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Do You See What I See?

Do You See What I See?. Denise A. John VEI 10/20/2006. Case. HPI: 35 y/o ♀ c/o’s of “seeing shapes, colors & partially-formed images.” ROS: (+) Mild headache/weight loss/poor energy/constipation Questions???. Classic Migraine Psychosis Psychiatric illness Schizophrenia

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Do You See What I See?

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  1. Do You See What I See? Denise A. John VEI 10/20/2006

  2. Case • HPI: 35 y/o ♀ c/o’s of “seeing shapes, colors & partially-formed images.” • ROS: (+) Mild headache/weight loss/poor energy/constipation Questions???

  3. Classic Migraine Psychosis Psychiatric illness Schizophrenia Affective disorders Conversion disorders Metabolic/toxic Electrolyte imbalance Uremic Liver dz Infection Alcohol/drug effects Neurodegenerative disorder Diffuse Lewy Body Parkinson’s Alzheimer’s Sleep-related hallucinations “ Hypnopompic “ Peduncular hallucinations Seizures Release hallucinations Differential Diagnosis

  4. Fortification Spectrum

  5. Case • FHX: • Glaucoma • Heart & liver dz; HTN; cancer; stroke • SHX: ø Tobacco/IVDA/ETOH • NKDA • MEDS: ASA; prednisone; pepcid; metoclopramide; anzemet; synthroid; colace; lexapro; zyprexa; morphine; lortab

  6. Case • PMHX: • Migraines • Pituitary GH-producing adenoma • Pituitary apoplexy • Subarachnoid hemorrhage • S/p trans-sphenoidal hypophysectomy x 2; CSF leak x 2 s/p repair • Panhypopituitarism • SIADH • Depression • Polycystic ovarian syndrome • Psoriatic arthritis

  7. Alert & oriented x 3 Normal affect NLP VA NLP CVF: Unable OU Motility: Full OU 11 IOP 12 5 Pupils 5 NR to light Partial reaction to near External/PLE exam unremarkable DFE: Mild disc pallor OU Macula/vessels/periphery unremarkable OU Case

  8. Patient

  9. Patient

  10. Visual Hallucinations Visual Hallucinations

  11. Visual Hallucinations Visual perceptions not associated with external visual stimuli

  12. Visual Hallucinations • Simple (non-formed): • Dots • Colors • Flashing lights • Geometric patterns

  13. Visual Hallucinations • Complex (formed): • Objects • Animals • People • Scenery

  14. Visual Illusions • Distortion or modification of a real visual image

  15. Visual Hallucinations • Most are NOT due to psychiatric dz • Related to ocular, optic nerve or brain pathology • Treatment involves managing underlying disorder • Insight into the reality of the hallucinations varies with the associated etiology • May interfere with daily functioning & cause significant anxiety

  16. Visual Hallucinations: Etiologies Visual Hallucinations: Etiologies

  17. “Seeing light” Insight preserved Visual hallucinations: “Scintillating blue spots on a black background Rubbing closed eyes “Seeing stars” Sneeze, head trauma, low blood pressure “Flashes of light” (photopsias) Dim lightening or total darkness Light twinkles to bright flashes Irritation of photoreceptors Vitreous traction Retinal detachment/ inflammation Optic neuritis Esp. with EOM/sound Phosphenes

  18. Psychosis • Visual Hallucinations: • Complex • Duration: Variable • +/- Other hallucinations • Esp. auditory • +/- Insight preservation

  19. Release Hallucinations • Complete or partial visual acuity/field loss from any cause • Commonly seen in AMD • Charles Bonnet Syndrome (CBS) • Described in 1769 • Swiss naturalist & philosopher • ~ 14% prevalence in U.S. eye clinics •  with age • Ø Gender predilection

  20. Release Hallucinations • Theory of CBS: • Sensory deprivation • Visual cortex  “release phenomenon” • Input from other cortical areas (esp. memory) “fill-in” the sensory deficit • Risk factors: • Bilateral visual loss •  age • Solitude •  Cognition

  21. Release Hallucinations • Visual hallucinations: • 65%: Weekly/monthly; 27%: Daily • People: 80%; animals: 38%; plants/trees: 25%; buildings/other scenery: 15% • Color: 63% • Movement: 47% • Duration: • 53%: 1-60 mins; 13% < 5 secs • Eyes open: 67% • Teurisse et al. Visual hallucinations in psychologically normal patients: CBS. Lancet, 1996

  22. Release Hallucinations • Insight preserved • Setting: • Fatigue • Stress • Early mornings/late evening • Poor lightening • Often spontaneously resolve • Worsening/improvement of visual loss

  23. Release Hallucinations • Management: • Reassurance of sanity • Keep eyes closed • Look away from visions • Improve lightening •  social interactions • Antipsychotic/antiepileptic medications

  24. Back to our patient… • Assessment: Visual - deprivation hallucinations (Charles Bonnet Syndrome) • Plan: • Psychiatry consulted • Olanzapine 5mg QHS

  25. References • BCSC. Neuro-Ophthalmology. AAO. 2004-05 • Kanski. Clinical Ophthalmology, 5th Ed. Butterworth Heinemann. 2003 • Teurisse et al. Visual hallucinations in psychologically normal patients: CBS. Lancet, 1996 • Manford et al. Complex visual hallucinations. Brain. 1998 • Visual hallucinations caused by vision impairment. Geriatrics. 2002. 57 (6): 45-6 • Charles Bonnet syndrome. Psychology of medicine. 1982;12: 251-61 • Charles Bonner syndrome: A review. Journal of Mental Disorders. 1997; 185 (3): 195-200 • Pelak et al. Visual Hallucinations. Current Science. 2006

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