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Clinical
Doina Gherghel MD, FRCOphth
The eye and the mind
Psychiatric encounters in optometric practice
In their day-to-day professional lives, optometrists and
ophthalmologists come into contact with various kinds of
ophthalmic disorders. However, many of our patients may also
experience psychological or psychiatric problems as a result of
their eye diseases, and so practitioners should be prepared to
recognise these and follow the appropriate course of action. This
article introduces this often overlooked aspect of optometric practice.
Effects of low vision
Visual loss is a common problem
encountered in optometric practice and it
affects patients of different ages and
backgrounds. It is estimated that in the
USA, around 12% of the population aged
65 years or older is legally blind, and an
additional 8% have chronic vision
impairments 1 .
There are a large number of ocular
diseases causing low vision, however, agerelated
macular degeneration (AMD),
glaucoma and diabetic retinopathy are the
most common causes of visual loss seen by
the optometrist. Besides their ocular
consequences, these diseases may also affect
the patient’s well-being, causing
psychological and psychiatric disturbances.
Low vision patients often suffer from
other systemic diseases, which together with
the visual impairment, may lead to a large
variety of social problems, such as physical
dependency, loneliness, social isolation and
often poverty. Sadly, elderly people usually
accept all of these as part of the natural part
of ageing, assuming that nothing can be
done 2 .
It has been demonstrated that a large
number of patients affected by AMD suffer a
very significant degree of psychological
distress. In a recent study, Brody et al 3 found
that 32.5% of patients with advanced AMD
met specific criteria for depressive disorders.
This percentage was twice the rate observed
in the general population of elderly adults
and similar to that found in patients
suffering from cancer and cardiovascular
diseases. Interestingly, depression scores for
glaucoma patients seem to be similar to
those of control patients 4 .
Although depression is often seen
among patients with visual loss, a
differentiation between major depression
and normal grief should be considered
before referring these patients to their GP.
In clinical depression, mood changes are
associated with neurovegetative symptoms
such as loss of sleep, energy, appetite and
concentration. The patient could be also
agitated and may be suicidal 5 . Whenever
such symptoms are detected, the patient
should be immediately referred for further
evaluation.
Visual hallucinations are another
common complaint reported by visually
impaired patients. In 1769, Charles Bonnet,
a Swiss scientist, described the case of his
grandfather who had his cataract removed at
the age of 78. Subsequently, at the age of 89,
he started having visual hallucinations
consisting of different coloured and dynamic
objects and people. Moreover, Charles
Bonnet himself experienced the same
phenomena towards the end of his life 6 .
These symptoms are now termed Charles
Bonnet syndrome. It is estimated that
approximately 10% of all visually impaired
patients will experience visual hallucinations
as long as they have a best-corrected visual
acuity (BCVA) of 6/36 or less. Charles
Bonnet syndrome is characterised by the
following clinical features 7 :
• Variable onset of highly organised visual
hallucinations
• The visual hallucinations are initially
simple and elementary and then progress
to more complex images. They tend to
occur periodically or almost continuously
• The hallucinations appear in the real
world, are bright, coloured (as in AMD)
or black and white (as in glaucoma or
diabetic retinopathy), are usually
animated and are outside of the patient’s
control
The explanation for the occurrence of
Charles Bonnet syndrome in low vision
patients is still under investigation. It seems
that an interruption on the normal visual
pathway results in an increase in the
spontaneous neural activity. Moreover, as
part of the normal ageing process, the
cortical inhibition decreases. Visual
hallucinations may be the result of the
complex interaction between increased
spontaneous neural activity and loss of
cortical inhibition. The visual cortex also has
complex interconnections and a pathological
increase in activity is widespread. It could be
that visual hallucinations reflect the
anatomical connection between different
visual areas 8 .
Loneliness, shyness and use of betablockers,
have also been implicated in the
aetiology of this syndrome.
The first psychological reaction to visual
hallucinations is complex and usually
positive. The patients report surprise,
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Clinical
curiosity and amazement and only very
rarely, fear. Later, however, the
embarrassment and fear that they may be
losing their sanity make these patients very
shy in reporting such symptoms. Only a
very open and strong relationship with their
doctor helps them overcome this inhibition.
Patients suffering from visual
hallucinations require a speedy intervention.
Measures can include 9 :
• Improving the patient’s visual acuity and
his or her physical condition
• Replacing medication, such as betablockers,
if necessary
• Psycho-education – patients should be
reassured that they are not losing their
sanity and taught how to cope
emotionally with the hallucinations
• Helping patients to decrease their social
isolation
• Explaining different techniques of
relaxation
• Teaching the patient techniques to stop
hallucinations, such as closing and
opening their eyes, looking or walking
away, approaching the hallucination,
visual fixation on the hallucination,
increasing the light, concentrating on
something else, trying to hit the
hallucination, shouting at the
hallucination, etc
Ocular diseases associated
with psychosis
Usher’s syndrome
Retinitis pigmentosa (RP) represents a group
of hereditary diseases characterised by
degeneration of photoreceptor cells and
progressive loss of visual function. The
general prevalence of the disease is one in
4,000 people worldwide and it is an
important cause of low vision and blindness
by the age of 60. A number of inherited
conditions are associated with RP, including
abetalipoproteinemia, Refsum’s disease,
Friedreich-like ataxia, Laurence-Moon-
Bardet-Biedl syndrome and Usher’s
syndrome. Almost all these diseases include
some degree of neurological implications or
mental retardation. However, this chapter
will focus on the psychiatric changes which
occur in Usher’s syndrome.
Usher’s syndrome is characterised by the
co-existence of progressive pigmentary
retinopathy, congenital sensorineural
hearing loss and vestibular dysfunction.
There are three types of Usher’s syndrome –
type 1 which is characterised by profound
congenital deafness and vestibular ataxia,
type 2 in which the hearing loss is mild and
non-progressive and type 3, with progressive
hearing loss.
Patients suffering from Usher’s syndrome
sometimes exhibit psychotic symptoms.
Links between the genes responsible for
schizophrenia and those for Usher’s
syndrome have been implicated as possible
causes for this association 10 ; it seems,
however, that the genetic theory is still in
doubt. It has also been suggested that the
psychotic breakdown in patients suffering
from Usher’s syndrome could be related to
stress induced by the physical and social
handicaps 11 . Other researchers have
purposed a neuropathological explanation
for the co-existence of Usher’s syndrome
and schizophrenia. According to this theory,
it seems that patients with Usher’s
syndrome have global anatomical cerebral
and cerebellar degenerations which could
lead to the observed psychotic changes 12 .
It is well known that vitamin A plays an
important role in the pathogenesis of RP. In
addition, vitamin A metabolism is also
associated with schizophrenia. Whether
there is any metabolic link between the two
disorders is still a matter of debate.
Behçet’s disease
Behçet’s disease is an immune complex
disease with occlusive vasculitis. It was first
described by the Turkish dermatologist,
Hulusi Behçet, in 1937. It occurs worldwide,
but is found more often in the Middle and
Far East. Diagnosis of Behçet’s disease is
based on clinical findings and, although
there is a large variety of clinical
manifestations, the most characteristic triad
of symptoms are recurrent hypopyon uveitis
associated with oral and genital ulcerations.
This disease may also affect the central
nervous system (neuro-Behçet) where
patients complain of altered mental status
and headaches. Arai et al 13 have suggested
that patients with neuro-Behçet suffer from
secondary dysfunction of the frontal cortex
due to anatomical damage of the brain stem
and pons. These pathological changes might
be responsible for the changes in personality
and dementia observed in these patients.
Ocular and facial
disfigurement
Ocular tumours and trauma often result in
facial disfigurement and can cause
psychological disorders in those who have
suffered them. Disfigurement affects not
only the patient’s self-image and sense of
attractiveness, but also his or her social and
occupational roles and interactions 14 . The
most common reactions are depression,
acute stress reactions, anxiety and
personality changes. When the facial
disfigurement is the result of a trauma, the
patient may experience the so-called ‘posttraumatic
stress disorder’ (PTSD), a
neurophysiological disease which occurs in
20-30% of people exposed to traumatic
stress 15 . People suffering from PTSD initially
respond with shock, disbelief and denial,
which can last hours, days or weeks. After
this period, the emotional response
becomes more complex and the patient
experiences feelings of anxiety, rage,
sadness, vulnerability and confusion 16 .
The ophthalmologist and optometrist
have an important role in the physical but
and psychological recovery of these
individuals. Whenever it is suspected that a
patient might be suffering from PTSD or
other forms of psychological distress, the
following procedures should be used 16 :
• Create a calm and quiet atmosphere in
the consulting room; by this method the
patient is more likely to open up and
gain a sense of control over his or her
emotions and reactions
• Try to establish a friendly relationship
and show interest in what the patient has
to say about him or herself
• Be equal to the patient; there is no need
for words of wisdom, sometimes the
patient just needs somebody to talk to
• Encourage the presence of family
members during discussion and analyse
how they cope with the situation. These
people often need reassurance so use the
opportunity to emphasise that they need
to take care of themselves in order to
better help the patient
• Assure a multidisciplinary approach of
the case. Work in collaboration with
psychologists and social workers in order
to establish good care for the patient
• Introduce the patient to local support
groups
No drugs are currently designated for the
treatment of PTSD.
Malingering
Optometrists and ophthalmologists are
often confronted with patients whose
clinical examination does not coincide with
the actual complaints. In malingering, the
patient intentionally complains of false or
grossly exaggerated symptoms, motivated by
external incentives such as avoiding school,
work, criminal prosecution or obtaining
financial compensation or drugs
(Diagnostic and Statistical Manual of
Mental Disorders, DSM-IV, 2000).
There are four general indications that a
patient could be malingering (from: “The
defence analysis of symptoms manipulation
and malingering”):
• The existence of a medico-legal context
(check if the patient has been referred by
a solicitor)
• The patient may complain of symptoms
which are far beyond any objective
findings
• The patient does not co-operate with
medical examination and treatment
• The patient has a personality disorder
When facing a possible malingerer, the
optometrist should handle the patient with
patience and to perform some simple tests
to help discover the real nature of the
‘disease’ (Table 1).
Hysteria
Conversion disorder (hysteria) represents a
polysymptomatic disorder which occurs
from early childhood, usually before 35
years of age. It is characterised by different
pseudoneurological symptoms such
weakness, aphonia, paralysis, urinary
retention, seizures and convulsions 17 . The
symptoms are not intentionally produced to
obtain benefits (differentiate conversion
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Clinical
Doina Gherghel MD
Table 1
Tests to perform in case of ocular malingering
1. If the patient claims to be totally blind:
- Initiate a blink by approaching an object or threatening the patient’s eye; the malingering
patient will blink, while a true blind person will not
- Test the optokinetic nystagmus
- Rotate a mirror in front of the patient; a malingering patient will involuntarily rotate his or
her eyes
2. If the patient has ‘lost’ their vision in one eye:
- Check for the presence of a relative afferent pupillary defect (RAPD); a normal eye has
normal pupillary reflexes
- Use stereoscopic or duochrome testing
3. Other tests and manoeuvres:
- Perform a visual field test
- Electroretinogram, visually evoked cortical potentials
- Change the distance at which you test the visual acuity, use fogging, etc
- Ask the patient to come for another examination. Malingering patients usually do not come
back
Table 2
Ocular signs and symptoms in hysteria
• Binocular or monocular blindness
• Fluctuating visual acuity
• Different visual field defects, such as
tubular fields, ring scotoma, hemianopias
• Diplopia
• Blepharospasm
• Ocular pain
• Problems with reading and writing
• Colour blindness
• Ocular paralysis
• Convergence spasm
disorder from malingering and factitious
disorders) and do not conform to the
‘classical’ clinical picture and physiological
mechanisms of the presumed disease, but
instead follow the patient’s idea about the
condition. Ocular hysteria may present with
a large variety of signs and symptoms
(Table 2).
Usually these symptoms are a
consequence of an emotional stress which
the patient represses into their unconscious.
It seems that many of these patients
subsequently develop different neurological
diseases. They should be referred for
psychological counselling and treatment.
Factitious disorders
(Münchausen’s syndrome)
According to the Diagnostic and Statistical
Manual of Mental Disorders (DSM-IV,
2000), “Factitious disorders are
characterised by physical or psychological
symptoms that are intentionally produced
or feigned in order to assume the sick role”.
“Fever of unknown aetiology” is the most
common medical example of a factitious
disorder. The difference between factitious
disorders and malingering is that in the
former, the patient seeks a psychological
benefit, while in the latter the benefit is
more material.
Münchausen’s syndrome is a more
chronic and severe form of factitious
disorder. It is characterised by a triad of
features 18 – simulated illness, ‘pseudologia
fantastica’ (pathological lying), and
‘peregrination’ (the patient has a huge
medical history and wanders from hospital
to hospital and from doctor to doctor). The
syndrome was named after the fictional Karl
Friedrich Hieronymous Baron von
Münchausen, known for his fabulous
anecdotes about his life published in 1786
by Rudolf Erich Raspe in “Baron
Münchausen’s narrative of his marvellous
travels and campaigns in Russia”. The name
was used for the first time in medicine by
Richard Asher in 1951 19 .
Münchausen’s syndrome is often
confused with hypochondria and, as such,
can be overlooked and minimised by
doctors. While in hypochondria the patient
actually believes that he or she is really ill,
in Münchausen’s syndrome, the patient
knows the unrealistic nature of the
complaint but is determined to get
attention at all costs. Some patients even
self-mutilate themselves to the extent of
self-enucleation. A more severe form of
Münchausen’s syndrome is the so-called
‘Münchausen’s by proxy’ in which a person
makes someone else sick in order to get
attention. A good example is when a parent
intentionally creates symptoms in a child to
get sympathy.
These patients should be managed with
increased care and continuously monitored
in how they handle their own bodies
because, in the effort to gain attention, the
patients can induce themselves a real illness
or even death. Whenever a child is involved,
the matter should be regarded as a form of
child abuse and should be reported as soon
as possible. The patient should be treated by
a multidisciplinary approach, and often
they require a referral for an urgent
psychiatric evaluation and treatment.
However, confrontation of the patient
should be done carefully and in a nonpunitive
way.
Psychiatric side effects of
ophthalmic medications
The most common way to treat eye diseases
is by using a large variety of topical
administrated solutions, suspensions, gels
or ointments. These drugs act primarily at
eye level, however, drugs passing into the
nasolacrimal duct can enter the systemic
circulation either via the nasal mucosa or
from the gastrointestinal tract after
ingestion, and can cause a multitude of
systemic side effects. Among them,
neuropsychiatric side effects are reported for
various topical ophthalmic medications
such as corticosteroids, beta-blockers,
acetazolamide, anticholinergic and
sympathomimetic eye drops.
Corticosteroids
Corticosteroids are possibly the most
commonly prescribed drugs in medicine.
They were first introduced to
ophthalmology in the 1950s, first as
systemic medication and then as drops,
ointments and solutions for local
injections. Their main effect is antiinflammatory,
accomplished via a large
variety of mechanisms such as
vasoconstriction and reduction of vascular
permeability, membrane stabilisation and
stabilisation of mast-cells and basofils,
suppression of lymphocyte proliferation
and mobilisation of PMNs, etc. Systemic
side effects of corticosteroids have been
reported with the oral and parenteral forms
of administration, however, systemic
absorption of topically administrated
corticosteroids is important. Depression,
mania, psychosis and other psychiatric
disorders have all been reported after
topical, long-term corticosteroid therapy.
Timolol
Timolol was introduced for the treatment of
glaucoma in 1977 and since then, it has
been an essential part of the management
of the disease. Only about 1% of topically
administrated timolol is absorbed into the
eye, leaving the other 99% available for
systemic absorption. Because the drug is
absorbed directly into the venous
circulation, it bypasses the hepatic
detoxifying metabolism, thus increasing the
risk of systemic toxicity 20 . Approximately
10% of glaucoma patients treated with
timolol can experience different psychiatric
problems, such as fatigue, depression,
dissociative behaviour, memory loss,
paranoia, confusion, hallucinations and
psychosis 21,22 . Psychiatric side effects
following betaxolol therapy have also been
reported.
CAIs
Carbonic anhydrase inhibitors (CAI) are
another class of drugs used in
ophthalmology as intraocular pressurelowering
agents. Initially administrated
systemically as acetazolamide, CAIs have
also been developed as topically active
forms under the names of dorzolamide and
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Clinical
brinzolamide. Carbonic anhydrase is a
widely distributed enzyme which
catalyses the production of H 2 CO 3
from CO 2 and H 2 O as well as the
degradation of H 2 CO 3 to CO 2 and
H 2 O throughout the body. The
inhibition of this enzyme carries
potentially numerous side effects.
Among them, tiredness, lack of
appetite and somnolence may be
appreciated as depression; however,
true depression and agitation have also
been reported.
Antocholinergics
Anticholinergic medications, such as
atropine, homatropine, scopolamine
and cyclopentolate, are often used in
ophthalmology as mydriatic and
cycloplegic drugs. They act by blocking
the cholinergic response of the iris
sphincter and ciliary muscle. Most of
the drug is destroyed by hepatic
metabolism, however, 13-50% is
excreted unchanged in the urine.
Consequently, people with renal
diseases may be at risk of systemic
toxicity after administration of
anticholinergic drops 23 . Visual and
auditory hallucinations, irritability,
restlessness, insomnia, confusion,
memory loss, delirum and paranoia
have all been reported in association
with anticholinergic systemic and
topical therapies.
Sympathomimetics
Sympathomimetic eye drops have a
large utilisation in ophthalmology.
Some agents are used in the treatment
of glaucoma, while others are used as
mydriatics, anaesthetics and
vasoconstrictors. It has been reported
that some of these agents may cause
anxiety, hallucinations, depression and
paranoia 21 .
Depression, psychosis, confusion,
hallucinations and other complaints of
psychiatric nature are sometimes
simply the result of topically
administered eye drops and,
unfortunately, the practitioner can very
often overlook the link between
mental complaints and, for example,
glaucoma treatment. These patients
could receive unnecessary psychiatric
referral and treatment, whereas simple
withdrawal of the drug results in
disappearance of these effects in one
to seven days 24 . To minimise
psychiatric effects, advise the patient to
apply a gentle pressure on the
canaliculi immediately after the
administration of the drug or to
simply close their eye for five minutes
after the instillation.
Conclusion
It is often easy to forget that each
patient is unique, with special
emotions and psychological needs. A
disabling eye disease affects not only
the patient’s self-image, but also his or
her entire family system and social life.
It may also trigger the appearance of a
large variety of mental disorders. On
the other hand, patients with preexisting
psychiatric disturbances may
produce physical symptoms which
could mimic some ophthalmic
diseases. Therefore, treatment and
rehabilitation of these patients should
address equally both the disease and
psychological maintenance factors 25 .
About the author
Doina Gherghel is an ophthalmologist
at the Neuroscience Research Institute,
Aston University, Birmingham.
Acknowledgement
Figure courtesy of the Scientist 15
(12): 8 copyright 2002, the Scientist
LLC. All rights reserved. Reproduced
with permission.
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