Complex visual hallucinations in a patient with macular degeneration: a case of the Charles Bonnet syndrome

A 67-year-old female with visual impairment secondary to macular degeneration complains of seeing frightening images for 3 days. She states that she sees a translucent elongated face with disproportionately large teeth and ears (Figure 1). There are no associated mental status changes, auditory hallucinations, headaches, fever or seizures. Clinical examination is normal aside from decreased visual acuity, bilateral drusen and geographic atrophy of the right retina. Diagnosis of Charles Bonnet syndrome was made based on history, physical examination and normal routine workup, including CT scan of the head. This syndrome, seen in 10–40% of elderly patients with visual impairment, is characterized by intricate visual images, typically of diminutive people, animals or geometric figures [1]. Patients characteristically lack auditory components and have preserved insight into these hallucinations [2]. Though frightening, patients should be reassured that the disease is benign and may spontaneously regress as the visual cortex slowly re-adjusts to diminishing vision [3].