703 - Seeing ain’t believing: Visual hallucinations after severe traumatic brain injury

Case Diagnosis: Charles-Bonnet Syndrome (CBS) after traumatic brain injury (TBI) with bilateral globe rupture treated with Seroquel, traditional rehabilitation, and AI-integrated smartglasses for successful discharge to the community.

Case Description:

Open TBI can result in an array of symptoms due to disruption of the cerebrum and surrounding structures. We describe a 63-year-old female with cerebral hemorrhages and sparing of the occipital lobes and bilateral globe rupture after a gunshot wound. During rehabilitation, she was found to have complex visual hallucinations. Neuro-ophthalmology evaluation was significant for phthisis bulbi and no light perception in the right eye. Evaluation by psychiatry and neuropsychology showed waxing and waning insight into vision loss consistent with CBS. In addition to standard rehabilitation, she received psychological counseling, education, sensor/auditory identifiers for reorientation, and a strategy of utilizing smartglasses to identify hallucinations. Pharmacotherapy with quetiapine decreased the frequency of hallucinations but worsened with antipsychotic down-titration.

Discussions:

CBS, also known as visual release phenomenon, presents typically as silent, simple or complex, visual hallucinations as a sequelae of vision impairment or loss. Hallucinations can improve over time, but can be persistent. The degree of visual impairment that leads to CBS is variable. It is significantly associated with older age and sensory deprivation. Insight can be waxing and waning due to the context of the hallucination but restored in retrospect. Pharmacotherapy with low-dose anti-psychotics, anticholinergics, and anti-epileptics has shown promise for reducing hallucinations. It is believed to be due to abnormal activity in the areas of the brain associated with vision in the absence of visual input.

Conclusions:

TBI and ocular damage frequently occur together, causing significant challenges for patients such as CBS. A multidisciplinary approach is essential not only for managing symptoms through medical and psychological treatment but also for educating on the condition. Complex cases such as this highlight the importance of acute inpatient rehabilitation.