Management of Charles Bonnet Syndrome in Elderly Patients

Diagnosis and Initial Assessment

• The diagnosis of Charles Bonnet syndrome should be confirmed by verifying the four characteristic features of CBS, including recurrent, vivid visual hallucinations, preserved insight, absence of other neurological or medical explanations, and some degree of vision loss, in the context of vision impairment, according to the American Academy of Ophthalmology 1
• Red flags requiring alternative diagnosis consideration include lack of insight despite CBS education, hallucinations that interact with the patient, or accompanying neurological signs, prompting comprehensive neurological evaluation with brain MRI and consideration of conditions like dementia with Lewy bodies, Parkinson's disease, or primary psychiatric disorders, as recommended by the American Academy of Ophthalmology 1, 2

First-Line Management: Education and Non-Pharmacological Strategies

• Education is therapeutic in itself, and the American Academy of Ophthalmology emphasizes that discussion with patients and caregivers about the benign nature of CBS hallucinations leads to significant relief, affecting 15-60% of visually impaired patients depending on the population studied 1
• Self-management techniques that may reduce hallucinations include eye movements, changing lighting conditions, and distraction techniques, which have limited evidence from case series but can be recommended as they are safe and may provide benefit, according to the American Academy of Ophthalmology 1

Vision Rehabilitation Referral

• Refer patients to vision rehabilitation services to optimize remaining vision and address psychological aspects, as recommended by the American Academy of Ophthalmology, which provides moderate-quality evidence that psychological therapies and support groups benefit vision-related quality of life and depression in visually impaired patients 1, 3
• Vision rehabilitation should address maximizing remaining vision through lighting modifications, magnification, and contrast enhancement, preventing social isolation and depression, and providing peer support groups where patients can discuss their experiences, according to the American Academy of Ophthalmology 3

Pharmacological Intervention: When and What to Use

• Pharmacological treatment is NOT first-line and should be reserved for patients with severe distress despite education and non-pharmacological measures, as recommended by the American Academy of Ophthalmology, with limited evidence of efficacy for any pharmacological agent in typical CBS 1

Monitoring for Complications

• Screen for depression and anxiety at follow-up visits, as vision loss significantly increases risk of mental health deterioration, and professional psychiatric assessment should be recommended for patients reporting severe mood changes, interference with daily life, or suicidal ideation, according to the American Academy of Ophthalmology 1

Common Pitfalls to Avoid

• Do not prescribe antipsychotics reflexively for CBS hallucinations, as typical CBS patients maintain insight and the hallucinations are benign, and do not overlook medication-induced causes such as anticholinergics, steroids, or dopaminergic agents that may contribute to hallucinations, as recommended by the American Academy of Ophthalmology and Praxis Medical Insights 1, 4
• Do not dismiss the psychological impact of vision loss itself, which requires addressing through rehabilitation and support services, according to the American Academy of Ophthalmology 1, 3

Treatment of Charles Bonnet Syndrome Hallucinations

Pharmacological Interventions

• Atypical antipsychotics, such as risperidone, olanzapine, and quetiapine, have been used to control problematic hallucinations in patients with Charles Bonnet syndrome, although the evidence is limited, as reported by the American Academy of Family Physicians 5, 6

Guidelines for Diagnosis and Management of Charles Bonnet Syndrome Secondary to Stroke‑Related Visual Field Loss

Diagnostic Criteria

• Four essential features must be present: recurrent vivid visual hallucinations, preserved insight that the images are unreal, absence of another neurological or medical condition that explains the hallucinations, and any degree of visual loss (e.g., left visual‑field deficit from stroke)【7】【8】【9】【10】【11】.
• Prevalence: CBS occurs in 15 %–60 % of individuals with visual impairment, indicating it is a common benign phenomenon【7】【8】【9】【10】.

Red‑Flag Findings Requiring Alternative Evaluation

• Lack of insight despite education about CBS【10】.
• Interactive hallucinations that respond to the patient【10】.
• New or progressive neurological signs beyond the original stroke deficits【12】.
• Cognitive decline or behavioral changes suggestive of dementia with Lewy bodies, Parkinson’s disease, or Alzheimer’s disease【7】【8】【9】【10】.

Recommended Work‑Up

• Formal visual‑field testing with automated perimetry to precisely document the defect【11】【12】.
• Medication review to exclude drugs that can provoke hallucinations (anticholinergics, systemic steroids, dopaminergic agents, other psychoactive medications)【7】【8】【9】【10】.
• Psychiatric screening for depression and anxiety, which are heightened in patients with vision loss【7】【8】【9】; employ validated depression‑screening tools【11】.

Management

First‑Line: Patient Education and Reassurance

• Education about the cortical‑release mechanism and reassurance that hallucinations are benign provides significant symptom relief and reduces anxiety【7】【8】【9】【10】 (observational evidence).

Second‑Line: Non‑Pharmacological Self‑Management

• Eye‑movement techniques (rapid saccades or blinking) can lessen hallucination frequency【10】.
• Distraction strategies (conversation, music, tactile stimulation) are effective adjuncts【10】.

Vision‑Rehabilitation Referral (Strong Recommendation)

• Referral to comprehensive vision‑rehabilitation services is strongly recommended to optimize residual vision (lighting, magnification, contrast) and provide psychological support; moderate‑quality evidence shows improvement in vision‑related quality of life and depression【7】【8】【9】.

Pharmacologic Therapy (Reserved for Severe, Refractory Cases)

• No robust evidence supports the efficacy of any medication for typical CBS; pharmacologic agents are not recommended as first‑line【7】【8】【9】【10】.
• Consider medication only when severe distress persists despite education and non‑pharmacologic measures【7】【8】【9】【10】.
• Atypical antipsychotics (risperidone, olanzapine, quetiapine) have only anecdotal support and should be used cautiously【7】【8】【9】【10】.

Follow‑Up

• Ongoing ophthalmology follow‑up is advised to monitor visual function and reinforce support measures【7】【8】【9】.