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Visual Snow and Universally Reported Downloaded from jnnp.bmj.com on September 9, 2014 - Published by group.bmj.com PostScript LETTERS wall. Patients sometimes reported that one case to the next. The visual noise the disturbance was visible in the dark symptomatology consists of flickering ‘ ’ and with eyes closed but this was not bright achromatic dots affecting the Should visual snow and universally reported. Persistence of whole visual field in a bilateral and sym- persistence of after-images be after-images occurred in six patients metrical manner. Some patients describe recognised as a new visual (33%). This was usually described as the the visual images themselves being persistence of an object when fixing it broken up rather than superimposed syndrome? and then looking away—especially at a dots. Persistence of after-images fre- blank wall. ‘Trails’ behind moving quently coexists, and in a lower propor- Although seldom recorded in the medical objects were often also described. tion, tinnitus is reported. This ‘ ’ literature, the visual snow phenomenon, Tinnitus was present in three patients phenomenon is reported by young (2nd– as described by patients, leads to a distres- (15%). 4th decade) and healthy individuals, with sing visual condition and often to multiple Thirteen women and seven men were neither ophthalmic nor neurological unnecessary investigations and inappropri- affected. Symptoms occured mainly in disease. Gender predominance is female ate treatments. It impairs daily life, espe- the 2nd–4th decade of life, half the 2:1. All these patients had normal ocular fi cially through dif culty in reading, patients being referred within this age and neurological examinations. Patients focussing and other visual tasks. Medical range. The first onset of symptoms was in group 2 (isolated persistence of after records of 27 patients were reviewed. They ranged from the age of 2 years, or ‘from images) and 3 (solitary persistent phos- were referred to our neuro-ophthalmic the earliest memories’ to as old as phene) were less common in this group. clinic between 2005 and 2010 with unclas- 48 years. Most of the patients could not It is likely that group 2 is closely related fi si ed positive visual phenomena. All link their visual condition to any to group 1 given the overlap of symp- patients underwent a careful history and trigger. Five patients had pre-existing toms between the groups. The nosology complete clinical ophthalmic examination. migraine with visual aura (25%) but of the single patient in group 3 (one Most of them had electrophysiology assess- only two related the beginning of the author (GTP) has seen several other cases ment and neuroimaging. symptoms to a migraine. In another two outside the study period) is uncertain. patients, there was mention of a minor Visual snow has been associated with RESULTS head injury one and several weeks, the use of recreational drugs. LSD-like Three of the patients had suffered post- respectively, prior to the onset of symp- substances (psilocybin) or other psyche- traumatic visual discomfort especially toms. Only one patient disclosed con- delic drugs (ecstasy) are known for recur- when exposed to bright light, one experi- sumption of a recreational drug lysergic rent hallucinations. When such enced a phosphene in the central visual acid diethylamine (LSD). Two patients hallucinations are continuous and persist field and 23 patients complained of visual suffered from panic attacks. for months or years after cessation of drug snow and/or intrusive after-images consumption, the condition has been “ without any known precipitant. Among Ocular examination was unremarkable, referred to as hallucinogen persisting per- ” 1 the latter, 20 experienced visual snow, 3 with normal afferent visual function ception disorder . Visual symptoms persistent after-images only: (except for one patient who had an ambly- described have features in common with 1. Twenty patients were classified as suffer- opic eye) and normal intraocular examin- those reported by our patients. Alterations ‘ ’ ation. All patients had normal automated in synaptic connectivity have been postu- ing visual snow with or without per- 2 sistence of after-images. These patients perimetry. Thirteen patients underwent lated as underlying the disorder. Other consistently described ‘grainy’, ‘dotty’ investigations including electrophysiology authors associate visual snow like symp- or ‘pixelated’ vision affecting the entire (ERG: 10 patients; visually evoked poten- toms with persistent visual aura in the 3 fi visual fieldofbotheyesequally tials (VEP): seven patients) or imaging context of migraine, with modi cations (table 1). The visual experience is studies (MRI: four patients; CT scan: three in corticocortical and corticosubcortical ‘ ’ ‘ patients). All the investigations returned interconnectivity postulated to account for likened to television (TV) snow or TV 4 noise’ which is the random dot pattern normal. permanent perceptual changes. of static displayed when there is no 2. Three female patients described the Treatment with acetazolamide and val- signal on an analoguei TV monitor, phenomenon of persisting after-images proic acid has been reported successful in hence, the term ‘visual snow’.The only. Age at presentation was within some persistent aura cases, with a more the 2nd and 4th decades. Two patients marked effect on headache than on the symptoms were continuous with some 5 fluctuation, frequently varying with underwent electrodiagnostic and visual disturbance. The prevalence of changes in ambient illumination. The imaging investigations which were migraine and visual aura in phenomenon was often more promin- normal. cases presenting with visual snow symp- ent when an unstructured field was 3. One young adult suffered a binocular toms should await a prospective study. viewed, such as a blue sky or a white visual positive phenomenon. This was However, our patient cohort, referred to a limited to a bright bar of light in the neuro-ophthalmology clinic because of central field of vision. Examination unexplained visual symptoms, demon- and investigations (ERG, VEP, MRI, strates that neither migraine nor recre- iIn some cultures, the noise is rather seen as black bugs on a white background and CT-scan) were unremarkable. ational drug use are necessary associations described, for example, in Scandinavian with symptoms of visual snow and persist- countries as ‘war of the ants’. It should also be CONCLUSIONS ent after-images. The descriptions pro- noted that the reference to TV in this The group of subjective visual complaints vided by patients have a syndromic syndrome may become less common because contemporary digital displays produce noise that include visual snow and persistence consistency and we consider that the which is less random and often revert to a blue of after-images (group 1 in the results phenomenon merits future study. screen if there is no signal. section) is syndromically consistent from Furthermore, patients can be reassured J Neurol Neurosurg Psychiatry September 2014 Vol 85 No 9 1057 Downloaded from jnnp.bmj.com on September 9, 2014 - Published by group.bmj.com PostScript Table 1 Visual snow and after-images patients Onset of Age at Duration of Description of Migraine MHx VA Brain CT Gender symptoms presentation symptoms symptoms +visual aura psy Tinnitus RE VA LE VEP ERG or MRI 1 F 26 30 4 Grainy vision 1 6/6 6/6 N N 2 F 40 41 1 TV static 6/5 6/5 3 M 20 25 5 Dots of light 6/5 6/5 4 F 9 39 30 Grainy vision 6/5 6/6 N N 5 F 32 32 0 Smoke rings 6/6 6/6 N N N 6 F 30 34 4 Dotty vision 6/5 6/5 N 7 M 31 31 0 Visual noise, 6/6 6/6 N N after-image 8 F 19 19 0 White blobs 1 6/6 6/6 N N N 9 F 8 21 13 Grainy vision 1 6/5 6/5 N N 10 F 28 29 1 Dotty vision 6/5 6/5 N N N 11 F 49 49 0 Dotty vision 1 6/6 6/6 N 12 M 17 25 8 Sparkling granules, 6/5 6/5 after-image 13 F 48 49 1 Orange rain 1 6/6 6/6 N 14 F 26 26 0 Vision instability, 1 6/4 6/24 after-image amblyopia 15 M 23 24 1 Vision static 6/4 6/4 NN 16 M 2 20 18 TV static, after-image 1 6/5 6/6 NN 17 M 4 33 29 Visual snow 1 6/5 6/6 18 F 22 24 2 Visual snow, 1 1 6/5 6/5 after-image 19 M 16 21 5 TV static, after-image 1 6/6 6/6 20 F 20 21 1 TV static 6/5 6/5 Duration of symptoms, age of onset and age at presentation in years. Migraine and visual aura, psychiatric medical history (MHx psy) 1=present. LE, left eye; N, in the normal range; RE, right eye; TV, television; VA, visual acuity; VEP, visual evoked potentials. that the condition, although disabling, is Received 27 September 2013 benign, in the sense, that it does not lead Revised 25 January 2014 to visual loss. Special investigations may Accepted 28 January 2014 Published Online First 7 March 2014 still be required for patient reassurance, – but in this group of patients did not assist J Neurol Neurosurg Psychiatry 2014;85:1057 1058. doi:10.1136/jnnp-2013-306827 in the diagnosis which must be made on a clinical and syndromic basis. REFERENCES 1 Lerner AG, Gelkopf M, Skladman I, et al. Flashback 1,2 1,2,3 and Hallucinogen Persisting Perception Disorder: Anne-Caroline Bessero, Gordon T Plant clinical aspects and pharmacological treatment 1Department of Neuro-Ophthalmology, Moorfields Eye approach. Isr J Psychiatry Relat Sci 2002;39:92–9. Hospital, London, UK 2 Kilpatrick ZP, Bard Ermentrout G. Hallucinogen 2Department of Neuro-Ophthalmology, The National persisting perception disorder in neuronal networks Hospital for Neurology and Neurosurgery, London, UK with adaptation.
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