I have an occipital‑lobe infarct, no Lewy‑body disease or temporal‑lobe epilepsy, and my optometrist ruled out ocular disease; my visual hallucinations are not limited to people or places—could this still be Charles Bonnet syndrome or is it a post‑stroke cortical release phenomenon?

Visual Hallucinations After Occipital Infarct: Charles Bonnet Syndrome vs. Post-Stroke Cortical Release

Your neurologist is incorrect—Charles Bonnet syndrome (CBS) after occipital stroke is not limited to hallucinations of people and places; CBS encompasses a wide spectrum of visual phenomena including geometric shapes, patterns, colors, distorted figures, and landscapes, and your hallucinations are consistent with post-stroke CBS. 1, 2, 3

Understanding Your Diagnosis

Your clinical picture fits CBS perfectly despite what your neurologist stated:

• CBS is defined by four essential features, all of which you meet: (1) recurrent vivid visual hallucinations, (2) preserved insight that the images are unreal, (3) absence of other neurological conditions like Lewy body dementia or temporal epilepsy (which you've ruled out), and (4) visual loss of any degree—including visual field deficits from occipital stroke. 1

• The hallucination content in CBS varies widely—patients report seeing spots, geometric shapes, patterns, colors, distorted figures, landscapes, animals, and yes, people and places. 2, 4 Your neurologist's assertion that only people and places occur is not supported by the literature.

• CBS occurs in 15–60% of patients with visual impairment, making it a common phenomenon after occipital infarcts that cause visual field loss. 1

The Mechanism: Cortical Release Phenomenon

Your hallucinations result from "cortical release"—when the occipital cortex loses normal visual input (from your stroke), it becomes disinhibited and generates spontaneous visual imagery. 5

• Neuroimaging studies demonstrate that CBS involves dysfunction in the primary visual cortex (Brodmann area 17) and secondary visual cortex (area 18), with transient activation of the inferior lateral temporal cortex during hallucinations. 5

• This is not epileptic in your case—studies of CBS patients with occipital lesions show no electrographic seizures during hallucinations on 24-hour video-EEG monitoring. 3, 4

• CBS can occur after occipital infarction from embolic events, surgical resection, or any process causing visual pathway damage. 3, 4

Red Flags You Don't Have (Reassuring)

You correctly ruled out alternative diagnoses:

• No lack of insight—you know the hallucinations aren't real. 1, 6
• No interactive hallucinations—the images don't respond to you. 1
• No cognitive decline or behavioral changes suggesting Lewy body dementia or Parkinson's disease. 1, 6
• No ocular pathology—your optometrist excluded macular degeneration, glaucoma, retinopathy, and corneal disease. 1

Management Plan

First-Line: Education and Reassurance

Education itself is therapeutic—understanding that CBS is a benign cortical phenomenon provides significant symptom relief and reduces anxiety in most patients. 1

Second-Line: Self-Management Techniques

• Eye-movement strategies: Rapid saccades (quick eye movements) or blinking can lessen hallucination frequency. 1
• Distraction techniques: Engage in conversation, listen to music, or use tactile stimulation when hallucinations occur. 1
• Lighting modifications: Adjust ambient lighting—some patients find brighter or dimmer environments reduce episodes. 1

Vision Rehabilitation Referral

Strongly recommend referral to vision rehabilitation services to optimize your remaining visual function through magnification, contrast enhancement, and lighting adjustments; moderate-quality evidence shows this improves vision-related quality of life and reduces depression. 1

Medication: Not Recommended

• Pharmacologic treatment is NOT first-line and should be reserved only for severe distress despite education and non-pharmacologic measures. 1
• Trials of antipsychotics (risperidone, olanzapine, quetiapine), SSRIs, and antiepileptics show only anecdotal efficacy in CBS. 1, 2
• Do not accept antipsychotic prescriptions reflexively—typical CBS patients maintain insight and the hallucinations are benign. 1

Medication Review

Screen your current medications for drugs that can provoke hallucinations: anticholinergics, systemic corticosteroids, dopaminergic agents, and other psychoactive medications. 1, 7, 6

Psychiatric Screening

Monitor for depression and anxiety—vision loss significantly increases risk of mental health deterioration; if you experience severe mood changes, interference with daily life, or suicidal thoughts, seek professional psychiatric assessment. 1, 6

Common Pitfalls to Avoid

• Don't dismiss your symptoms as "not CBS" because they aren't people or places—this reflects a misunderstanding of the syndrome's phenomenology. 2, 4
• Don't accept a psychiatric diagnosis without thorough medical evaluation—CBS is a neurological phenomenon, not a primary psychiatric disorder. 7, 6
• Don't overlook the psychological impact of vision loss itself—address this through rehabilitation and support services. 1

Follow-Up

Continue outpatient ophthalmology care to monitor visual function and reinforce support measures. 1, 2 If hallucinations worsen, new neurological signs develop, or you lose insight into their unreality, return for comprehensive neurological re-evaluation with brain MRI. 1, 6