Do You See What I See? Denise A. John VEI10/20/2006.
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Transcript of Do You See What I See? Denise A. John VEI10/20/2006.
Do You See What Do You See What I See?I See?Denise A. JohnDenise A. John
VEIVEI
10/20/200610/20/2006
CaseCase HPI: 35 y/o HPI: 35 y/o ♀♀ c/o’s of “seeing shapes, c/o’s of “seeing shapes,
colors & partially-formed images.” colors & partially-formed images.” ROS: (+) Mild headache/weight ROS: (+) Mild headache/weight
loss/poor energy/constipationloss/poor energy/constipation
Questions???Questions???
Differential DiagnosisDifferential Diagnosis Classic Classic MigraineMigraine
PsychosisPsychosis Psychiatric illnessPsychiatric illness
SchizophreniaSchizophrenia Affective disordersAffective disorders Conversion Conversion
disordersdisorders Metabolic/toxicMetabolic/toxic
Electrolyte Electrolyte imbalanceimbalance
UremicUremic Liver dzLiver dz InfectionInfection
Alcohol/drug effects Alcohol/drug effects
Neurodegenerative Neurodegenerative disorderdisorder
Diffuse Lewy BodyDiffuse Lewy Body Parkinson’sParkinson’s Alzheimer’sAlzheimer’s
Sleep-related Sleep-related hallucinationshallucinations “ “ Hypnopompic “ Hypnopompic “
Peduncular Peduncular hallucinationshallucinations
SeizuresSeizures
Release Release hallucinationshallucinations
Fortification Spectrum
CaseCase FHX: FHX:
GlaucomaGlaucoma Heart & liver dz; HTN; cancer; strokeHeart & liver dz; HTN; cancer; stroke
SHX: ø Tobacco/IVDA/ETOHSHX: ø Tobacco/IVDA/ETOH
NKDANKDA
MEDS: ASA; prednisone; pepcid; MEDS: ASA; prednisone; pepcid; metoclopramide; anzemet; synthroid; metoclopramide; anzemet; synthroid; colace; lexapro; zyprexa; morphine; colace; lexapro; zyprexa; morphine; lortab lortab
CaseCase PMHX: PMHX:
Migraines Migraines Pituitary GH-producing adenomaPituitary GH-producing adenoma
Pituitary apoplexy Pituitary apoplexy Subarachnoid hemorrhageSubarachnoid hemorrhage S/p trans-sphenoidal hypophysectomy x S/p trans-sphenoidal hypophysectomy x
2; CSF leak x 2 s/p repair 2; CSF leak x 2 s/p repair PanhypopituitarismPanhypopituitarism SIADH SIADH
DepressionDepression Polycystic ovarian syndromePolycystic ovarian syndrome Psoriatic arthritisPsoriatic arthritis
CaseCase Alert & oriented x 3Alert & oriented x 3
Normal affectNormal affect
NLPNLP VVA A NLPNLP
CVF: Unable OUCVF: Unable OU
Motility: Full OUMotility: Full OU
1111 IOPIOP 1212
55
PupilsPupils 55
NR to lightNR to light Partial reaction to Partial reaction to
nearnear
External/PLE exam External/PLE exam unremarkableunremarkable
DFE: DFE: Mild disc pallor OUMild disc pallor OU Macula/vessels/Macula/vessels/
periphery periphery unremarkable OUunremarkable OU
Patient
Patient
Visual Visual HallucinationsHallucinations
Visual HallucinationsVisual Hallucinations Visual perceptions not associated Visual perceptions not associated
with external visual with external visual
stimulistimuli
Visual HallucinationsVisual Hallucinations
Simple (non-Simple (non-formed):formed): DotsDots ColorsColors Flashing lights Flashing lights Geometric Geometric
patterns patterns
Visual HallucinationsVisual Hallucinations
Complex Complex (formed):(formed): ObjectsObjects AnimalsAnimals PeoplePeople Scenery Scenery
Visual IllusionsVisual Illusions
Distortion or modification of a Distortion or modification of a real visual imagereal visual image
Visual HallucinationsVisual Hallucinations Most are NOT due to psychiatric dzMost are NOT due to psychiatric dz
Related to ocular, optic nerve or brain Related to ocular, optic nerve or brain pathologypathology
Treatment involves managing underlying Treatment involves managing underlying disorderdisorder
Insight into the reality of the hallucinations Insight into the reality of the hallucinations varies with the associated etiologyvaries with the associated etiology
May interfere with daily functioning & May interfere with daily functioning & cause significant anxiety cause significant anxiety
Visual Visual Hallucinations:Hallucinations:
EtiologiesEtiologies
PhosphenesPhosphenes ““Seeing light”Seeing light”
Insight preservedInsight preserved
Visual hallucinations:Visual hallucinations: ““Scintillating blue spots Scintillating blue spots
on a black backgroundon a black background Rubbing closed eyesRubbing closed eyes
““Seeing stars”Seeing stars” Sneeze, head Sneeze, head
trauma, low blood trauma, low blood pressurepressure
““Flashes of light” Flashes of light” (photopsias)(photopsias)
Dim lightening or total Dim lightening or total darkness darkness
Light twinkles to bright Light twinkles to bright flashesflashes
Irritation of Irritation of photoreceptors photoreceptors
Vitreous tractionVitreous traction Retinal detachment/ Retinal detachment/
inflammationinflammation Optic neuritisOptic neuritis
Esp. with EOM/soundEsp. with EOM/sound
PsychosisPsychosis Visual Hallucinations:Visual Hallucinations:
ComplexComplex Duration: VariableDuration: Variable
+/- Other hallucinations+/- Other hallucinations Esp. auditoryEsp. auditory
+/- Insight preservation+/- Insight preservation
Release HallucinationsRelease Hallucinations Complete or partial visual acuity/field loss Complete or partial visual acuity/field loss
from any causefrom any cause Commonly seen in AMDCommonly seen in AMD
Charles Bonnet Syndrome (CBS)Charles Bonnet Syndrome (CBS) Described in 1769 Described in 1769
Swiss naturalist & philosopherSwiss naturalist & philosopher ~ 14% prevalence in U.S. eye clinics~ 14% prevalence in U.S. eye clinics
with age with age Ø Gender predilectionØ Gender predilection
Release HallucinationsRelease Hallucinations Theory of CBS:Theory of CBS:
Sensory deprivationSensory deprivation Visual cortex Visual cortex “release phenomenon” “release phenomenon”
Input from other cortical areas (esp. memory) Input from other cortical areas (esp. memory) “fill-in” the sensory deficit“fill-in” the sensory deficit
Risk factors:Risk factors: Bilateral visual lossBilateral visual loss ageage SolitudeSolitude CognitionCognition
Release HallucinationsRelease Hallucinations Visual hallucinations:Visual hallucinations:
65%: Weekly/monthly; 27%: Daily65%: Weekly/monthly; 27%: Daily People: 80%; animals: 38%; plants/trees: People: 80%; animals: 38%; plants/trees:
25%; buildings/other scenery: 15%25%; buildings/other scenery: 15% Color: 63% Color: 63% Movement: 47%Movement: 47% Duration:Duration:
53%: 1-60 mins; 13% < 5 secs53%: 1-60 mins; 13% < 5 secs Eyes open: 67%Eyes open: 67%
Teurisse et al. Visual hallucinations in psychologically Teurisse et al. Visual hallucinations in psychologically normal patients: CBS. Lancet, 1996normal patients: CBS. Lancet, 1996
Release HallucinationsRelease Hallucinations Insight preserved Insight preserved
Setting:Setting: FatigueFatigue StressStress Early mornings/late eveningEarly mornings/late evening Poor lighteningPoor lightening
Often spontaneously resolve Often spontaneously resolve Worsening/improvement of visual loss Worsening/improvement of visual loss
Release HallucinationsRelease Hallucinations Management:Management:
Reassurance of sanityReassurance of sanity Keep eyes closedKeep eyes closed Look away from visionsLook away from visions Improve lighteningImprove lightening social interactionssocial interactions Antipsychotic/antiepileptic Antipsychotic/antiepileptic
medicationsmedications
Back to our patient…Back to our patient… AssessmentAssessment:: Visual - deprivation Visual - deprivation
hallucinations hallucinations
(Charles Bonnet Syndrome)(Charles Bonnet Syndrome)
Plan:Plan: Psychiatry consultedPsychiatry consulted
Olanzapine 5mg QHSOlanzapine 5mg QHS
ReferencesReferences BCSC. Neuro-Ophthalmology. AAO. 2004-05BCSC. Neuro-Ophthalmology. AAO. 2004-05 Kanski. Clinical Ophthalmology, 5Kanski. Clinical Ophthalmology, 5thth Ed. Butterworth Heinemann. Ed. Butterworth Heinemann.
20032003 Teurisse et al. Visual hallucinations in psychologically normal Teurisse et al. Visual hallucinations in psychologically normal
patients: CBS. Lancet, 1996patients: CBS. Lancet, 1996 Manford et al. Complex visual hallucinations. Brain. 1998Manford et al. Complex visual hallucinations. Brain. 1998 Visual hallucinations caused by vision impairment. Geriatrics. Visual hallucinations caused by vision impairment. Geriatrics.
2002. 57 (6): 45-62002. 57 (6): 45-6 Charles Bonnet syndrome. Psychology of medicine. 1982;12: Charles Bonnet syndrome. Psychology of medicine. 1982;12:
251-61251-61 Charles Bonner syndrome: A review. Journal of Mental Charles Bonner syndrome: A review. Journal of Mental
Disorders. 1997; 185 (3): 195-200Disorders. 1997; 185 (3): 195-200 Pelak et al. Visual Hallucinations. Current Science. 2006Pelak et al. Visual Hallucinations. Current Science. 2006