1. Do You See What I See? Denise A. John VEI10/20/2006

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

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

4. Fortification Spectrum

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

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

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

8. Patient

10. Visual Hallucinations

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

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

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

15. Visual Illusions Distortion or modification of a real visual image Distortion or modification of a real visual image

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

17. Visual Hallucinations: Etiologies

18. Phosphenes “Seeing light” “Seeing light” Insight preserved Insight preserved Visual hallucinations: Visual hallucinations: “Scintillating blue spots on a black background “Scintillating blue spots on a black background Rubbing closed eyes Rubbing closed eyes “Seeing stars” “Seeing stars” Sneeze, head trauma, low blood pressure 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

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

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

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

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

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

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

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

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