients with transient visual disturbance had higher headache-related disability and more psychiatric comorbidities. Chronic migraine was more common in migraine without aura than migraine with aura patients (41.9% vs. 11.8%, OR = 5.48 [95% CI: 4.33-7.02], p < 0.001). The associations remained after adjusting confounding factors. CONCLUSION Presence of non-aura transient visual disturbance may suggest a higher migraine-related disability and is linked to higher risk of chronic migraine than typical migraine aura in migraine patients. Further studies are needed to elucidate the potential mechanism.
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Affiliation(s)
- Yu-Chien Tsao
- Keelung Hospital of the Ministry of Health and Welfare, Keelung, Taiwan.,Institute of Clinical Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yen-Feng Wang
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Jong-Ling Fuh
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Wei-Ta Chen
- Keelung Hospital of the Ministry of Health and Welfare, Keelung, Taiwan.,School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Kuan-Lin Lai
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Hung-Yu Liu
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Shuu-Jiun Wang
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Shih-Pin Chen
- Institute of Clinical Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Division of Translational Research, Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan
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Sampatakakis SN, Lymperopoulos L, Mavridis T, Karagiorgis G, Papadopoulos C, Deligianni CI, Mitsikostas DD. Visual snow: A systematic review and a case series. Cephalalgia 2022; 42:1409-1419. [PMID: 35945691 DOI: 10.1177/03331024221118917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Visual Snow Syndrome is a recently recognized neurological condition presenting, continuous, tiny dots across the entire visual field, accompanied by nyctalopia, photophobia and palinopsia that persist for months. It may be part of migraine aura spectrum, yet its definition is still questionable. Diagnostic criteria for Visual Snow Syndrome are included in the supplemental material of ICHD-3. We aimed to summarize recent data to improve the understanding of Visual Snow Syndrome. METHODS After presenting four new cases, we conducted a PRISMA systematic search in PubMed/MEDLINE and Embase databases using the keyword "visual snow" with specific inclusion and exclusion criteria. RESULTS From the 855 articles identified 30 were included for the qualitative analysis. These reports covered five aspects related to Visual Snow Syndrome: epidemiology, clinical features, comorbidities, pathophysiology, and treatment. We found limited data concerning Visual Snow Syndrome's epidemiology (one study). Clinical presentation (22 articles) and the comorbidities (migraine with aura and tinnitus most often, five reports) are described in detail. The pathophysiology of Visual Snow Syndrome is only approached with hypotheses, but several neuroimaging studies have been identified (seven articles). Treatment is based on single case reports only. CONCLUSION Data for Visual Snow Syndrome are few and not strong enough to support Visual Snow Syndrome as a medical identity. Further investigation is needed.
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Affiliation(s)
- Stefanos N Sampatakakis
- 1st Department of Neurology, Eginition Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Loukas Lymperopoulos
- 1st Department of Neurology, Eginition Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Theodoros Mavridis
- 1st Department of Neurology, Eginition Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Georgios Karagiorgis
- 1st Department of Neurology, Eginition Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Constantinos Papadopoulos
- 1st Department of Neurology, Eginition Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Christina I Deligianni
- Danish Headache Center, Rigshospitalet Glostrup, Faculty of Medicine, Universtiy of Copenhagen, Copenhagen, Denmark
| | - Dimos D Mitsikostas
- 1st Department of Neurology, Eginition Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
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29
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Fraser CE, Vaphiades MS, Van Stavern GP, Lee AG. Should Visual Snow and Visual Snow Syndrome Be Evaluated Outside of Standard In-clinic Ophthalmologic Testing? J Neuroophthalmol 2022; 42:384-389. [PMID: 35921623 DOI: 10.1097/wno.0000000000001675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Clare E Fraser
- Faculty of Health and Medicine (CF), Department of Ophthalmology, Save Sight Institute, University of Sydney, Sydney, Australia; Departments of Ophthalmology, Neurology and Neurosurgery (MV), University of Alabama, Birmingham, Alabama; Department of Ophthalmology and Visual Sciences (GPV), Washington University in St. Louis School of Medicine, St Louis, Missouri; and Department of Ophthalmology, Blanton Eye Institute (AGL), Houston Methodist Hospital, Houston, Texas
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30
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Irwin SL, Greene KA, Pavitt SJ, Ross AC. Headache in the Pediatric Population: Focus on Migraine. Semin Neurol 2022; 42:479-488. [DOI: 10.1055/s-0042-1757927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractPediatric headache is a common condition with significant impact on quality of life and ability to function in academic, social, and extracurricular activities. Most pediatric patients seen in primary care and neurology clinics with headache have primary headache disorders. Diagnosis is largely based on clinical history. Imaging is rarely needed in the absence of red flag features. Careful diagnosis is important to guide appropriate treatment. Treatment focuses on a biopsychosocial model integrating lifestyle, pharmacologic and nonpharmacologic treatment modalities. As few therapies are approved in the pediatric population, treatments are often used off-label based on evidence extrapolated from adult studies. Outcomes vary over time but are generally favorable when headache disorders are diagnosed promptly and managed in a multidisciplinary setting.
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Affiliation(s)
- Samantha L. Irwin
- Department of Neurology, University of California, San Francisco (UCSF), California
| | - Kaitlin A. Greene
- Division of Pediatric Neurology, Department of Pediatrics, Oregon Health and Science University (OHSU), Portland, Oregon
| | - Sara J. Pavitt
- Department of Neurology, University of Texas, Austin, Texas
| | - Alexandra C. Ross
- Department of Pediatrics, University of California, San Francisco (UCSF), California
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31
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Kondziella D. Visual snow syndrome and the emperor's new clothes. Brain Commun 2022; 4:fcac178. [PMID: 35898721 PMCID: PMC9311787 DOI: 10.1093/braincomms/fcac178] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 05/08/2022] [Accepted: 07/05/2022] [Indexed: 11/15/2022] Open
Abstract
This scientific commentary refers to 'Microstructure in patients with visual snow syndrome: an ultra-high field morphological and quantitative MRI study', by Strik et al. (https://doi.org/10.1093/braincomms/fcac164).
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Affiliation(s)
- Daniel Kondziella
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Strik M, Clough M, Solly EJ, Glarin R, White OB, Kolbe SC, Fielding J. Microstructure in patients with visual snow syndrome: an ultra-high field morphological and quantitative MRI study. Brain Commun 2022; 4:fcac164. [PMID: 35974797 PMCID: PMC9373960 DOI: 10.1093/braincomms/fcac164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 03/02/2022] [Accepted: 06/21/2022] [Indexed: 12/03/2022] Open
Abstract
Visual snow syndrome is a neurological condition characterized by continuous visual disturbance and a range of non-visual symptoms, including tinnitus and migraine. Little is known about the pathological mechanisms underlying visual snow syndrome. Here, we assessed brain morphometry and microstructure in visual snow syndrome patients using high-resolution structural and quantitative MRI. Forty visual snow syndrome patients (22 with migraine) and 43 controls underwent 7-Tesla MRI (MP2RAGE, 0.75 mm isotropic resolution). Volumetric and quantitative T1 values were extracted for white and grey matter regions and compared between groups. Where regions were significantly different between groups (false discovery rate corrected for multiple comparisons), post hoc comparisons were examined between patients with and without migraine. For visual snow syndrome patients, significant MRI variables were correlated with clinical severity (number of visual symptoms, perceived visual snow intensity, disruptiveness, fatigue and quality of life) and psychiatric symptoms prevalent in visual snow syndrome (depression, anxiety and depersonalization). Finally, cortical regions and individual thalamic nuclei were studied. Compared with controls, visual snow syndrome patients demonstrated a trend towards larger brain and white matter volumes and significantly lower T1 values for the entire cortex (P < 0.001), thalamus (P = 0.001) and pallidum (P = 0.001). For the patient group, thalamic T1 correlated with number of visual symptoms (P = 0.019, r = 0.390) and perceived disruptiveness of visual snow (P = 0.010, r = 0.424). These correlations did not survive multiple comparison corrections. As for specificity in visual snow syndrome group, T1 changes were most evident in caudal regions (occipital cortices) followed by parietal, temporal and prefrontal cortices. T1 values differed between groups for most individual thalamic nuclei. No differences were revealed between patients with and without migraine. In visual snow syndrome patients, we observed no changes in morphometry, instead widespread changes in grey matter microstructure, which followed a caudal-rostral pattern and affected the occipital cortices most profoundly. Migraine did not appear to independently affect these changes. Lower T1 values may potentially result from higher neurite density, myelination or increased iron levels in the visual snow syndrome brain. Further investigation of these changes may enhance our understanding of the pathogenesis of visual snow syndrome, ultimately leading to new treatment strategies.
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Affiliation(s)
- Myrte Strik
- Melbourne Brain Centre Imaging Unit, Department of Radiology, Melbourne Medical School, University of Melbourne , Melbourne, VIC 3010 , Australia
| | - Meaghan Clough
- Department of Neuroscience, Central Clinical School, Monash University , Melbourne, VIC 3004 , Australia
| | - Emma J Solly
- Department of Neuroscience, Central Clinical School, Monash University , Melbourne, VIC 3004 , Australia
| | - Rebecca Glarin
- Melbourne Brain Centre Imaging Unit, Department of Radiology, Melbourne Medical School, University of Melbourne , Melbourne, VIC 3010 , Australia
| | - Owen B White
- Department of Neuroscience, Central Clinical School, Monash University , Melbourne, VIC 3004 , Australia
| | - Scott C Kolbe
- Department of Neuroscience, Central Clinical School, Monash University , Melbourne, VIC 3004 , Australia
| | - Joanne Fielding
- Department of Neuroscience, Central Clinical School, Monash University , Melbourne, VIC 3004 , Australia
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Abstract
OBJECTIVES Visual snow syndrome is relatively a recently recognized neurological entity presenting primarily with positive visual disturbance. Etiology is largely speculative. METHODS Authors report here on a child case of ADHD that developed a probable visual snow syndrome related to methylphenidate. RESULTS AND CONCLUSIONS Although remaining rare, prescribers ought to be cognizant of such unusual methylphenidate-related perceptual alterations.
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Weiß S, Rohde V, Hautmann X, Schittkowski M. [Visual snow syndrome - a pixelated vision]. DIE OPHTHALMOLOGIE 2022; 119:627-631. [PMID: 33950282 DOI: 10.1007/s00347-021-01398-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 04/12/2021] [Accepted: 04/14/2021] [Indexed: 01/26/2023]
Affiliation(s)
- Sophia Weiß
- Klinik für Augenheilkunde, Bereich Strabologie, Neuroophthalmologie, okuloplastische Chirurgie, Universitätsmedizin Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Deutschland.
| | - Veit Rohde
- Klinik für Neurochirurgie, Universitätsmedizin Göttingen, Göttingen, Deutschland
| | - Xenia Hautmann
- Klinik für Neurochirurgie, Universitätsmedizin Göttingen, Göttingen, Deutschland
| | - Michael Schittkowski
- Klinik für Augenheilkunde, Bereich Strabologie, Neuroophthalmologie, okuloplastische Chirurgie, Universitätsmedizin Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Deutschland
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Evers S, Holle-Lee D, Schankin CJ, Kull P, Raffaelli B. Visual snow syndrome is probably not mediated by CGRP: A case series. Cephalalgia 2022; 42:1294-1298. [PMID: 35614870 DOI: 10.1177/03331024221099220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Visual snow syndrome is a phenomenon for which no effective treatment is known. It is highly comorbid with migraine, therefore we performed a retrospective chart review of patients with visual snow syndrome treated with a monoclonal antibody against calcitonin gene related peptide or its receptor. FINDINGS We enrolled 15 patients with visual snow syndrome who received at least once a monoclonal antibody against calcitonin gene related peptide or its receptor. None of the patients reported relief of visual snow syndrome whereas those patients with comorbid migraine reported a very good efficacy of the antibody against the migraine headache but not against the migraine aura. CONCLUSION The data suggest that visual snow syndrome is not mediated by calcitonin gene related peptide in a relevant way and that the calcitonin gene related peptide receptor is not involved in the network underlying the visual snow syndrome.
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Affiliation(s)
- Stefan Evers
- Department of Neurology, Krankenhaus Lindenbrunn, Coppenbrügge, Germany.,Faculty of Medicine, University of Münster, Germany
| | | | - Christoph J Schankin
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Pia Kull
- Department of Neurology, Charité Universitätsmedizin Berlin, Germany
| | - Bianca Raffaelli
- Department of Neurology, Charité Universitätsmedizin Berlin, Germany.,Clinician Scientist Program, Berlin Institute of Health at Charité (BIH), Berlin, Germany
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36
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Ford H, Fraser CL, Solly E, Clough M, Fielding J, White O, Van Der Walt A. Hallucinogenic Persisting Perception Disorder: A Case Series and Review of the Literature. Front Neurol 2022; 13:878609. [PMID: 35599738 PMCID: PMC9120359 DOI: 10.3389/fneur.2022.878609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 04/11/2022] [Indexed: 11/18/2022] Open
Abstract
Background Hallucinogen persisting perception disorder (HPPD) is characterized by the re-emergence of perceptual symptoms experienced during acute hallucinogen intoxication following drug cessation. The underlying pathophysiology is poorly understood. We report the clinical characteristics and investigation findings of a series of HPPD cases with a literature review of previous case reports. We draw parallels between the features of HPPD and Visual Snow Syndrome (VSS). Methods Retrospective case series of 13 patients referred from neuro-ophthalmologists. Literature review with 24 HPPD case reports were identified through database search using the terms “hallucinogenic persisting perception disorder” OR “hallucinogen persisting perception disorder.” Results Lysergic acid diethylamide (LSD), 3,4-Methyl enedioxy methamphetamine (MDMA) and cannabinoid use was common. Cannabinoids and MDMA were mostly used in association with classical hallucinogens. The most frequent symptoms in our patients were visual snow, floaters, palinopsia, photophobia and nyctalopia. In the literature other symptoms included visual hallucinations altered motion perception, palinopsia, tracers and color enhancement. Ophthalmic and neurologic investigations were mostly normal. The majority of patients had ongoing symptoms. Two of our patients fully recovered—one after treatment with benzodiazepine and one without treatment. Twenty-five percent of cases from the literature fully recovered. Conclusions HPPD presents with heterogeneous visual phenomena on a background of previous classic and non-classic hallucinogen use. Ophthalmic investigations are typically normal. The symptoms of HPPD in our case series overlap with the typical features of Visual Snow Syndrome (VSS). Patients presenting with VSS should be screened for past recreational drug use. The DSM-5 description of HPPD does not include visual snow, nyctalopia, photophobia or floaters. A revision of the diagnostic criteria to include these symptoms may better reflect the typical clinical phenotype. Increased awareness of HPPD as a secondary cause of VSS can avoid extensive investigations. Controlled trials comparing primary and secondary VSS patients are needed to understand the pathophysiology better and optimize treatment for HPPD.
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Affiliation(s)
- Hannah Ford
- Department of Neurology, Alfred Health, Melbourne, VIC, Australia
| | - Clare L. Fraser
- Faculty of Health and Medicine, Save Sight Institute, The University of Sydney, Sydney, NSW, Australia
| | - Emma Solly
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Meaghan Clough
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Joanne Fielding
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Owen White
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Anneke Van Der Walt
- Department of Neurology, Alfred Health, Melbourne, VIC, Australia
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia
- Department of Neuro-Ophthalmology, Royal Victorian Eye and Ear Hospital, Melbourne, VIC, Australia
- *Correspondence: Anneke Van Der Walt
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White OB, Fielding J, Pelak VS, Schankin CJ. Editorial: Visual Snow: Old Problem, New Understanding. Front Neurol 2022; 13:884752. [PMID: 35493832 PMCID: PMC9051336 DOI: 10.3389/fneur.2022.884752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Accepted: 03/14/2022] [Indexed: 12/04/2022] Open
Affiliation(s)
- Owen B. White
- Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
- *Correspondence: Owen B. White
| | - Joanne Fielding
- Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
| | | | - Christoph J. Schankin
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Raviskanthan S, Ray JC, Mortensen PW, Lee AG. Neuroimaging in Visual Snow - A Review of the Literature. FRONTIERS IN OPHTHALMOLOGY 2022; 2:758963. [PMID: 38983561 PMCID: PMC11182151 DOI: 10.3389/fopht.2022.758963] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Accepted: 02/17/2022] [Indexed: 07/11/2024]
Abstract
Since the first description of visual snow syndrome (VSS) in 1995, there has been increasing interest particularly within the past 5-10 years in phenotyping the condition and differentiating it from conditions such as migraine with aura and hallucinogen persisting perception disorder. Structural and functional neuroimaging has provided valuable insights in this regard, yielding functional networks and anatomical regions of interest, of which the right lingual gyrus is of particular note. Various modalities, including functional magnetic resonance imaging (fMRI), positron emission tomography (PET), and single photon emission computed tomography (SPECT), have all been studied in patients with visual snow. In this article, we conduct a comprehensive literature review of neuroimaging in VSS.
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Affiliation(s)
- Subahari Raviskanthan
- Department of Ophthalmology, Blanton Eye Institute, Houston Methodist Hospital, Houston, TX, United States
- Department of Neurology, Alfred Health, Melbourne, VIC, Australia
- Department of Neuro-Ophthalmology, Royal Victorian Eye and Ear Hospital, Melbourne, VIC, Australia
| | - Jason C. Ray
- Department of Neurology, Alfred Health, Melbourne, VIC, Australia
- Department of Neuroscience, Monash University, Clayton, VIC, Australia
- Department of Neurology, Austin Health, Heidelberg, VIC, Australia
| | - Peter W. Mortensen
- Department of Ophthalmology, Blanton Eye Institute, Houston Methodist Hospital, Houston, TX, United States
| | - Andrew G. Lee
- Department of Ophthalmology, Blanton Eye Institute, Houston Methodist Hospital, Houston, TX, United States
- Department of Ophthalmology, Weill Cornell Medicine, New York, NY, United States
- Department of Neurology, Weill Cornell Medicine, New York, NY, United States
- Department of Neurosurgery, Weill Cornell Medicine, New York, NY, United States
- Department of Ophthalmology, University of Texas Medical Branch, Galveston, TX, United States
- Department of Ophthalmology, University of Texas MD Anderson Cancer Center, Houston, TX, United States
- Department of Ophthalmology, Texas A and M College of Medicine, Bryan, TX, United States
- Department of Ophthalmology, The University of Iowa Hospitals and Clinics, Iowa City, IA, United States
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Puledda F, Villar-Martínez MD, Goadsby PJ. Case Report: Transformation of Visual Snow Syndrome From Episodic to Chronic Associated With Acute Cerebellar Infarct. Front Neurol 2022; 13:811490. [PMID: 35242098 PMCID: PMC8886039 DOI: 10.3389/fneur.2022.811490] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 01/24/2022] [Indexed: 12/23/2022] Open
Abstract
Visual snow syndrome is a novel neurological condition characterized by a panfield visual disturbance associated with several additional symptoms. Although it is usually a continuous and primary disorder, cases of intermittent visual snow have been described in the literature, as well as rare secondary forms. This report is the first description of a case of intermittent visual snow syndrome, which transformed into a persistent form following a posterior circulation stroke due to vertebral artery dissection. At 1 and 2 years after experiencing the acute cerebellar infarct, the patient's only neurological sequalae was visual snow. This case provides a description of how visual snow syndrome may be caused by an underlying brain disorder, and highlights the importance of the cerebellum in the pathophysiology of this relatively unknown condition. It further shows evidence of how existing predispositions might be relevant to the development of visual snow, in certain subjects and following specific circumstances.
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Affiliation(s)
- Francesca Puledda
- Headache Group, Wolfson Centre for Age-Related Diseases (CARD), SLaM Biomedical Research Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, National Institute for Health Research (NIHR)-Wellcome Trust King's Clinical Research Facility, King's College Hospital, London, United Kingdom
| | - María Dolores Villar-Martínez
- Headache Group, Wolfson Centre for Age-Related Diseases (CARD), SLaM Biomedical Research Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, National Institute for Health Research (NIHR)-Wellcome Trust King's Clinical Research Facility, King's College Hospital, London, United Kingdom
| | - Peter J Goadsby
- Headache Group, Wolfson Centre for Age-Related Diseases (CARD), SLaM Biomedical Research Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, National Institute for Health Research (NIHR)-Wellcome Trust King's Clinical Research Facility, King's College Hospital, London, United Kingdom.,Department of Neurology, University of California, Los Angeles, Los Angeles, CA, United States
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Abstract
Purpose of Review Until the last 5 years, there was very little in the literature about the phenomenon now known as visual snow syndrome. This review will examine the current thinking on the pathology of visual snow and how that thinking has evolved. Recent Findings While migraine is a common comorbidity to visual snow syndrome, evidence points to these conditions being distinct clinical entities, with some overlapping pathophysiological processes. There is increasing structural and functional evidence that visual snow syndrome is due to a widespread cortical dysfunction. Cortical hyperexcitability coupled with changes in thalamocortical pathways and higher-level salience network controls have all shown differences in patients with visual snow syndrome compared to controls. Summary Further work is needed to clarify the exact mechanisms of visual snow syndrome. Until that time, treatment options will remain limited. Clinicians having a clearer understanding of the basis for visual snow syndrome can appropriately discuss the diagnosis with their patients and steer them towards appropriate management options.
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Affiliation(s)
- Clare L Fraser
- Faculty of Health and Medicine, Save Sight Institute, The University of Sydney, 8 Macquarie Street, Sydney, NSW, 2000, Australia. .,Macquarie Ophthalmology, School of Clinical Medicine, Macquarie University, Sydney, Australia.
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Case Report: Visual Snow Syndrome following Repetitive Mild Traumatic Brain Injury. Optom Vis Sci 2022; 99:413-416. [PMID: 35001065 DOI: 10.1097/opx.0000000000001862] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
SIGNIFICANCE Visual snow syndrome is a recently recognized condition with its own diagnostic criteria, evolving pathophysiologic research, and potential treatment options. PURPOSE This report documents a rare, but likely underdiagnosed condition called visual snow syndrome. A review of the current literature on pathophysiology and treatments is discussed. CASE REPORT A 40-year-old white male started experiencing symptoms of constant pulsating pixels throughout his entire visual field approximately 3 weeks after a series of mild concussions. Additionally, he experienced a persistence of images and photosensitivity. The patient had normal eye exams, visual fields and retinal imaging. Brain magnetic resonance imaging, magnetic resonance angiography, electroencephalography, and cerebrospinal fluid analysis were unremarkable. A positron emission tomography scan demonstrated hypometabolism in the posterior parietal lobes and left posterior cingulate gyrus. Pharmacological treatment with anti-epileptic and migraine medications were unsuccessful. Tinted lenses were essentially ineffective with a 10% reduction in symptoms reported with the use of a custom blue tinted lens. Vision rehabilitation aids with optical character recognition were utilized for prolonged reading needs. CONCLUSIONS Although rare, visual snow syndrome should be considered in all patients reporting continuous pixelations in their vision for over 3 months, especially when accompanied by at least two of the following: photosensitivity, palinopsia, enhanced entopic phenomena, or nyctalopia. The pathophysiology is still unclear at this point with evidence suggesting a link to the secondary visual cortex, specifically the lingual gyrus. More studies are needed to determine the exact cause, especially studies that separate visual snow syndrome patients with and without comorbid migraine. Because the pathophysiology is unclear, the treatment course is also unclear. Anecdotal evidence may suggest that tinted lenses may be of some value.
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Guay M, Lagman-Bartolome AM. Onset of Visual Snow Syndrome After the First Migraine Episode in a Pediatric Patient: A Case Report and Review of Literature. Pediatr Neurol 2022; 126:46-49. [PMID: 34736063 DOI: 10.1016/j.pediatrneurol.2021.08.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 08/14/2021] [Accepted: 08/16/2021] [Indexed: 01/24/2023]
Abstract
INTRODUCTION Visual snow syndrome (VSS) is a neurological disorder characterized by persistent positive visual disturbances. VSS is known to be a rare condition; however, it is becoming increasingly recognized by neurologists and neuroophthalmologists. Despite this, it is not commonly described in pediatric patients. METHODS We describe a pediatric girl with onset of persistent visual phenomena at age 13 years, which she described as "TV static," with associated afterimages, photopsia, nyctalopia, and photophobia. These visual disturbances have persisted for two years. RESULTS The patient's MRI revealed approximately 15 T2/fluid-attenuated inversion recovery hyperintensities in keeping with changes secondary to migraine. The ophthalmologic examination did not reveal an underlying cause. The patient's visual symptoms have been resistant to medications. CONCLUSION VSS is a recently described syndrome that is debilitating to patients. Further case descriptions, characterization of presentation, and management of patients with VSS, specifically in pediatric cases, are required.
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Affiliation(s)
- Meagan Guay
- McMaster University, Hamilton, Ontario, Canada.
| | - Ana Marissa Lagman-Bartolome
- Centre for Headache, Women's College Hospital, University of Toronto, Toronto, Ontario, Canada; Division of Neurology, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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Müller F, Kraus E, Holze F, Becker A, Ley L, Schmid Y, Vizeli P, Liechti ME, Borgwardt S. Flashback phenomena after administration of LSD and psilocybin in controlled studies with healthy participants. Psychopharmacology (Berl) 2022; 239:1933-1943. [PMID: 35076721 PMCID: PMC9166883 DOI: 10.1007/s00213-022-06066-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 01/14/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND LSD and psilocybin are increasingly used in phase I trials and evaluated as therapeutic agents for mental disorders. The phenomenon of reoccurring drug-like experiences after the acute substance effects have worn off was described for both substances and especially attributed to LSD. According to the DSM-V, the persisting and distressing manifestation of these experiences is called hallucinogen-persisting perception disorder (HPPD). Data on both conditions is very limited. OBJECTIVE This study aims to provide descriptive data on reoccurring drug-like experiences after the administration of LSD and psilocybin in controlled studies with healthy participants. METHODS AND MATERIALS Data from 142 healthy subjects enrolled in six double-blinded, placebo-controlled, randomized cross-over studies were analyzed. In total, 60 subjects received LSD; 27 subjects received LSD, MDMA, and D-amphetamine; 31 subjects received LSD and psilocybin; and 25 subjects received psilocybin and escitalopram. At the end-of-study visit (mean 39.8 days after last study session, SD 37.2), subjects were asked for any reoccurring drug effects since the initial substance effects had worn off. Those reporting reoccurring perception changes more than 24 h after administration were contacted for follow-up (mean follow-up duration: 31.2 months, SD 28.6). RESULTS Thirteen out of 142 subjects reported reoccurring drug-like experiences (LSD: seven, psilocybin: two, both: four). The reported phenomena were predominantly mild and perceived as neutral to pleasant. Flashbacks were mostly of visual nature, lasted for seconds to minutes, and occurred within a week after the last drug administration. Two subjects reported distressing experiences that subsided spontaneously. One subject reported brief and pleasant visual perception changes which reoccurred for 7 months. None of the subjects reported impairment in their daily lives. None of the cases met DSM-V criteria for HPPD. CONCLUSION Reoccurring drug-like experiences after the administration of LSD and psilocybin are a common phenomenon occurring in up to 9.2% of healthy subjects (7.8% for LSD, 8.3% for psilocybin and 14.3% if both substances are administered). Additionally, our work suggests that flashback phenomena are not a clinically relevant problem in controlled studies with healthy participants.
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Affiliation(s)
- Felix Müller
- Department of Psychiatry (UPK), University of Basel, Wilhelm Klein-Strasse 27, 4012, Basel, Switzerland.
| | - Elias Kraus
- Department of Psychiatry (UPK), University of Basel, Wilhelm Klein-Strasse 27, 4012, Basel, Switzerland
| | - Friederike Holze
- Division of Clinical Pharmacology and Toxicology, Department of Biomedicine and Department of Clinical Research, University Hospital Basel, University of Basel, 4031, Basel, Switzerland
| | - Anna Becker
- Division of Clinical Pharmacology and Toxicology, Department of Biomedicine and Department of Clinical Research, University Hospital Basel, University of Basel, 4031, Basel, Switzerland
| | - Laura Ley
- Division of Clinical Pharmacology and Toxicology, Department of Biomedicine and Department of Clinical Research, University Hospital Basel, University of Basel, 4031, Basel, Switzerland
| | - Yasmin Schmid
- Division of Clinical Pharmacology and Toxicology, Department of Biomedicine and Department of Clinical Research, University Hospital Basel, University of Basel, 4031, Basel, Switzerland
| | - Patrick Vizeli
- Division of Clinical Pharmacology and Toxicology, Department of Biomedicine and Department of Clinical Research, University Hospital Basel, University of Basel, 4031, Basel, Switzerland
| | - Matthias E Liechti
- Division of Clinical Pharmacology and Toxicology, Department of Biomedicine and Department of Clinical Research, University Hospital Basel, University of Basel, 4031, Basel, Switzerland
| | - Stefan Borgwardt
- Department of Psychiatry and Psychotherapy, University of Lübeck, 23538, Lübeck, Germany
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Tuekprakhon A, Pawestri AR, Suvannaboon R, Thongyou K, Trinavarat A, Atchaneeyasakul LO. Rare Co-Occurrence of Visual Snow in a Female Carrier With RPGR ORF15-Associated Retinal Disorder. Front Genet 2021; 12:728085. [PMID: 34659350 PMCID: PMC8517444 DOI: 10.3389/fgene.2021.728085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Accepted: 09/20/2021] [Indexed: 11/13/2022] Open
Abstract
X-linked retinitis pigmentosa (XLRP), a rare form of retinitis pigmentosa (RP), is predominantly caused by mutations in the retinitis pigmentosa GTPase regulator (RPGR) gene. Affected males often present with severe phenotypes and early disease onset. In contrast, female carriers are usually asymptomatic or show stationary phenotypes. Herein, we reported an 8-year-old female carrier, a daughter of a confirmed RP father with RPGR mutation, with an early onset of progressive cone-rod pattern retinal dystrophy. Additionally, the carrier experienced visual snow-like symptom as long as she recalled. Ophthalmological examination showed the reduction of visual acuity and attenuation of photoreceptor functions since the age of 5 years. Further analysis revealed a heterozygous pathogenic variant of the RPGR gene and a random X-inactivation pattern. Although she harboured an identical RPGR variant as the father, there were phenotypic intrafamilial variations. The information on the variety of genotypic and phenotypic presentations in XLRP carriers is essential for further diagnosis, management, and monitoring of these cases, including the design of future gene therapy trials.
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Affiliation(s)
- Aekkachai Tuekprakhon
- Department of Ophthalmology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.,Nuffield Department of Medicine, Wellcome Centre for Human Genetics, University of Oxford, Oxford, United Kingdom
| | | | - Ragkit Suvannaboon
- Department of Ophthalmology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.,Research Division, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Ketwarin Thongyou
- Department of Ophthalmology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Adisak Trinavarat
- Department of Ophthalmology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - La-Ongsri Atchaneeyasakul
- Department of Ophthalmology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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45
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Puledda F, Vandenbussche N, Moreno-Ajona D, Eren O, Schankin C, Goadsby PJ. Evaluation of treatment response and symptom progression in 400 patients with visual snow syndrome. Br J Ophthalmol 2021; 106:1318-1324. [PMID: 34656983 PMCID: PMC9411880 DOI: 10.1136/bjophthalmol-2020-318653] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 03/24/2021] [Accepted: 03/26/2021] [Indexed: 11/03/2022]
Abstract
AIMS To gather information on useful medications to treat visual snow syndrome (VSS) as well as to validate an instrument to assess its clinical severity and the course of the disorder over time. METHODS Four hundred patients with VSS were included in this web-based prospective questionnaire study. All subjects completed a treatment questionnaire and a clinical diary. The first allowed evaluation of the effects of previous medications on visual snow, while the second measured VSS symptoms daily over the course of 30 days. RESULTS Patients commonly reported previous use of medications such as antidepressants, antiepileptics, antibiotics and benzodiazepines. However, none of these drug classes was beneficial for the majority of patients. Recreational drugs and alcohol worsened visual snow symptoms in several reports. Vitamins and benzodiazepines had high therapeutic ratios, although in most cases they did not change the course of VSS.The monthly diary confirmed that the static in VSS is a consistent symptom over time. It also showed that indoor and fluorescent lights have a worse effect on symptoms when compared with natural outdoor lighting. CONCLUSIONS The study confirms clinical experience that medications are generally ineffective in VSS, with the exception of vitamins and perhaps benzodiazepines, which could be beneficial in some patients. The 30-day diary represents a useful tool to measure symptom progression over time, which could be used in future trials on VSS.
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Affiliation(s)
- Francesca Puledda
- Headache Group, Wolfson CARD, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK .,NIHR-Wellcome Trust King's Clinical Research Facility, SLaM Biomedical Research Centre, King's College Hospital, NIHR, London, UK
| | | | - David Moreno-Ajona
- Headache Group, Wolfson CARD, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK.,NIHR-Wellcome Trust King's Clinical Research Facility, SLaM Biomedical Research Centre, King's College Hospital, NIHR, London, UK
| | - Ozan Eren
- Neurology, University Hospital LMU Munich, Munchen, Germany
| | | | - Peter J Goadsby
- Headache Group, Wolfson CARD, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK.,NIHR-Wellcome Trust King's Clinical Research Facility, SLaM Biomedical Research Centre, King's College Hospital, NIHR, London, UK.,Neurology, University of California Los Angeles, Los Angeles, California, USA
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Brooks CJ, Chan YM, Fielding J, White OB, Badcock DR, McKendrick AM. Visual contrast perception in visual snow syndrome reveals abnormal neural gain but not neural noise. Brain 2021; 145:1486-1498. [PMID: 34633444 DOI: 10.1093/brain/awab383] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 09/17/2021] [Accepted: 09/21/2021] [Indexed: 11/14/2022] Open
Abstract
Visual snow syndrome is a neurological condition characterised by a persistent visual disturbance, visual snow, in conjunction with additional visual symptoms. Cortical hyperexcitability is a potential pathophysiological mechanism, which could be explained by increased gain in neural responses to visual input. Alternatively, neural noise in the visual pathway could be abnormally elevated. We assessed these two potential competing neural mechanisms in our studies of visual contrast perception. Cortical hyperexcitation also occurs in migraine, which commonly co-occurs with visual snow syndrome. Therefore, to determine whether the effect of visual snow syndrome can be distinguished from interictal migraine, we recruited four participant groups: controls, migraine alone, visual snow syndrome alone, visual snow syndrome with migraine. In the first experiment, we estimated internal noise in 20 controls, 21 migraine participants, 32 visual snow syndrome participants (16 with migraine) using a luminance increment detection task. In the second experiment, we estimated neural contrast gain in 21 controls, 22 migraine participants, 35 visual snow syndrome participants (16 with migraine) using tasks assessing sensitivity to changes in contrast from a reference. Contrast gain and sensitivity were measured for the putative parvocellular and ON and OFF magnocellular pathways, respectively. We found that luminance increment thresholds and internal noise estimates were normal in both visual snow syndrome and migraine. Contrast gain measures for putative parvocellular processing and contrast sensitivity for putative OFF magnocellular processing were abnormally increased in visual snow syndrome, regardless of migraine status. Therefore, our results indicate that visual snow syndrome is characterised by increased neural contrast gain but not abnormal neural noise within the targeted pathways.
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Affiliation(s)
- Cassandra J Brooks
- Department of Optometry and Vision Sciences, University of Melbourne, Parkville, Australia
| | - Yu Man Chan
- Department of Optometry and Vision Sciences, University of Melbourne, Parkville, Australia
| | - Joanne Fielding
- Department of Neurosciences, Central Clinical School, Monash University, Melbourne, Australia
| | - Owen B White
- Department of Neurosciences, Central Clinical School, Monash University, Melbourne, Australia
| | - David R Badcock
- School of Psychological Science, The University of Western Australia, Crawley, Western Australia
| | - Allison M McKendrick
- Department of Optometry and Vision Sciences, University of Melbourne, Parkville, Australia
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Michels L, Stämpfli P, Aldusary N, Piccirelli M, Freund P, Weber KP, Fierz FC, Kollias S, Traber G. Widespread White Matter Alterations in Patients With Visual Snow Syndrome. Front Neurol 2021; 12:723805. [PMID: 34621237 PMCID: PMC8490630 DOI: 10.3389/fneur.2021.723805] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 08/04/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Visual snow is considered a disorder of central visual processing resulting in a perturbed perception of constant binocular flickering or pixilation of the whole visual field. The underlying neurophysiological and structural alterations remain elusive. Methods: In this study, we included patients (final n = 14, five dropouts; five females, mean age: 32 years) with visual snow syndrome (VSS) and age- and sex-matched controls (final n = 20, 6 dropouts, 13 females, mean age: 28.2 years). We applied diffusion tensor imaging to examine possible white matter (WM) alterations in patients with VSS. Results: The patient group demonstrated higher (p-corrected < 0.05, adjusted for age and sex) fractional anisotropy (FA) and lower mean diffusivity (MD) and radial diffusivity (RD) compared to controls. These changes were seen in the prefrontal WM (including the inferior fronto-occipital fascicle), temporal and occipital WM, superior and middle longitudinal fascicle, and sagittal stratum. When additionally corrected for migraine or tinnitus-dominant comorbidities in VSS-similar group differences were seen for FA and RD, but less pronounced. Conclusions: Our results indicate that patients with VSS present WM alterations in parts of the visual cortex and outside the visual cortex. As parts of the inferior fronto-occipital fascicle and sagittal stratum are associated with visual processing and visual conceptualisation, our results suggest that the WM alterations in these regions may indicate atypical visual processing in patients with VSS. Yet, the frequent presence of migraine and other comorbidities such as tinnitus in VSS makes it difficult to attribute WM disruptions solely to VSS.
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Affiliation(s)
- Lars Michels
- Department of Neuroradiology, Clinical Neuroscience Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Philipp Stämpfli
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zurich, Zurich, Switzerland
| | - Njoud Aldusary
- Department of Neuroradiology, Clinical Neuroscience Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland.,Department of Diagnostic Radiology, Faculty of Applied Medical Sciences, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Marco Piccirelli
- Department of Neuroradiology, Clinical Neuroscience Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | | | - Konrad P Weber
- Department of Neurology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Fabienne C Fierz
- Department of Ophthalmology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Spyros Kollias
- Department of Neuroradiology, Clinical Neuroscience Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Ghislaine Traber
- Institute of Molecular and Clinical Ophthalmology Basel (IOB), Basel, Switzerland.,Department of Ophthalmology, University of Basel, Basel, Switzerland
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48
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Vaphiades MS, Grondines B, Cooper K, Gratton S, Doyle J. Diagnostic Evaluation of Visual Snow. Front Neurol 2021; 12:743608. [PMID: 34603194 PMCID: PMC8481612 DOI: 10.3389/fneur.2021.743608] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Accepted: 08/17/2021] [Indexed: 01/24/2023] Open
Abstract
Introduction: To determine which patients with visual snow (VS) and VS syndrome (VSS) require standard ophthalmologic testing including automated visual field and which patients require further testing such as macular spectral domain optical coherence tomography (SD-OCT), electrophysiology, and neuroimaging. Materials and Methods: We retrospectively reviewed 52 consecutive patients at three institutions with VS and VSS including the University of Alabama, Callahan Eye Hospital, the University of Missouri-Kansas City School of Medicine, and the Little Rock Eye Clinic from the years 2015 to 2021. We collected historical information, examination findings, ophthalmic testing, electrophysiology, and neuroimaging. Results: Of the 52 patients with VS and VSS, eight of the 52 cases met the clinical criteria for VSS. The ages ranged from 7 to 79 years, with a mean age of 25 years (SD = 14.0). There were 22 males and 30 females. Color vision was tested in 51 cases and was normal in 47 cases (92%). A funduscopic exam was performed in all 52 cases and was normal in 46 cases (88%). The macular SD-OCT was normal in all of the 19 cases that it was performed (100%). A Humphrey visual field was performed in 50 cases and was normal in 43 (86%). A visually evoked potential (VEP) was normal in 18 of the 19 cases where it was obtained (95%). The full-field electroretinography (ffERG) was obtained in 28 cases and was normal in 25 (89%). The multifocal electroretinography (mfERG) was normal in 11 of 12 cases (92%). Only four patients accounted for all of the abnormal electrophysiological tests. In the 37 cases that had an MRI, 29 were normal (78%). Only one patient revealed a lesion in the visual pathway (right optic nerve enhancement in an optic neuritis patient). Conclusions: Patients with VS and VSS, if typical in presentation and with normal testing, do not require a workup beyond a thorough history, neuro-ophthalmologic examination, and automated perimetry. If this testing is abnormal, then ancillary testing is required.
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Affiliation(s)
- Michael S Vaphiades
- Department of Ophthalmology, University of Alabama, Birmingham, AL, United States
| | - Brendan Grondines
- Department of Ophthalmology, University of Alabama, Birmingham, AL, United States
| | - Kasey Cooper
- Department of Ophthalmology, University of Alabama, Birmingham, AL, United States
| | - Sean Gratton
- Department of Ophthalmology, University of Missouri-Kansas City School of Medicine, Kansas City, MO, United States
| | - Jennifer Doyle
- Department of Ophthalmology, Little Rock Eye Clinic, Little Rock, AK, United States
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49
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Klein A, Schankin CJ. Visual Snow Syndrome as a Network Disorder: A Systematic Review. Front Neurol 2021; 12:724072. [PMID: 34671311 PMCID: PMC8521005 DOI: 10.3389/fneur.2021.724072] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 08/31/2021] [Indexed: 11/13/2022] Open
Abstract
Aim: By reviewing the existing clinical studies about visual snow (VS) as a symptom or as part of visual snow syndrome (VSS), we aim at improving our understanding of VSS being a network disorder. Background: Patients with VSS suffer from a continuous visual disturbance resembling the view of a badly tuned analog television (i.e., VS) and other visual, as well as non-visual symptoms. These symptoms can persist over years and often strongly impact the quality of life. The exact prevalence is still unknown, but up to 2.2% of the population could be affected. Presently, there is no established treatment, and the underlying pathophysiology is unknown. In recent years, there have been several approaches to identify the brain areas involved and their interplay to explain the complex presentation. Methods: We collected the clinical and paraclinical evidence from the currently published original studies on VS and its syndrome by searching PubMed and Google Scholar for the term visual snow. We included original studies in English or German and excluded all reviews, case reports that did not add new information to the topic of this review, and articles that were not retrievable in PubMed or Google Scholar. We grouped the studies according to the methods that were used. Results: Fifty-three studies were found for this review. In VSS, the clinical spectrum includes additional visual disturbances such as excessive floaters, palinopsia, nyctalopia, photophobia, and entoptic phenomena. There is also an association with other perceptual and affective disorders as well as cognitive symptoms. The studies that have been included in this review demonstrate structural, functional, and metabolic alterations in the primary and/or secondary visual areas of the brain. Beyond that, results indicate a disruption in the pre-cortical visual pathways and large-scale networks including the default mode network and the salience network. Discussion: The combination of the clinical picture and widespread functional and structural alterations in visual and extra-visual areas indicates that the VSS is a network disorder. The involvement of pre-cortical visual structures and attentional networks might result in an impairment of "filtering" and prioritizing stimuli as top-down process with subsequent excessive activation of the visual cortices when exposed to irrelevant external and internal stimuli. Limitations of the existing literature are that not all authors used the ICHD-3 definition of the VSS. Some were referring to the symptom VS, and in many cases, the control groups were not matched for migraine or migraine aura.
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Affiliation(s)
| | - Christoph J. Schankin
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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E. Eren O, Wilhelm H, J. Schankin C, Straube A. Visual Phenomena Associated With Migraine and Their Differential Diagnosis. DEUTSCHES ARZTEBLATT INTERNATIONAL 2021; 118:647-653. [PMID: 34636719 PMCID: PMC8762590 DOI: 10.3238/arztebl.m2021.0287] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 04/29/2021] [Accepted: 06/29/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Visual phenomena are of many different kinds; their differential diagnosis is usually possible with directed history-taking. In this review, we describe common visual phenomena that must be distinguished from a migraine aura. METHODS This review is based on publications retrieved by a selective search in PubMed and the Web of Knowledge/Science, with special attention to the current classification of the International Headache Society and the recommendations of the German Migraine and Headache Society. The following search terms were used: "visual phenomena/phenomenon," "migraine aura," and "persistent/complication/ long-lasting/ongoing." RESULTS The most helpful questions for differential diagnosis are whether the symptoms are present in one eye only or in both, whether their onset was sudden or over minutes or days, and whether the phenomenon has occurred only once or repeatedly, or is persistently present. A visual aura associated with migraine must be distinguished, in rare cases, from an isolated epileptic aura, from cerebral/retinal ischemia, or from visual snow. Further differential diagnoses include a persisting perceptual disturbance after hallucinogen use (HPPD, "hallucinogen persisting perception disorder") and the Charles Bonnet syndrome (CBS); the latter arises as a consequence of severely impaired vision. Posterior reversible encephalopathy syndrome (PRES) is rare and generally reveals itself over its further course through the appearance of additional clinical manifestations. Primary ophthalmological causes can usually be readily identified and classified by ophthalmological examination. CONCLUSION Patients with visual phenomena typically consult physicians from various medical specialties. A correct differential diagnosis can be made based on the history if the physician views the symptoms in their overall context to determine the particular disease entity that is responsible.
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Affiliation(s)
- Ozan E. Eren
- Department of Neurology, University Hospital, LMU Munich, Munich, Germany
| | | | | | - Andreas Straube
- Department of Neurology, University Hospital, LMU Munich, Munich, Germany
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