Do You See What I See Denise A

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

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

Case n HPI: 35 y/o ♀ c/o’s of “seeing shapes, colors & partially-formed images.

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

Differential Diagnosis n Classic Migraine n Psychosis n Psychiatric illness n Schizophrenia n Affective

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

Fortification Spectrum

Fortification Spectrum

Case n FHX: n Glaucoma n Heart & liver dz; HTN; cancer; stroke n

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

Case n PMHX: n Migraines n Pituitary GH-producing adenoma n Pituitary apoplexy n Subarachnoid

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

Case n Alert & oriented x 3 n Normal affect 5 n Pupils 5

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

Patient

Patient

Patient

Patient

Visual Hallucinations

Visual Hallucinations

Visual Hallucinations Visual perceptions not associated with external visual stimuli

Visual Hallucinations Visual perceptions not associated with external visual stimuli

Visual Hallucinations n Simple (non-formed): n Dots n Colors n Flashing lights n Geometric

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

Visual Hallucinations n Complex (formed): n Objects n Animals n People n Scenery

Visual Hallucinations n Complex (formed): n Objects n Animals n People n Scenery

Visual Illusions n Distortion or modification of a real visual image

Visual Illusions n Distortion or modification of a real visual image

Visual Hallucinations n Most are NOT due to psychiatric dz n Related to ocular,

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

Visual Hallucinations: Etiologies

Visual Hallucinations: Etiologies

Phosphenes n “Seeing light” n Insight preserved n Visual hallucinations: n “Scintillating blue spots

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

Psychosis n Visual Hallucinations: n Complex n Duration: Variable n +/- Other hallucinations n

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

Release Hallucinations Complete or partial visual acuity/field loss from any cause n n n

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

Release Hallucinations n Theory of CBS: n Sensory deprivation n Visual cortex “release phenomenon”

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

Release Hallucinations n Visual hallucinations: 65%: Weekly/monthly; 27%: Daily n People: 80%; animals: 38%;

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

Release Hallucinations n Insight preserved n Setting: n Fatigue n Stress n Early mornings/late

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

Release Hallucinations n Management: n Reassurance of sanity n Keep eyes closed n Look

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

Back to our patient… Assessment: Visual - deprivation hallucinations (Charles Bonnet Syndrome) n n

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

References n n n n BCSC. Neuro-Ophthalmology. AAO. 2004 -05 Kanski. Clinical Ophthalmology, 5

References n n n n BCSC. Neuro-Ophthalmology. AAO. 2004 -05 Kanski. Clinical Ophthalmology, 5 th 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