Illusory palinopsia

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Illusory palinopsia
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Palinopsia simulation
Specialty Ophthalmology

Illusory palinopsia is a subtype of palinopsia, a visual disturbance defined as the persistence or recurrence of a visual image after the stimulus has been removed. [1] Palinopsia is a broad term describing a heterogeneous group of symptoms, which is divided into hallucinatory palinopsia and illusory palinopsia. [2] Illusory palinopsia is likely due to sustained awareness of a stimulus and is similar to a visual illusion: the distorted perception of a real external stimulus.

Contents

Illusory palinopsia is caused by migraines, [3] hallucinogen persisting perception disorder (HPPD), [4] prescription drugs, and head trauma, [5] but is also sometimes idiopathic. [6] Illusory palinopsia consists of afterimages that are short-lived or unformed, occur at the same location in the visual field as the original stimulus, and are often exposed or exacerbated based on environmental parameters such as stimulus intensity, background contrast, fixation, and movement. [2] Illusory palinopsia symptoms occur continuously or predictably, based on environmental conditions. The term is from Greek: palin for "again" and opsia for "seeing".

Signs and symptoms

Illusory palinopsia is often worse with high stimulus intensity and contrast ratio in a dark adapted state. Multiple types of illusory palinopsia often co-exist in a patient and occur with other diffuse, persistent illusory symptoms such as halos around objects, dysmetropsia (micropsia, macropsia, pelopsia, or teleopsia), Alice in Wonderland Syndrome, visual snow, and oscillopsia. Illusory palinopsia consists of the following four symptom categories.

Prolonged indistinct afterimage

Prolonged indistinct afterimages are unformed and occur at the same location in the visual field as the original stimulus. Stimulus intensity, contrast, and fixation length affects the generation and severity of these perseverated images. For example, after seeing a bright light such as a car headlight or a camera flash, a persistent afterimage remains in the visual field for several minutes. [5] Patients often report photophobia, which can restrict their ability to perform outdoor activity. The prolonged image or light is typically isochromatic (positive afterimage) to the original stimulus, but can fade to different colors over time. [7] Afterimages from lights tend to last longer than the indistinct afterimages from other brightly colored objects. Palinoptic prolonged light afterimages of the complementary color are differentiated from physiological afterimages based on afterimage intensity and duration. [2] [8]

Light streaking

Light streaking describes a comet-like tail which is seen due to motion between a person or a light. [4] The streaking usually persists for several seconds before fading and often occurs with bright lights on a dark background. Patients commonly report of difficulty with night driving since the headlights of oncoming cars cause multiple streaks which obscure vision. [5]

Visual trailing

Visual trailing describes an object in motion leaving frozen copies in its wake. [9] [10] These motion-induced afterimages may be discontinuous such as in a film reel or may be blurred together such as in a long-exposure photograph. If discontinuous, the patient also usually reports akinetopsia. The perseverated images last a few seconds and are usually identical in color and shape to the original stimulus. Most cases describe visual trails during movement of an object, although there are also reports from the movement of the observer's head or eyes. [6]

Variant image perseveration

There are a few cases of palinopsia with many of the same features as hallucinatory palinopsia (formed image perseveration) but with some important differences. The formed perseverated image may only last a couple seconds [11] or may be black or translucent. [12] These variants usually lack the realistic clarity of hallucinatory palinopsia, and the generation of the palinoptic images is affected by fixation time, motion, stimulus intensity, or contrast. These variants probably represent an overlap in hallucinatory and illusory palinopsia but are included in illusory palinopsia since they often co-exist with the other illusory symptoms.

Cause

Of the published cases of palinopsia that are idiopathic or attributed to migraines, HPPD, prescription drugs, or head trauma, 94% described illusory palinopsia. [2] Trazodone, [9] nefazodone, [13] mirtazapine, [14] topiramate, [15] clomiphene, [16] oral contraceptives, and risperidone [17] have been reported to cause illusory palinopsia. Clomiphene and oral contraceptives are the only prescription drugs reported to cause permanent symptoms. [16] HPPD is most common after LSD ingestion, but can occur after any hallucinogen use. HPPD is commonly described in psychiatric literature and illusory palinopsia symptoms are sometimes not defined as palinopsia. It is not clear if there is a relationship between HPPD and the quantity and strength of hallucinogen doses taken. [4] [18]

Pathophysiology

Illusory palinopsia is a dysfunction in visual perception, presumably related to diffuse neuronal excitability alterations in the anterior and posterior visual pathways. [19] Because of the drugs that cause illusory palinopsia, 5-HT2a receptor excitotoxicity or a disruption of GABAergic transmission have been proposed as possible mechanisms. However, the neuropharmacology of the visual system is probably too complex to pinpoint the visual disturbances to a single neurotransmitter or neurotransmitter receptor. The generation of illusory palinopsia is often dependent on ambient light or motion, and the symptoms could be a pathological exaggeration of normal light perception and motion perception mechanisms. [1] [2] Prolonged indistinct afterimages are symptomatically similar to physiological afterimages, and light streaking and visual trailing are symptomatically similar to motion blur when viewing fast-moving objects.

Light and motion perception are dynamic operations involving processing and feedback from structures throughout the central nervous system. A patient frequently has multiple types of diffuse, persistent illusory symptoms which represent dysfunctions in both light and motion perception. [3] [5] Light and motion are processed via different pathways, which suggests that there are diffuse or global excitability alterations in the visual pathway. Faulty neural adaptation and feedback between the anterior and posterior visual pathways could cause persistent excitability changes. Movement-related palinopsia could be due to inappropriate or incomplete activation of the motion suppression mechanisms (visual masking/backward masking and corollary discharges) related to visual stability during eye or body movements, which are present in saccadic suppression, blinking, smooth pursuit, etc. [2] [20] [21] [22]

Palinopsia in migraineurs

Illusory palinopsia may occur during a migraine aura, as do other diffuse illusory symptoms such as halos around objects, visual snow, dysmetropsia, and oscillopsia. In a rare migraine subtype known as persistent visual aura without infarction, illusory palinopsia symptoms (prolonged indistinct afterimages, light streaking, and visual trailing) persist after the migraine has abated. [23] [24] Alternatively, up to 10% of all migraineurs report of formed afterimages that only last a couple seconds and do not occur with other illusory symptoms. These momentary afterimages appear at a different location in the visual field than the original stimulus, occur a few times per month, and are affected by external light and motion. (variant image perseveration). [11] Migraineurs with these momentary afterimages report significantly fewer migraine headaches than migraineurs without these afterimages (4.3 vs. 14.4 attacks/year). [11] These afterimages probably represent an overlap in hallucinatory and illusory palinopsia. Studying these momentary formed afterimages, in relation to alterations in cortical excitability, could advance our understanding of migraine pathogenesis and mechanisms associated with encoding visual memory.

Diagnosis

Palinopsia necessitates a full ophthalmologic and neurologic history and physical exam. There are no clear guidelines on the work-up for illusory palinopsia, but it is not unreasonable to order automated visual field testing and neuroimaging since migraine aura can sometimes mimic seizures or cortical lesions. [25] However, in a young patient without risk factors or other worrisome symptoms or signs (vasculopathy, history of cancer, etc.), neuroimaging for illusory palinopsia is low-yield but may grant the patient peace of mind. [2]

The physical exam and work-up are usually non-contributory in illusory palinopsia. Diagnosing the etiology of illusory palinopsia is often based on the clinical history. Palinopsia is attributed to a prescription drug if symptoms begin after drug initiation or dose increase. Palinopsia is attributed to head trauma if symptoms begin shortly after the incident. Continuous illusory palinopsia in a migraineur is usually from persistent visual aura. HPPD can occur any time after hallucinogen ingestion and is a diagnosis of exclusion in patients with previous hallucinogen use. Migraines and HPPD are probably the most common causes of palinopsia. Idiopathic palinopsia may be analogous to the cerebral state in persistent visual aura with non-migraine headache or persistent visual aura without headache.

Due to the subjective nature of the symptoms and the lack of organic findings, clinicians may be dismissive of illusory palinopsia, sometimes causing the patient distress. There is considerable evidence in the literature confirming the symptom legitimacy, so validating the patient's symptoms can help ease anxiety. Unidirectional visual trails or illusory symptoms confined to part of a visual field suggest cortical pathology and necessitate further work-up. [26] [27] [28]

Treatment

There is limited data on treating the visual disturbances associated with HPPD, persistent visual aura, or post-head trauma visual disturbances, and pharmaceutical treatment is empirically based. It is not clear if the etiology or type of illusory symptom influences treatment efficacy. Since the symptoms are usually benign, treatment is based on the patient's zeal and willingness to try many different drugs. There are cases which report successful treatment with clonidine, clonazepam, lamotrigine, nimodipine, topiramate, verapamil, divalproex sodium, gabapentin, furosemide, and acetazolamide, as these drugs have mechanisms that decrease neuronal excitability. However, other patients report treatment failure from the same drugs. [23] [24] Based on the available evidence and side-effect profile, clonidine might be an attractive treatment option. [2] Many patients report improvement from sunglasses. FL-41 tinted lenses may provide additional relief, as they have shown some efficacy in providing relief to visually-sensitive migraineurs. [29]

Related Research Articles

<span class="mw-page-title-main">Migraine</span> Disorder resulting in recurrent moderate-severe headaches

Migraine is a common neurological disorder characterized by recurrent headaches. Typically, the associated headache affects one side of the head, is pulsating in nature, may be moderate to severe in intensity, and could last from a few hours to three days. Non-headache symptoms may include nausea, vomiting, and sensitivity to light, sound, or smell. The pain is generally made worse by physical activity during an attack, although regular physical exercise may prevent future attacks. Up to one-third of people affected have aura: typically, it is a short period of visual disturbance that signals that the headache will soon occur. Occasionally, aura can occur with little or no headache following, but not everyone has this symptom.

<span class="mw-page-title-main">Optical illusion</span> Visually perceived images that differ from objective reality

In visual perception, an optical illusion is an illusion caused by the visual system and characterized by a visual percept that arguably appears to differ from reality. Illusions come in a wide variety; their categorization is difficult because the underlying cause is often not clear but a classification proposed by Richard Gregory is useful as an orientation. According to that, there are three main classes: physical, physiological, and cognitive illusions, and in each class there are four kinds: Ambiguities, distortions, paradoxes, and fictions. A classical example for a physical distortion would be the apparent bending of a stick half immerged in water; an example for a physiological paradox is the motion aftereffect. An example for a physiological fiction is an afterimage. Three typical cognitive distortions are the Ponzo, Poggendorff, and Müller-Lyer illusion. Physical illusions are caused by the physical environment, e.g. by the optical properties of water. Physiological illusions arise in the eye or the visual pathway, e.g. from the effects of excessive stimulation of a specific receptor type. Cognitive visual illusions are the result of unconscious inferences and are perhaps those most widely known.

<span class="mw-page-title-main">Headache</span> Pain in the head or neck

Headache, also known as cephalalgia, is the symptom of pain in the face, head, or neck. It can occur as a migraine, tension-type headache, or cluster headache. There is an increased risk of depression in those with severe headaches.

<span class="mw-page-title-main">Micropsia</span> Medical condition

Micropsia is a condition affecting human visual perception in which objects are perceived to be smaller than they actually are. Micropsia can be caused by optical factors, by distortion of images in the eye, by changes in the brain, and from psychological factors. Dissociative phenomena are linked with micropsia, which may be the result of brain-lateralization disturbance.

<span class="mw-page-title-main">Alice in Wonderland syndrome</span> Medical condition

Alice in Wonderland syndrome (AIWS), also known as Todd's syndrome or dysmetropsia, is a neuropsychological condition that causes a distortion of perception. People may experience distortions in visual perception of objects, such as appearing smaller (micropsia) or larger (macropsia), or appearing to be closer (pelopsia) or farther (teleopsia) than they are. Distortion may also occur for senses other than vision.

<span class="mw-page-title-main">Afterimage</span> Image that continues to appear in the eyes after a period of exposure to the original image

An afterimage is an image that continues to appear in the eyes after a period of exposure to the original image. An afterimage may be a normal phenomenon or may be pathological (palinopsia). Illusory palinopsia may be a pathological exaggeration of physiological afterimages. Afterimages occur because photochemical activity in the retina continues even when the eyes are no longer experiencing the original stimulus.

<span class="mw-page-title-main">Visual snow syndrome</span> Visual impairment

Visual snow syndrome (VSS) is an uncommon neurological condition in which the primary symptom is that affected individuals see persistent flickering white, black, transparent, or coloured dots across the whole visual field. Other common symptoms are palinopsia, enhanced entoptic phenomena, photophobia, insomnia, and headaches. The condition is typically always present and has no known cure, as viable treatments are still under research. Migraine and tinnitus are common comorbidities and are both associated with a more severe presentation of the syndrome.

<span class="mw-page-title-main">Hallucinogen persisting perception disorder</span> Medical condition

Hallucinogen persisting perception disorder (HPPD) is a non-psychotic disorder in which a person experiences apparent lasting or persistent visual hallucinations or perceptual distortions after a previous use of drugs, including but not limited to psychedelics, dissociatives, entactogens, THC, and SSRIs. Despite being designated as a hallucinogen-specific disorder, the specific contributory role of psychedelic drugs is unknown.

Palinopsia is the persistent recurrence of a visual image after the stimulus has been removed. Palinopsia is not a diagnosis; it is a diverse group of pathological visual symptoms with a wide variety of causes. Visual perseveration is synonymous with palinopsia.

<span class="mw-page-title-main">Aura (symptom)</span> Symptom of epilepsy and migraine

An aura is a perceptual disturbance experienced by some with epilepsy or migraine. An epileptic aura is a seizure.

Acephalgic migraine is a neurological syndrome. It is a relatively uncommon variant of migraine in which the patient may experience some migraine symptoms such as aura, nausea, photophobia, and hemiparesis, but does not experience headache. It is generally classified as an event fulfilling the conditions of migraine with aura with no headache. It is sometimes distinguished from visual-only migraine aura without headache, also called ocular migraine.

Akinetopsia, also known as cerebral akinetopsia or motion blindness, is a term introduced by Semir Zeki to describe an extremely rare neuropsychological disorder, having only been documented in a handful of medical cases, in which a patient cannot perceive motion in their visual field, despite being able to see stationary objects without issue. The syndrome is the result of damage to area V5, whose cells are specialized to detect directional visual motion. There are varying degrees of akinetopsia: from seeing motion as frames of a cinema reel to an inability to discriminate any motion. There is currently no effective treatment or cure for akinetopsia.

Persistent aura without infarction (PAWOI) is a rare and seemingly benign condition, first described in case reports in 1982 as "prolonged/persistent migraine aura status", and in 2000 as "migraine aura status", that is not yet fully understood. PAWOI is said to possibly be a factor involved in a variety of neurological symptoms, including visual snow, loss of vision, increased afterimages, tinnitus, and others. The pathogenesis of PAWOI is unknown. It is not clear which medical examinations are useful in diagnosing PAWOI. At present, PAWOI is usually diagnosed solely based on the patient's current and past symptoms. It is possible that an "overactive brain" or a chemical imbalance underlies the disorder. Various medications have been tried as treatment, notably acetazolamide, valproate, lamotrigine, topiramate, and furosemide.

Vestibular migraine (VM) is vertigo with migraine, either as a symptom of migraine or as a related neurological disorder.

The classification of all headaches, including migraines, is organized by the International Headache Society, and published in the International Classification of Headache Disorders (ICHD). The current version, the ICHD-3 beta, was published in 2013.

Preventive treatment of migraine can be an important component of migraine management. Such treatments can take many forms, including everything from surgery, taking certain drugs or nutritional supplements, to lifestyle alterations such as increased exercise and avoidance of migraine triggers.

Migralepsy is a rare condition in which a migraine is followed, within an hour period, by an epileptic seizure. Because of the similarities in signs, symptoms, and treatments of both conditions, such as the neurological basis, the psychological issues, and the autonomic distress that is created from them, they individually increase the likelihood of causing the other. However, also because of the sameness, they are often misdiagnosed for each other, as migralepsy rarely occurs.

Hallucinatory palinopsia is a subtype of palinopsia, a visual disturbance defined as the persistent or recurrence of a visual image after the stimulus has been removed. Palinopsia is a broad term describing a group of symptoms which is divided into hallucinatory palinopsia and illusory palinopsia. Hallucinatory palinopsia refers to the projection of an already-encoded visual memory and is similar to a complex visual hallucination: the creation of a formed visual image where none exists.

Cerebral diplopia or polyopia describes seeing two or more images arranged in ordered rows, columns, or diagonals after fixation on a stimulus. The polyopic images occur monocular bilaterally and binocularly, differentiating it from ocular diplopia or polyopia. The number of duplicated images can range from one to hundreds. Some patients report difficulty in distinguishing the replicated images from the real images, while others report that the false images differ in size, intensity, or color. Cerebral polyopia is sometimes confused with palinopsia, in which multiple images appear while watching an object. However, in cerebral polyopia, the duplicated images are of a stationary object which are perceived even after the object is removed from the visual field. Movement of the original object causes all of the duplicated images to move, or the polyopic images disappear during motion. In palinoptic polyopia, movement causes each polyopic image to leave an image in its wake, creating hundreds of persistent images (entomopia).

A migrainous infarction is a rare type of ischaemic stroke which occurs in correspondence with migraine aura symptoms. Symptoms include headaches, visual disturbances, strange sensations and dysphasia, all of which gradually worsen causing neurological changes which ultimately increase the risk of an ischaemic stroke. Typically, women under the age of 45 who experience migraine with aura (MA) are at the greatest risk for developing migrainous infarction, especially when combined with smoking and use of oral contraceptives.

References

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