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

BACKGROUND/AIMS

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

METHODS

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

RESULTS

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

CONCLUSION

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

Atypical Charles Bonnet syndrome secondary to frontal meningioma: a case report

BACKGROUND

Charles Bonnet Syndrome (CBS) is a rare clinical entity that is classically composed of visual hallucinations in the context of an altered optic pathway with preservation of reality judgment. This case aims to present the association of visual hallucinations with complex alterations of the nervous structures adjacent to the visual pathway and an atypical clinical presentation, thus explaining the possible mechanisms involved in the generation of these symptoms.

CASE PRESENTATION

A 43-year-old man presents seeking care due to visual hallucinations with partial preservation of reality judgment and symptoms compatible with a major depressive disorder, including irritability and diminished hygiene habits. He has a history of complete gradual loss of vision and hyposmia. Due to poor treatment response during hospitalization, an MRI was obtained, which showed a frontal tumor lesion with meningioma characteristics adjacent to the olfactory groove and compression of the optic chiasm. He underwent surgical resection of the lesion, which remitted the psychotic symptoms, but preserving the visual limitation and depressive symptoms.

CONCLUSIONS

The presence of visual hallucinations, without other psychotic features as delusions, is a focus of attention for basic structural pathologies in the central nervous system. Affection at any level of the visual pathway can cause CBS. When finding atypical symptoms, a more in-depth evaluation should be made to allow optimization of the diagnosis and treatment.

"Playthings of the Brain": Phantom Visions in Charles Bonnet Syndrome

Charles Bonnet Syndrome (CBS) is a condition of the visually impaired, in which hallucinations - or, more appropriately, visions - of geometric patterns, people, and objects appear within the visual field. Most people with CBS are older adults, a function of increased likelihood of visual deterioration in later life, but the condition can occur at any age. Diagnostic criteria vary among professions, but generally includes awareness that the visions are not real, the absence of other accompanying sensory hallucinations, and the absence of dementia or other neurological condition. The mechanism by which the phenomenon occurs is not well understood, although some speculation exists that it is akin to phantom limb syndrome. Although there has recently been increasing awareness about the condition, many in the fields of medicine, optometry, and social work have not heard of it. As front-line providers for clients, it is important that social workers be well informed about the condition to alleviate anxiety our clients may have about expressing their experiences with the condition.

[Complex visual hallucinations in the visually impaired, the Charles Bonnet syndrome]

Charles Bonnet syndrome (CBS) is characterised by recurrent, complex and vivid visual hallucinations in the absence of cognitive dysfunction. Individuals with CBS usually maintain insight into the unreal nature of their hallucinatory experiences. There is a strong association between CBS and acquired visual loss and the most commonly described ocular pathology is age-related macular degeneration. However, CBS has been described in the context of visual impairment due to pathologies anywhere along the visual pathway. It is widely agreed that CBS is an underreported diagnosis caused by patients' reluctance to admit their hallucinatory experience because of fear of being labelled mentally ill. CBS is a diagnosis of exclusion and careful assessment must be made to ensure that other etiologies causing the symptoms are ruled out. Knowledge of CBS is nonetheless important, as it constitutes a benign differential diagnosis to diseases presenting themselves with visual hallucinations. In many patients the hallucinations generate considerable anxiety aggravated by the lack of awareness of CBS. Thus, a major part of the treatment is careful information about the benign nature of the condition. Optimizing visual function also has beneficial effects on the hallucinations. This is conducted by optical means such as visual aids and the employment of different types of surgical procedures.

Charles Bonnet syndrome in a child with congenital glaucoma

CASE REPORT

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

DISCUSSION

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