Expanding the Spectrum of Charles Bonnet Syndrome: Severe Psychiatric Manifestations Associated With Total Vision Loss

Abstract

Charles Bonnet syndrome (CBS) is typically characterized by complex, non-threatening visual hallucinations in patients with visual impairment who maintain insight that their perceptions are unreal. While primarily considered an ophthalmological phenomenon, recent evidence suggests that CBS may overlap with psychiatric disorders presenting with complex visual hallucinations and impaired insight, complicating both diagnosis and management. These interactions challenge the view of CBS as a benign and isolated condition, especially when symptoms become more entrenched, resemble psychosis, or co-occur with pre-existing psychiatric disorders. We present a new, atypical case involving a patient with CBS and evolving psychotic symptoms at the Olive View Medical Center in California. Our case highlights a 40-year-old female patient with bilateral blindness and a history of CBS, schizoaffective disorder, and repeated Lanterman-Petris-Short conservatorships. At presentation, she exhibited aggressive behavior, possible delusions, responses to internal stimuli, and significant difficulties in self-care. Treatment included a regimen of olanzapine (25 mg daily), haloperidol (15 mg daily), gabapentin (1800 mg daily), hydroxyzine (150 mg daily), and divalproex sodium (2000 mg daily), resulting in some symptom amelioration but persistent psychotic features. The patient's ongoing conservatorship demonstrates the severity and chronicity of her condition. This case suggests that even in patients with total vision loss, CBS has the potential to evolve beyond isolated visual hallucinations to include severe psychiatric sequelae, including psychotic symptoms. These findings call for greater clinical vigilance, timely ophthalmologic and psychiatric consultation, and interdisciplinary management. Further research is needed to elucidate the neurobiological mechanisms linking sensory deprivation to complex hallucinations and psychiatric disturbances. An improved understanding of these processes may guide more accurate diagnostics and inform targeted interventions, ultimately improving outcomes.

Keywords: atypical psychosis; charles bonnet syndrome; schizoaffective disorder; secondary psychotic features; sensory deprivation; total bilateral blindness; visual hallucinations.