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CLINICAL REVIEW: Anu Jacob, Sanjeev Prasad, Mike Boggild, and Sanjeev Chandratre Charles Bonnet syndrome—elderly people and visual hallucinations BMJ 2004; 328: 1552-1554 [Full text]

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Visual hallucinations due to dementia

SH Guptha   (30 June 2004)

No mention of Polymyalgia Rheumatica or Temporal arteritis

James Cave   (2 July 2004)

?Inappropriate medicines

Lionel KOWAL   (3 July 2004)

Charles Bonnet Syndrome and statins

Anne Collins   (12 July 2004)

Charles Bonnet syndrome-elderlypeople and visual hallucinations

Imran Rahman   (20 July 2004)

Defining Charles Bonnet syndrome

Stephen A Madill   (29 July 2004)

Charles Bonnet Syndrome

Philip J Hobson   (24 January 2005)

Eneucleation Patients

rosalie winter   (3 February 2008)

Visual hallucinations due to dementia 30 June 2004
SH Guptha, Consultant Physician, Medicine for the Elderly Edith Cavell Hospital, Peterborough PE3 9GZ Send response to journal: Re: Visual hallucinations due to dementia	Dear Sir, I read with interest the case report of a patient with Charles-Bonnet syndrome. The authors conclude in their lesson that "not all elderly people presenting with visual hallucinations have dementia". The definition of dementia has evolved over the years with the increasing recognition of isolated and subtle memory deficits as a presenting feature in many patients long before other cognitive domains are affected but a dementing illness presenting only with isolated visual hallucinations with no other behavioural problems and intact cognitive domains would be very unusual. Certainly in this context, a diagnosis of dementia would be clinically incorrect. The lesson should therefore read"not all elderly people with visual hallucinations have dementia" SH Guptha Ref: 1) Anu Jacob, Sanjeev Prasad, Mike Boggild, Sanjeev Chandratre. Charles Bonnet syndrome—elderly people and visual hallucinations.BMJ 2004;328:1552 -1554 Competing interests: None declared
No mention of Polymyalgia Rheumatica or Temporal arteritis 2 July 2004
James Cave, GP Downland Practice, Newbury RG20 8UY Send response to journal: Re: No mention of Polymyalgia Rheumatica or Temporal arteritis	I was surprised not to see any reference to PMR or TA in this article, or the use of steroids. I have had some experience of visual hallucinations in the very elderly completely resolved with oral steroid use. Competing interests: None declared
?Inappropriate medicines 3 July 2004
Lionel KOWAL, Ocular Motility Clinic Director, Royal Victorian Eye and Ear Hospital, Melbourne, Australia 19 Simpson St., East Melbourne, Australia Send response to journal: Re: ?Inappropriate medicines	Is it correct for an elderly gent with known obstructive airways disease to be taking a beta blocker? Competing interests: None declared
Charles Bonnet Syndrome and statins 12 July 2004
Anne Collins, Teacher North Yorkshire Send response to journal: Re: Charles Bonnet Syndrome and statins	A relative with Macular Degeneration has severe bouts of Charles Bonnet Syndrome visions. Sometimes these are triggered by stress but is it possible that use of statins to reduce cholesterol could also be a factor? Recent treatment with statins has co-incided with severe bouts of visions. It seems amazing given the number of people with age-related macular degeneration that the relative's GP and Hospital Opthalmic department claim no knowledge of CB syndrome. Competing interests: None declared
Charles Bonnet syndrome-elderlypeople and visual hallucinations 20 July 2004
Imran Rahman, Spr Ophthalmology Manchester Royal Eye Hospital, M13 9WL Send response to journal: Re: Charles Bonnet syndrome-elderlypeople and visual hallucinations	Editor- Jacob et al (1) described a textbook case of the Charles- Bonnet Syndrome (CBS). They describe this syndrome as uncommon, but quote an incidence highlighted in my review of the syndrome in 2003 (2), of 10- 15%. Naturally, the referral of such patients often falls via general practitioners to Ophthalmologists or Psychiatrists as most patients have visual hallucinations associated with visual loss. This is supported by the large volume of literature about this condition being published in journals aimed at these specialties. I believe the incidence of CBS is far greater than that documented, as patients in this predominately elderly group are in fear of being labeled with insanity and thus only admit to the hallucinations on direct questioning. A large number of patients in ophthalmic practice are visually impaired and if asked, the majority will admit to CBS type hallucinations, only to be relieved to know that insanity has been ruled out. This in it self may alleviate the hallucinations. It must be pointed out, however, that there is no universal agreement that visual impairment is in fact associated with the hallucinations. Certainly, no clear level of visual acuity at which CBS occurs has been documented. Patients with visual impairment of any cause and any level of acuity may be susceptible to CBS. Although the theory for CBS hallucinations was only touched on by the authors, I agree that the mechanism is uncertain. However, the sensory deprivation theory provides the most sensible explanation for such hallucinations (3). This can be thought of as phantom visions, similar to those of ‘phantom limb’ syndrome. In the absence of a normal afferent input, the visual cortex exhibits spontaneous activity, giving rise to conscious imagery. A similar syndrome is found with patients suffering acquired deafness, resulting in musical auditory hallucinations (4). Undoubtedly, greater awareness of CBS in the general medical field is welcomed. 1. Jacob A, Prasad S, Boggild M, Chandratre S. Charles Bonnet Syndrome-elderly people and visual hallucinations. BMJ 2004;328:1552-4 2. Menon GJ, Rahman I, Menon SJ, Dutton GN. Complex visual hallucinations in the visually impaired: the Charles Bonnet Syndrome. Surv Ophthalmol 2003;48:58-72 3. Bartlett JEA: A case of organised visual hallucinations in an old man with cataract, and their relationship to the phenomena of the phantom limb. Brain 1951;74: 363-373 4. Griffiths TD: Musical hallucinosis in acquired deafness: Phenomenology and brain substrate. Brain 2000;123: 2065-2076 Competing interests: None declared
Defining Charles Bonnet syndrome 29 July 2004
Stephen A Madill, Specialist registrar in Ophthalmology King's College Hospital, Denmark Hill, London SE5 9RS Send response to journal: Re: Defining Charles Bonnet syndrome	We read with interest Jacob, Prasad, Boggild and Chandratre’s article on a classical presentation of Charles Bonnet Syndrome(1). They correctly highlight the continuing debate over whether Charles Bonnet syndrome requires an association with eye disease or not. The reason for this is that there are still two definitions of Charles Bonnet syndrome being used concurrently in clinical practice. The controversy started with De Morsier himself when, having defined Charles Bonnet syndrome in 1936 as formed visual hallucinations in the psychologically normal elderly patient in association with eye disease, he redefined it in 1967 to formed visual hallucinations in elderly people with retained insight and thus removed the necessity for eye disease at all(2). These 2 definitions continue to be used interchangeably. Thus the paper by Podoll et al(3) cited in Jacob’s article contains a mixture of patients with and without eye disease. None of the 4 patients referred to with Charles Bonnet syndrome and ‘normal’ visual acuities (authors’ classification) have significant eye pathology. The definition of Charles Bonnet used for these particular patients is therefore the more recent of De Morsier’s. As Jacob et al report, the primary theory for aetiology is deafferentation. It is hypothesised that reduced sensory input to the visual cortex leads to Charles Bonnet ‘release hallucinations’. Deafferentation is therefore dependent on concurrent pathology of the anterior visual pathway. However other factors such as social isolation may also play a role(4) since not every elderly patient with reduced vision develops Charles Bonnet syndrome. Although the two definitions have their uses, it is important for authors to be aware of both particularly when comparing studies. We suggest that the classification of Charles Bonnet as formed visual hallucinations in psychologically normal elderly patients continues to be clinically useful but that the more specific definition of formed visual hallucinations in elderly patients with retained insight in combination with eye disease is more robust(2) and has now survived almost two and a half centuries since Charles Bonnet’s original observations. 1. Jacob A, Prasad S, Boggild M, Chandratre S. Charles Bonnet syndrome-elderly people and visual hallucinations. BMJ 2004; 328: 1552- 1554. (June 26th). 2. ffytche DH, Howard RJ. The perceptual consequences of visual loss: positive pathologies of vision. Brain 1999; 122: 1247-1260. 3. Podoll K, Osterheider M, Noth J. Das Charles Bonnet-syndrom. Fortschr Neurol Psychiat 1989; 57: 43-60. 4. Menon GJ, Rahman I, Menon SJ, Dutton G. Complex Visual Hallucinations in the Visually Impaired: The Charles Bonnet Syndrome. Surv Ophthalmol 2003; 48: 58-72. Competing interests: None declared
Charles Bonnet Syndrome 24 January 2005
Philip J Hobson, Locum GP Newgate Medical Group S80 1HP Send response to journal: Re: Charles Bonnet Syndrome	Dear Editor I was interested to read your recent article describing Charles Bonnet syndrome. This syndrome is of visual hallucinations in a partially sighted or blind person, who has no mental illness or dementia. There is apparently no known treatment. Six weeks ago I was called to see a male patient aged 81. His wife was concerned that he was becoming demented. He is a man who is partially sighted and described seeing poached eggs on his mantelpiece and persons sitting in chairs next to him. He was fully aware that these hallucinations were not real and they did not particularly disturb him. He had had the hallucinations for several weeks. When I saw him there was no doubt that he was not depressed and was not having a dementing process. Physical examination was perfectly normal other than generalised spondylosis, which caused him some degree of dizziness. I explained to him and his wife that I thought he had Charles Bonnet syndrome. I suggested that I ask a Consultant Psychiatrist to see him to confirm the diagnosis. He and his wife were quite happy with that, but he also was concerned about his dizziness. I explained that his cervical spondylosis was responsible for this, but I prescribed Betahistine 16mg tds. Several days later the Consultant Psychiatrist saw him at his home. She agreed that he had Charles Bonnet syndrome but was quite surprised that his hallucinations had completely disappeared. I have seen him on several occasions since then and there has been no recurrence of the visual hallucinations. He continues to take Betahistine. There are several references to Charles Bonnet syndrome on the internet but none says there is any treatment. Could his hallucinations have disappeared because of the reassurance that he was not going mad, or could Betahistine indeed be helpful for the syndrome? Yours sincerely Dr P J Hobson Newgate Medical Group, Worksop Competing interests: None declared The patient whose case is described has given signed informed consent to publication.
Eneucleation Patients 3 February 2008
rosalie winter, R.N Grad Dip Counselling 2110 Send response to journal: Re: Eneucleation Patients	Thank you for your great article. I had an eneucleation of my left eye fifteen years ago due to ICE syndrome. I used to have fireworks that would rival any new years eve and I see bizarre faces when I am going off to sleep or when I meditate. Occasionally I see The faces of my deceased parents and that warms me. Look at Lost Eye.com and you will see some stories from my one eyed pals. Finally I can relax and thanks for giving me my sanity back. Regards Rosalie Winter Competing interests: None declared