Visual hallucinations after acute visual loss in a young child

An overview of psychological and social factors in Charles Bonnet syndrome

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

The elephant in the room: understanding the pathogenesis of Charles Bonnet syndrome

PURPOSE

Charles Bonnet syndrome (CBS) is a syndrome characterised by complex visual hallucinations in individuals who are cognitively normal, though often elderly and visually impaired. Although first described over 250 years ago, the condition remains poorly understood and difficult to treat.

RECENT FINDINGS

Our understanding of CBS pathogenesis has advanced little since it was first described, and much of the recent literature consists of case studies strikingly similar to the first published account of CBS. However, imaging studies have provided some indication as to the cortical areas implicated in the genesis of complex visual hallucinations, and the existence of similar hallucinatory syndromes in other sensory modalities suggests a common underlying mechanism.

SUMMARY

This review begins by describing what is currently known about CBS, focusing on epidemiology, clinical presentation and diagnosis. It then explores potential starting points for better understanding the pathogenesis of CBS, namely the existence of similar conditions in other sensory modalities and the reproduction of complex visual hallucinations in sensory deprivation scenarios. Finally, it discusses how CBS should be approached in clinical practice.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Visual Hallucination in Craniometaphyseal Dysplasia Successfully Treated with Olanzapine

Objective:

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

Case Summary:

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

Discussion:

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

Conclusions:

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

Association study of inflammatory genes with rheumatic heart disease in North Indian population: A multi-analytical approach

Rheumatic heart disease (RHD) is an inflammatory, autoimmune disease; occurring as a consequence of group A streptococcal infection complicated by rheumatic fever (RF). An inappropriate immune response is the central signature tune to the complex pathogenesis of RHD. However, some of those infected develop RHD, and genetic host susceptibility factors are thought to play a key role in diseasedevelopment. Therefore, the present study was designed to explore the role of genetic variants in inflammatory genes in conferring risk of RHD. The study recruited total of 700 subjects, including 400 RHD patients and 300 healthy controls. We examined the associations of 8 selected polymorphisms in seven inflammatory genes: IL-6 [rs1800795G/C], IL-10 [rs1800896G/A], TNF-A [rs1800629G/A], IL-1β [rs2853550C/T], IL-1VNTR [rs2234663], TGF-β1 [rs1800469C/T]; [rs1982073T/C], and CTLA-4 [rs5742909C/T] with RHD risk. Genotyping for all the polymorphisms was done using PCR-ARMS/PCR/RFLP methods. Multifactor dimensionality reduction and classification and regression tree approaches were combined with logistic regression to discover high-order gene-gene interactions in studiedgenes involved in RHD susceptibility.In univariate logistic regression analysis, we found significant association of variant-containing genotypes (CT&TT) of TGF-β1 869T/C [rs1982073]; [p=0.0.004 & 0.001, OR (95% CI)=1.65 (1.2-2.3) & 2.25 (1.4-3.6) respectively], variant genotype (CC) of IL-1β -511C/T [rs2853550]; [p=0.001, OR (95% CI)=2.33 (1.4-3.8)] and IL-1 VNTR [rs2234663]; [p=0.03, OR (95% CI)=5.25 (1.2-23.4)] SNPs with RHD risk. CART analysis revealed that individuals with the combined genotypes of TGF-β1T/C_ rs1982073 (CT/TT) and IL-1 β_ rs2853550 (CC) had significantly higher susceptibility for RHD [p=0.0005, OR (95% CI)=5.91 (2.9-12.5)]. In MDR analysis, TGF-β1 869T>C yielded the highest testing accuracy of 0.562. In conclusion, using multi-analytical approaches, our study revealed important role of TGF-β1 869T/C [rs1982073] in RHD susceptibility.

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

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

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

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

The Charles Bonnet syndrome: a review

The Charles Bonnet syndrome (CBS) derives from complex visual hallucinations. Neurologists, ophthalmologists, and psychiatrists have studied this entity for many years. Despite interest in CBS recently in contemporary American medical literature, investigators have not agreed upon a universal definition of this entity. This article reviews the current literature on CBS and related phenomena, offers specific criteria to define this syndrome, and suggests future work in this area.