Letter to the Editor
Charles Bonnet syndrome secondary to intravitreal ranibizumab in a patient with exudative age-related macular degeneration
Síndrome de Charles Bonnet secundario a ranibizumab intravítreo en un paciente con degeneración macular asociada a la edad
Pilar Cifuentes-Canorea
, Nestor Ventura-Abreu, Julián García-Feijoo, Enrique Santos-Bueso
Corresponding author
Unidad de Neurooftalmología, Servicio de Oftalmología, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
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The patient was stable for some 3 years with VA of 0.1 in the right eye (RE) and 0.05 in the left eye (LE). He came to our emergency department by decreasing the VA in both eyes. The optical coherence tomography (Heidelberg Engineering Inc., Heidelberg, Germany) showed a macular degeneration reactivation, which lead to the indication of ranibizumab, injected in both eyes, an antiangiogenic drug used in the treatment of ARMD. A month later, during check-up, VA had improved one line in RE, while LE remaining stable. On this visit, the patient reported that 10 days after the injection the patient began to have visual hallucinations early in the morning which consisted of seeing, from her balcony, some men dressed in green wielding rifles in front of her house; hallucinations lasted for half an hour and occurred daily. The patient was in good cognitive status and was aware that the hallucinations were not real.</p><p id="par0015" class="elsevierStylePara elsevierViewall">On examination she had a VA of 0.15 in RE and 0.05 in LE. There were no alterations in the exploration of the anterior pole, intraocular pressure was 16<span class="elsevierStyleHsp" style=""></span>mmHg in both eyes, and atrophic ARMD was found in the fundus of eye, not indicative of treatment. Referred to our Neuro-ophthalmology service, the patient was diagnosed with CBS. After 3 months, the patient had the same VA as before the treatment and the hallucinations were gone.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The pathophysiology of this syndrome is still unclear; there is the theory of cortical deafferentation by loss of visual stimuli in patients with low VA. This loss of stimuli would result in neuronal changes as a compensatory phenomenon, which could present a process of hyperarousal and consequent visual hallucinations. These would be triggered by any external light stimulus coming from the environment.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The main risk factor for developing CBS is a low VA. In the case here reported, despite having a very low VA for a long period of time, the patient had never presented visual hallucinations prior to the intravitreal injection. The CBS was developed after treatment with ranibizumab, which produced a VA improvement due to a decrease in intraretinal oedema and the restructuring of the photoreceptor layer. Visual hallucinations ceased coinciding with the end of the effect of intravitreal medication and recovery of the initial VA. No other systemic causes or treatment changes that could justify the appearance of visual hallucinations were found.</p><p id="par0030" class="elsevierStylePara elsevierViewall">In the medical literature there are few reported cases of CBS associated with bevacizumab treatment,<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> another antiangiogenic drug also used in the treatment of ARMD.</p><p id="par0035" class="elsevierStylePara elsevierViewall">In conclusion, we emphasize the importance of knowing and identifying this syndrome in patients with low VA, and especially in those receiving antiangiogenic therapy for ARMD.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Cifuentes-Canorea P, Ventura-Abreu N, García-Feijoo J, Santos-Bueso E. Síndrome de Charles Bonnet secundario a ranibizumab intravítreo en un paciente con degeneración macular asociada a la edad. Med Clin (Barc). 2016;146:516.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Complex visual hallucinations in the visually impaired: the Charles Bonnet syndrome" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "G.J. Menon" 1 => "I. Rahman" 2 => "S.J. Menon" 3 => "G.N. 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