Cases That Test Your Skills The woman who saw the light R. Andrew Sewell, MD, Megan S. Moore, MD, Bruce H. Price, MD, Evan Murray, MD, Alan Schiller, PhD, and Miles G. Cunningham, MD, PhD How would you Since her first psychotic break 7 years ago, Ms. G sees dancing handle this case? lights and splotches continuously. What could be causing her Visit CurrentPsychiatry.com to input your answers visual hallucinations? and see how your colleagues responded HISTORY Visual disturbances history of migraines. Ms. G has a history of ex- Ms. G, age 30, has schizoaffective disorder and periencing well-formed visual hallucinations, presents with worsening auditory hallucina- such as the devil, but has not had them for tions, paranoid delusions, and thought broad- several years. casting and insertion, which is suspected to be She had 5 to 10 episodes over the last 2 related to a change from olanzapine to aripip- years that she describes as seizures—“an razole. She complains of visual disturbances— earthquake, a huge whooshing noise,” accom- a hallucination of flashing lights—that she panied by heart palpitations that occur with describes as occurring “all the time, like salt- stress, in public, in bright lights, or whenever and-pepper dancing, and sometimes splotch- she feels vulnerable. These episodes are not es.” Her visual symptoms are worse when she associated with loss of consciousness, incon- closes her eyes and in dimly lit environments, tinence, amnesia, or post-ictal confusion and but occur in daylight as well. Her vision is oth- she can stop them with relaxation techniques erwise unimpaired. such as deep breathing and reminding herself The visual disturbances started with Ms. G’s to calm down. The last episode was 2 months first psychotic break at age 23 and have per- ago and seemed unrelated to her visual phe- sisted continuously. She reports that at first, nomena. She also complains of occasional the spots were more intense, like an incessant paresthesias in her extremities but denies diz- strobe light. These symptoms are aggravated ziness, presyncope, or blurry or double vision. by sleep deprivation and anger and improve Ms. G is obese and has no history of head only with topiramate, 100 mg/d, which was injury or birth defects. Her family history is prescribed a year earlier after a neurologic negative for epilepsy; however, her mother consultation but discontinued because of cog- has bipolar disorder and father has schizo- nitive side effects. phrenia. Her medications are phentermine, Ms. G also complains of dull, aching, contin- 37.5 mg/d for short-term management of uous headaches in the center of her forehead, which do not wake her, are not worse in the Dr. Sewell is clinical instructor in psychiatry, Yale University School morning, and do not vary with the intensity of Medicine, New Haven, CT. Dr. Moore is an instructor in psychiatry, of her visual symptoms. The headaches are in- Dr. Price is chief of neurology, Dr. Murray is a staff neurologist and instructor in neurology, Dr. Schiller is a clinical neuropsychologist corporated into her system of delusions; she and assistant director of the consultation-liaison service, believes they “drain the electricity from her neuropsychology department, and Dr. Cunningham is director Current Psychiatry of the Laboratory for Neural Reconstruction, McLean Hospital/ 44 July 2010 head” and make her feel better. She denies a Harvard Medical School, Boston, MA. Cases That Test Your Skills obesity, oxcarbazepine, 600 mg/d for sup- floaters, or blurred vision in the peripheral posed partial seizures, sertraline, 100 mg/d for visual field that are worse in dim illumina- depression, aripiprazole, 10 mg/d, and nizati- tion and localizable by the patient. Retinal dine, 150 mg/d, for gastroesophageal reflux detachment can cause photopsia, floaters, disease. She does not use alcohol, cigarettes, or a “curtain” or “shadow” moving over or illicit drugs. Ms. G obtained a master’s de- the visual field, which may be accompa- gree in health communications and works as nied by central or peripheral vision loss.3 a research assistant at a local medical school. Severe myopia is a risk factor for retinal detachment. Which condition does Ms. G’s presentation New-onset photopsia can suggest cy- suggest? tomegaloviral retinitis in an immune- a) migraine compromised patient, and ocular-vascular b) occipital lobe seizure crisis in a patient with sickle cell disease. Clinical Point c) arteriovenous malformation New-onset or recurrent photopsia with bi- Treatment of d) retinal detachment lateral blurred vision, ataxia, vertigo, dys- e) all of the above arthria, or drop attacks may be caused by hallucinations varies vertebrobasilar artery insufficiency (VBAI). from emergent Photopsia has been reported as the present- ophthalmologic exam The authors’ observations 4 ing symptom in carotid artery dissection. and retinal surgery to Visual hallucinations are not distortions Photopsia correlated with eye movement antipsychotic therapy of reality but original false perceptions implicates the retina or optic nerve. All of that co-occur with real perceptions.1 They these etiologies except for VBAI should be to simple observation vary from simple, elemental hallucina- referred to an ophthalmologist for indirect tions involving flashes of light or geomet- ophthalmoscopy and evaluation. ric figures to more complex elaborations such as seeing crawling insects or a flock Nonemergent causes of photopsia include: of angels.2 Hallucinations can originate • drug toxicity anywhere in the visual system from the • migraine headache lens to the visual cortex and can be vas- • thyroid ophthalmopathy cular, toxic, electrophysiologic, structural, • arteriovenous malformations or neurochemical manifestations of neuro- • seizures logic, psychiatric, or ophthalmologic dis- • psychiatric disorders. orders. Depending on the hallucination’s Digoxin, cocaine, paclitaxel, and clo- etiology, treatment varies from emergent miphene may have ocular side effects, ophthalmologic examination and retinal including photopsia. The first symptoms surgery to antipsychotic therapy to simple of digitalis toxicity often are visual and observation. Photopsia is a perception include photopsia, yellow or green discol- of flashing lights, and its etiology varies; oration of the visual field, halos, and the causes can be categorized as emergent or appearance of frost over objects.5 Signs nonemergent. of cocaine intoxication can include visual hallucinations such as photopsia, shad- Emergent causes of photopsia typi- ows, moving objects, and insects crawling cally have a sudden onset, often can be and co-occurring euphoria, hypervigi- diagnosed from associated symptoms or lance, impaired judgment, and autonomic medical history, and must be recognized changes such as tachycardia, pupillary quickly to prevent permanent vision loss. dilation, hypertension, and nausea.6 High- Posterior vitreous detachment and retinal dose paclitaxel infusion has been reported Current Psychiatry tearing can manifest as flashes of light, to cause photopsia.7 Clomiphene can cause Vol. 9, No. 7 45 Cases That Test Your Skills Table 1 Diagnoses suggested by photopsia phenomena Feature Suggested diagnosis Appearance Twinkling lights with grey spots Emboli Zigzag lines Occipital epilepsy White flashes Vitreous traction on the retina Flickering lights and shimmering Clomiphene use Temporally located flashes of light, floaters, or Posterior vitreous detachment and retinal tearing blurred vision that is worse in dim illumination Location Temporal Migraine or retinal pathology Clinical Point Central Occipital lesion or embolus Seizure activity in the Monocular Retinal pathology occipital cortex and Binocular Cerebral cause adjacent areas can Duration Lightning quick Vitreous detachment produce static lights Lasts up to 30 minutes Migraine or occipital epilepsy and stars flickering lights and shimmering that per- of 18 patients with occipital epilepsy, visual sists after discontinuing the medication.8 seizures lasted from a few seconds to 3 min- Migraine with aura, which includes utes—although rarely 20 to 150 minutes— photopsia 39% of the time,9 often involves and occurred in multiple clusters a day or an expanding central visual disturbance or week.10 All but 2 patients had secondary scotoma, and usually is confined to 1 visual generalized tonic-clonic convulsions. Oc- field but may involve both. The aura typi- cipital seizures often are misdiagnosed as cally lasts 10 to 20 minutes and often is fol- the visual aura of migraine, particularly lowed by headache. Patients often report a when elementary visual hallucinations are history of episodic stereotyped auras and followed by post-ictal headache and vom- headache. Ocular examination is normal. iting.11 Lights with a color or a spherical Ophthalmic migraine, also known as shape suggest occipital epilepsy. Consider ocular or retinal migraine, is thought to be ordering an electroencephalogram (EEG) if caused by transient vasospasm of the cho- the clinical diagnosis is unclear. roidal or retinal arteries and can be precipi- tated by postural changes, exercise, and oral Which approach would you chose to evaluate contraceptives. It manifests as a gradual vi- Ms. G’s photopsia? sual disturbance in a mosaic scotomata pat- a) EEG tern that enlarges, producing total unilateral b) thyroid function tests visual loss lasting from minutes to an hour, c) urine toxicology and—misleadingly—can be associated with d) ophthalmology consultation minimal or no