Charles Bonnet Syndrome (CBS): Successful Treatment of Visual Hallucinations Due to Vision Loss with Agomelatine in Three Cases

BackgroundCBS becomes more prevalent as the population ages. CBS is characterized by the triad of impairment of vision, complex visual hallucinations with insight, mentally normal people. Although visual hallucinations in the elderly are often associated with dementia with Lewy body, Alzheimer's disease and delirium, they are excluded from the diagnosis of typical CBS. Here, we describe three typical CBS patients whose visual hallucinations developed after bilateral severe visual impairment due to diabetic retinopathy. The effectiveness of agomelatine adds to evidence implicating serotonergic and melatoninergic pathways in the pathogenesis of visual hallucinations.Case reportThe average age of these three patients (2 males and 1 female) is 71. Except for the visual hallucinations, all patients showed no psychiatric symptoms or cognitive decline or neurological focal signs. They were frequently upset by the fact of hallucinating, fearing that they are losing their minds. They lived in fear of impending insanity, guilty feeling, unhappy mood, insomnia. The frequency of visual hallucinations stopped with agomelatine 25 mg/day for 3 weeks in these cases.DiscussionTo our knowledge, this is the first report describing the effectiveness of agomelatine in treating typical CBS patients and indicates that agomelatine is an safer option for the treatment of CBS, especially in the elderly, diabetic population. Therapeutic options for CBS still remain poor and of uncertain benefit for the individual patient. CBS has a high prevalence rate (0.4%–30%) among the visually impaired. Clinicians must ask elderly people with visual impairment whether they have hallucinations. Firm reassurance that the syndrome is not related to mental illness is a major relief to an elderly person burdened already with failing vision.Disclosure of interestThe authors have not supplied their declaration of competing interest.