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Phantom Visions Are Real Aspect of Vision Loss

Rena Tonkin was surprised to see grapes dangling from trees as she and her daughter drove back to Portland from the Oregon Coast.

That unusual sight was Tonkin’s first experience with Charles Bonnet Syndrome (CBS), a common condition that causes “phantom” visions in people with reduced or poor vision.  It is named after an 18 th century Swiss philosopher and writer who described how his blind grandfather reported seeing detailed and fanciful patterns, buildings and people.

Tonkin, who has lost eyesight from age-related macular degeneration (AMD), continues to have visual hallucinations, but is no longer frightened by them. “I now see children wearing plaid clothing jumping around in front of me,” she says, joking that her long career in design may have something to do with the images.

Hallucinations from CBS usually pop up from memory and may be the brain’s way of compensating for the loss of visual input it gets from the eye’s photoreceptor cells, explains Thomas Hwang, M.D., a retina specialist at OHSU Casey Eye Institute.  Studies show that the syndrome is more prevalent in older people and may affect about 10 to 15 percent of those with low vision.  People with CBS may have frequent visual hallucinations at first, which can range from simple repeated patterns to complex images of landscapes, people dressed in elaborate costumes or animals. Over time, they usually taper off and may eventually stop.

Although CBS is physically harmless, it can be emotionally wearing. Sufferers may be reluctant to tell their doctor or family about their visions because they are embarrassed or fear it is a sign of a mental health problem or dementia. There is no cure for CBS, but talking about it may help, says Hwang.

“I really feel that Charles Bonnet needs to be talked about, especially to anyone experiencing rapid vision loss. Seeing things just adds to the anxiety of losing eyesight,” says Marja Byers, executive director of Blindskills, a Salem, Ore. organization that serves visually impaired and blind people.  Byers says she experienced CBS soon after eye surgery, when she saw bushes, tall grasses and a weeping willow while at a restaurant.  “I’m really glad I knew what it was before it happened. It would have been absolutely terrifying,” she says.

When members of Blindskills’ support group bring up CBS at meetings, “others are suddenly confessing that they also are experiencing visions. It’s very common but people don’t want to say anything,” says Byers. 

Tonkin’s daughter Cheryl Tonkin also believes that family members need to be clued in about CBS. “It’s important for caregivers and family to know what it is so they can reassure their loved ones and realize it’s not a serious cognitive issue,” she says.

Coping with Charles Bonnet Syndrome

You may find it helpful try one of their suggestions for making the images fade or disappear:

  • Changing your environment may help. Turn on the TV or radio, move around or make the room brighter with lighting or by opening curtains.
  • Look directly at the image, move your eyes or blink rapidly.
  • Reach out and try to touch the hallucination.

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What Is Charles Bonnet Syndrome?

Charles Bonnet Syndrome (CBS) is a condition that some people get when they lose some or all their vision. It causes them to have visual hallucinations (seeing things that aren't really there). A new study suggests this condition is surprisingly common among people with certain types of vision loss.

What Causes Charles Bonnet Syndrome?

With healthy vision, light enters the eye and is received by the  retina (the light-sensitive tissue in the back of the eye) . The retina converts these light rays into visual messages, which are sent to the brain, so we can see.

When people lose vision from diseases like age-related macular degeneration , glaucoma , or diabetic retinopathy , their visual system doesn't process new images. Without visual data coming in through the eyes, the brain fills the void and makes up images or recalls stored images for you to see. This is what causes the visual hallucinations of CBS. It is very similar to how people who have lost a limb may feel phantom pain and is not a sign of a mental health problem.

What Are Symptoms of Charles Bonnet Syndrome?

The main symptom of CBS is having visual hallucinations. Most people have them when they wake up. What people see varies, but can include:

  • repeating patterns of lines, dots, or other geometric shapes
  • landscapes, such as mountains or waterfalls
  • people, animals, or insects
  • people dressed in costume from an earlier time
  • imaginary creatures, like dragons

The hallucinations may move or remain still, and they can appear in black and white or color. The length of the hallucinations can last seconds, minutes, or hours.

How Is Charles Bonnet Syndrome Diagnosed?

There is no special test to find out if you have CBS. Your doctor will want to talk to you about your medical history. They will try to rule out other sources of visual hallucinations, including:

  • whether you take certain medications
  • mental health problems
  • other neurological (brain) conditions

If you have vision loss and visual hallucinations without these other conditions, you likely have CBS.

There is no cure or effective medical treatment for Charles Bonnet Syndrome (CBS) , but there are some techniques that can help you cope and manage the condition.

What you are seeing is not really there

People with CBS recognize that what they are seeing is not really there. With other causes of hallucinations, people may act on the hallucination. They do so because they believe that what they are seeing is real. You can feel reassured and less worried to know that your hallucinations come from vision loss.

Talk about your hallucinations

Whether you talk to your therapist, your doctor, a friend or a family member, describing your hallucinations to someone can make you feel less isolated. A CBS support group is also a great source of tips/coping strategies and a safe space to talk about your own experience with CBS. Also, simply reminding yourself or your loved one that the hallucinations are caused by vision loss and not the result of a mental health problem can be reassuring.

Change your environment

Do your hallucinations happen more often in dim lighting or in brightly lit rooms? If so, changing the lighting conditions may help reduce your hallucinations. For example, if they happen in dim light, turn on more lights or open the curtains. If you see the hallucinations when it’s very quiet, turning on a TV or radio may help.

Use your eyes

Some have found using the following techniques as the hallucinations begin can help stop them:

  • Move your eyes up-or-down or side-to-side (without moving your head)
  • Look away from the hallucinations
  • Stare at the hallucinations
  • Close your eyes and then open them

Rest and relaxation

Some people say fatigue and stress make their CBS worse. Be sure to get plenty of sleep and reduce anxiety with exercise, meditation or whatever you find helpful.

Seeing visual hallucinations can be upsetting—especially after losing your vision from another disease. But it's helpful to know that most people with CBS don't have scary or threatening hallucinations. Over time, the more you see the hallucinations, the more you will learn to manage them. In most cases, the hallucinations slow down considerably or stop after 1 to 2 years.

Low Vision Information and Resources

  • APH ConnectCenter (VisionAware):  Phone: 800-232-5463 Website: aphconnectcenter.org Email: [email protected]
  • Lighthouse Guild International:  Phone: 800-284-4422 Website: www.lighthouseguild.org
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Charles Bonnet Syndrome: Why Am I Having Visual Hallucinations?

Jens Juel, Portrait of Charles Bonnet Oil. 1777, Bibliothèque de Genève. Juel painted two identical portraits of Bonnet in Genève, the other one is in the collection of the Royal Danish Academy of Fine Arts.

Many vision professionals believe that a significant number of adults with various eye conditions, including macular degeneration , diabetic retinopathy , and glaucoma , experience Charles Bonnet (“Bo-NAY”) Syndrome , a condition that causes vivid, complex, recurring visual hallucinations, usually (but not only) in older adults with later-life vision loss.

By some estimates, as many as 20-30% of adults with low vision are affected by CBS, although actual numbers are difficult to determine, since few people who experience the symptoms are likely to discuss them with family members, friends, or physicians.

To better understand this reluctance, learning the basics about Charles Bonnet Syndrome (CBS), including its causes, symptoms, and experimental treatments and therapies that have shown promise in treating CBS is helpful.

Who Was Charles Bonnet?

Charles Bonnet (March 13, 1720 – May 20, 1793) was a Swiss naturalist and philosopher and the first person to describe the syndrome.

Initially, he observed symptoms of the syndrome in his 87-year-old grandfather, who was nearly blind from cataracts, yet still “saw” men, women, birds, carriages, buildings, scaffolding, and tapestries before his eyes.

In 1760, Bonnet described his eponymous syndrome, in which he documented a range of complex visual hallucinations in seemingly psychologically intact people.

Charles Bonnet Syndrome: Visual Hallucinations Are My Constant Companions

Sheila Rousey and her guide dog

VisionAware Peer Advisor Sheila Rousey is an educator, assistive technology specialist, and certified braille transcriber. She also has  Marfan syndrome , a congenital connective tissue disorder that can manifest itself in the body in many ways. In Sheila’s case, she was born with  cataracts  and microphthalmia [i.e., smaller eyes and eye sockets]. After surgery to remove her cataracts, Sheila developed  glaucoma  and – later on –  retinal detachments .

For the past three years Sheila has experienced Charles Bonnet Syndrome (CBS), a condition that causes vivid, complex, recurrent visual hallucinations, usually (but not exclusively) in adults and older adults with later-life vision loss. Says Sheila, “I am really pleased that the subject of CBS is finding its way into the conversation. Hopefully, the medical community will take a more serious look at the findings and low vision people will no longer only learn of it as a result of shared experiences through support groups.”

Learn more about the many ways that VisionAware can help you or your family member cope with vision loss:

  • Learn more about the wide range of  support groups .
  • Check out our  Getting Started Kit  for more ideas to help you live well with low vision.
  • Sign up with VisionAware  to receive free weekly email alerts for more helpful information and tips for everyday living with blindness or low vision.

What Is Charles Bonnet Syndrome?

Charles Bonnet Syndrome (CBS) is a condition that causes vivid, complex, recurring visual hallucinations, usually (but not only) in older adults with later-life vision loss. It was introduced into the English-speaking psychiatric literature in 1982.

The “visual hallucinations” associated with CBS can range from animated, colorful, dreamlike images to less complex visions of people, animals, vehicles, houses, and similar everyday images.

Lighthouse International (now Lighthouse Guild) provides a helpful illustration and definition of CBS “visions,” including an important distinction between CBS visions/illusions and delusions :

“[Individuals] who perceive these visions know they’re—mirages, of sorts. That is, the images are illusions , not delusions. The difference is that a person with delusions is convinced that what s/he sees is real. [People] with Charles Bonnet Syndrome may initially second-guess themselves but ultimately accept that their perceptions have no substance.”

In other words, adults with CBS are usually in good mental health and come to understand that these illusions or “hallucinations” are not sensate or “real.” In addition, the illusions associated with CBS are solely visual and do not occur in conjunction with the other senses (hearing, smell, taste, or touch).

What Causes Charles Bonnet Syndrome?

A photo of a window reflecting a blur moose.

CBS is sometimes referred to as “phantom vision” syndrome and can be compared to “phantom limb” syndrome, in which an individual can continue to receive sensation—and even pain signals—from a limb that has been amputated.

Similarly, in CBS, when retinal cells no longer receive and relay visual images to the brain due to eye disease or damage to the optic pathways, the visual system begins creating its own “phantom” images (such as this image of a blue moose reflected in the window at left) .

In a National Public Radio story about CBS , ophthalmologist Jonathan Trobe, M.D., from the University of Michigan, explained it this way:

The brain is a mash-up of stored visual memories. When visual cells in the brain stop getting information, which happens when your rods and cones stop working, the cells compensate. If there’s no data coming in, they ‘make up’ images.

Lighthouse International (now Lighthouse Guild) also explains the “phantom vision” associated with CBS:

The cause of this disorder is thought to be a misfire in the brain similar to the neurological mixup that occurs in patients with phantom limb syndrome. As vision wanes, the brain continues to interpret visual imagery in the absence of corresponding visual input, just as it sometimes continues to process pain signals from a limb that’s no longer there.

Experimental Treatments, Therapies, and Research in The Netherlands

Bartiméus and Royal Dutch Visio , agencies that work with blind and low vision persons in the Netherlands, have developed several treatments for people with CBS.

A primary intervention has been the development of CBS peer support groups, which provide information about CBS; instruction in relaxation techniques to better cope with images/hallucinations; ongoing emotional support; and a forum for sharing experiences that can help decrease social isolation.

Input from the CBS peer support groups has been instrumental in developing the following techniques to lessen or manage images and hallucinations:

  • closing the eyes and then opening them
  • moving the eyes in rapid back-and-forth and up-and-down movements
  • looking away, or walking away, from the images or hallucinations
  • staring at, or fixating on, the images
  • turning on a light
  • concentrating on something else/looking for a distraction
  • approaching and/or hitting at the image or hallucination
  • shouting at the image or hallucination

More Interventions for Charles Bonnet Syndrome

Charles Bonnet Syndrome is a “diagnosis of exclusion,” which means the diagnosis can be made if there is no other neurological diagnosis to explain the hallucinations. If there are additional neurological problems or symptoms such as memory loss, weakness, or tremor, a patient should be referred to a neurologist to rule out other conditions contributing to the hallucinations.

The Royal National Institute of Blind People (RNIB) in the United Kingdom provides several helpful suggestions to help with CBS visions and hallucinations:

Sometimes just standing up or moving slightly can help to get rid of the hallucinations. Some people also find that looking directly at the image they are seeing causes it to fade. Sometimes moving your eyes or blinking rapidly can also help. When a hallucination starts, look from left to right, about once every second for 15 to 30 seconds, without moving your head. Your eyes should be held open during the movements. If the hallucination continues, have a rest for a few seconds and try another 15 to 30 seconds of looking left and right. If the hallucinations have not diminished or stopped after four or five periods of looking left and right for 15 to 30 seconds, the exercise is unlikely to work and you can stop. It may be worth trying again on another occasion or for a different type of hallucination. The level of lighting may influence your hallucinations. If your hallucinations happen in dim light, try opening the curtains or turn on a light or the television, as the change in lighting may help to stop the hallucinations. If your CBS happens when there’s a lot of light, then switching off a light may also help.

According to Lighthouse International,

After a year or perhaps 18 months, the brain seems to adjust to the person’s declining vision, and the hallucinations begin to recede. Roughly one third of patients with low vision develop Charles Bonnet syndrome, including those with age-related macular degeneration, cataracts, diabetic retinopathy, and other eye disorders. The hallucinations are more likely to occur when the person is awake, alone, and in dim light, or when he or she is physically inactive or lacks distractions, such as television. Sometimes consultation with a neurologist or other specialist is necessary to rule out any serious disorders that may mimic Charles Bonnet syndrome [such as migraine, epilepsy, brain tumors, dementia, Parkinson’s disease, or mental illness, for example]. For most patients, however, just knowing that they aren’t becoming mentally ill and that the symptoms will eventually subside is all the treatment they need .

More Information

MD Support: The Eyes of the Macular Degeneration Community has produced an informative Charles Bonnet Syndrome video, entitled Hallucinations and Low Vision: Understanding Charles Bonnet Syndrome.

By Maureen A. Duffy, M.S., CVRT

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Phantom Eye Syndrome: A Review of the Literature

Agda m. andreotti.

Department of Dental Materials and Prosthodontics, Araçatuba Dental School, São Paulo State University (UNESP), José Bonifácio 1193, 16015-050 Araçatuba, SP, Brazil

Marcelo C. Goiato

Eduardo p. pellizzer, aldiéris a. pesqueira, aimée m. guiotti, humberto gennari-filho, daniela m. dos santos.

The purpose of this literature review was to describe the main features of phantom eye syndrome in relation to their possible causes, symptoms, treatments, and influence of eye amputation on quality of life of anophthalmic patients. For this, a bibliographical research was performed in Pubmed database using the following terms: “eye amputation,” “eye trauma,” “phantom eye syndrome,” “phantom pain,” and “quality of life,” associated or not. Thirteen studies were selected, besides some relevant references contained in the selected manuscripts and other studies hallowed in the literature. Thus, 56 articles were included in this review. The phantom eye syndrome is defined as any sensation reported by the patient with anophthalmia, originated anophthalmic cavity. In phantom eye syndrome, at least one of these three symptoms has to be present: phantom vision, phantom pain, and phantom sensations. This syndrome has a direct influence on the quality of life of the patients, and psychological support is recommended before and after the amputation of the eyeball as well as aid in the treatment of the syndrome. Therefore, it is suggested that, for more effective treatment of phantom eye syndrome, drug therapy should be associated with psychological approach.

1. Introduction

The loss of an eye directly influences the quality of life of the anophthalmic individuals and may trigger several social, familiar, and psychic problems, resulting in devastating emotional effects on the patient, such as fears of meeting new people, difficulties of establishing emotional ties and organizing their lives in the face of new circumstances, and feelings of insecurity and fear of being socially outcast [ 1 ].

Three types of surgery are applied when performing eye amputation: enucleation is the removal of the globe from the orbit, involving the separation of all connections between the globe and the patient including the sclera [ 2 ], evisceration is a procedure in which the intraocular contents are removed while the sclera, Tenon's capsule, conjunctiva, and optic nerve are preserved [ 3 ], and exenteration is a radical procedure consisting of removal of the orbital contents, including orbital fat, conjunctival sac, globe, and part or all of the eyelids [ 2 , 4 ].

The great majority of eye amputations are undertaken to treat potentially life threatening malignancies [ 2 – 6 ] or implacably progressive conditions unresponsive to other treatments [ 4 ]. The eye amputation may also aid in attenuation of severe deformity, pain or less often aid as treatment for nonmalignant disease [ 4 , 7 ]. The three most common indications for enucleation are intraocular malignancy, a blind painful eye [ 3 , 5 ], prevention of sympathetic ophthalmia, phthisis [ 2 , 5 ], microphthalmia in a child to enhance bony orbital development, improvement of cosmesis [ 2 ], trauma, and miscellaneous among others [ 5 ].

These surgeries may bring up some complications grouped according to time of their appearance: surgical complications occur at the moment of the surgery; postoperative ones occur within the first days to months after surgery; and late complications normally occur months to years after surgery and among them, is the phantom eye syndrome [ 2 , 8 – 10 ].

Phantom eye syndrome is classified as painless and painful sensations referred to the amputated eye and clearly distinguishable from both cicatrix pain and any other sensory disturbances in or around the cicatrix [ 11 ], and it is always associated with phantom vision, phantom pain, and phantom sensations [ 8 , 10 , 12 , 13 ]. After limb amputation, more than 90% of patients experience phantom phenomena [ 12 , 14 ]. Studies report that 51% of people who have lost an eye can suffer from phantom eye syndrome [ 8 ]. Others claim that 46% of patients with eye amputation present at least one of the typical symptoms of phantom eye syndrome (visual hallucination, phantom pain, or phantom sensation) [ 12 ].

Most reports of phantom sensations and phantom pain deal with phantom limbs. Very little is written about phantom eye syndrome, possibly because removal of the ocular bulb is mostly performed to treat orbital area cancer, a condition with very low prevalence [ 11 ]. Given that this is a relatively new area and despite being a high prevalence phenomenon, this syndrome is scarcely discussed in published literature [ 10 ]. Thus, the aim of this study was, by reviewing the current literature, reporting the main features of the phantom eye syndrome in relation to their possible causes, symptoms, treatments, and influence of eye amputation in quality of life of anophthalmic patients.

2. Material and Methods

Literature search was performed in Pubmed database using the following terms and associations between them: “eye amputation,” “eye amputation AND phantom pain,” “eye amputation AND phantom eye syndrome,” “eye amputation AND quality of life,” “eye trauma AND phantom pain,” “eye trauma AND phantom eye syndrome,” “eye trauma AND quality of life,” “anophthalmia” AND “quality of life,” and “phantom eye syndrome.” The articles were selected according to the inclusion and exclusion criteria ( Table 1 ).

Inclusion and exclusion criteria for selection of articles.

Moreover, as few articles about the phantom eye syndrome were found, some articles that contain information about phantom pain in eye and in other limbs, than the eye, have also been selected, since the principle that leads to some phantom pain is the same for all organs.

Despite being published in another period than the determined in inclusion and exclusion criteria, some studies about phantom eye syndrome were also included, because they are hallowed in literature and have great importance in the subject of this study.

By using the keywords mentioned, 167 articles were found in Pubmed database, 13 of which were selected to compose this review, according to the inclusion and exclusion criteria. We also included studies contained in the references of selected articles that are relevant to the purpose of this review but were not found in the search using the keywords proposed. Some studies about phantom eye syndrome were also included, since they are hallowed in literature and have great importance in the subject of this study.

4. Review and Discussion

The phantom eye syndrome is associated with visual hallucinations, phantom pain, and phantom sensations.

4.1. Visual Hallucinations

Visual hallucinations are illusory perceptions in the removed eye owing a sense of reality but occurring without external stimulation of the sensory organ [ 12 ]. People, animals, buildings, and scenery are most often reported. The vision is described as well-defined, organized, and clear and may represent a release of the visual association cortex from vision; however, its mechanism is poorly understood [ 15 ].

Visual hallucinations may be elementary or complex. Elementary visual hallucinations include simple visual phenomena lacking meaning and form, while complex visual hallucinations consist of formed contours, objects, scenes, or persons, sometimes related to past experiences of the subject [ 10 , 12 , 16 , 17 ]. The elementary and complex hallucinations might be thought of as “true hallucinations”; that is, something which is not present in the external world is perceived [ 17 ].

Sörös et al., 2003 [ 12 ], stated that most patients with visual hallucinations report basic perceptions and that complex perceptions are less frequent, which corroborates Rasmussen et al., 2009, who reported that, from around 37 anophthalmic patients with visual hallucinations, 36% exhibited elementary visual hallucinations, and only 1% had complex visual hallucinations [ 10 ]. This is also related by Wilkinson [ 17 ], who stated that simple hallucinations form the majority in any study in which all types of hallucinations are evaluated, despite the fact that emphasis on complex hallucinations in many studies gives a different impression.

Probably because of the variety of levels and etiologies, the literature shows no consistent suggestions of either the factors triggering such hallucinations, the conditions necessary and sufficient to sustain them, or the effective methods of their suppression [ 17 ]. These hallucinations typically occur independently of any triggering factors or exercise of volition in the genesis of the image. In some individuals, however, they may be triggered by a wide variety of stimuli such as conditions of general sensory reduction, fatigue, stress, and low levels of illumination or even by bright light [ 10 , 12 , 16 , 17 ].

According to Kolmel [ 18 ], onset is typically within a few days of the event causing the anophthalmia and frequency generally decreases over time. Once manifested, images last for periods varying from seconds through minutes to hours [ 15 ]. Santhouse et al. [ 19 ] reported that, from 123 patients with hallucinations, 68% related that hallucinations occurred at least daily, with 23% hallucinating at least hourly or constantly. There was a tendency for hallucinations to last for minutes, rather than seconds or hours. These hallucinations can subsequently disappear, either spontaneously or in response to actions such as closing the eyes [ 16 ]. There are reports that these hallucinations may surcease in a period between a few weeks and 6 months after the eye amputation [ 10 , 16 ].

Phantom vision is a real and detailed phenomenon that is a concern to patients [ 15 ]. Historically, hallucinatory experiences have been deemed to signify mental instability; patients are therefore often reluctant to admit to their hallucinatory experiences [ 16 ]. So, they need to be reassured that these sensations are benign and do not signify psychiatric or psychological illness [ 15 ].

4.2. Phantom Pain

Phantom pain is a form of neuropathic pain [ 20 ], which may be caused by a lesion or disease of the somatosensory system [ 21 ], or may be related to damage of central or peripheral neurons [ 22 ]. It is defined as a feeling of pain in the limb that is no longer present [ 8 , 12 , 13 , 23 , 24 ], being considered an aftereffect of amputation [ 24 ] and affecting a large proportion of amputees, with an incidence of 50–85% [ 20 , 22 , 25 – 28 ].

The pain may be related to a specific position or movement of the phantom limb and can be caused or exacerbated by a number of physical factors, such as changes in climate or pressure on the remaining limb [ 22 ]. Some studies suggest a relationship between phantom limb pain and etiology of amputation and preamputation pain [ 23 , 24 , 29 , 30 ]. Jensen et al., 1985 [ 31 ], report that the presence of preamputation pain may increase the risk of phantom pain after amputation and that longer duration of preamputation pain is also a risk factor for chronic phantom pain. These findings are in accordance with Weiss and Lindell, 1996 [ 32 ], who state that more severe pain etiologies have been associated with more severe phantom pain after amputation, compared with less severe pain etiologies. Sörös et al., 2003 [ 12 ], also demonstrated a significant association between painful and nonpainful phantom experiences and preoperative pain in the symptomatic eye. However, Nicolodi et al., 1997 [ 11 ], demonstrated no connection with preamputation pain and phantom pain.

Moreover, there is increasing evidence that phantom pain results from improperly stored or chronically activated pain memories. Case studies have reported examples of pain “memories,” in which the painful phantom sensations resemble a type of pain experienced before amputation [ 26 , 27 , 29 , 33 , 34 ].

Phantom pain is also recognized to be an interaction of physical and psychological factors. Importantly, emotion can be a central factor in the production and maintenance of pain [ 26 ]. Patients who received less support before amputation tend to report greater pain in the phantom limb [ 35 ].

Studies relate that the onset of pain is early. Several studies have shown that 75% of patients develop pain within the first few days after amputation [ 36 – 38 ]. However, phantom pain may be delayed for months or years. Most patients with phantom pain have intermittent pain, with intervals that range from 1 day to several weeks. Even intervals of over a year have been reported. The pain often presents itself in the form of attacks that vary in duration from a few seconds to minutes or hours [ 23 ].

According to Gerding et al., 2003 [ 30 ], phantom eye pain is present in nearly 1/4 of patients after enucleation. As said previously, Rasmussen et al. in 2011 [ 28 ] conducted a study with 173 anophthalmic patients and reported that 23% of these patients had phantom pain, which is similar to Sörös et al., 2003 [ 12 ], who reported that, in a population of 123, the prevalence of phantom pain was 26%. But literature is still sparse regarding studies that associate phantom pain with eye amputation.

The pain coming from an anophthalmic cavity is originated from a dysfunctional cavity, indicating that there is a structural or pathological cause for pain, such as, conjunctival cysts, migration of the implant, lacrimal insufficiency, infectious or inflammatory conditions, tumors, hematoma, residual silicone, brain and diseases, compression or irritation of the trigeminal nerve, psychological causes, and the need for modification of prostheses [ 28 , 39 ]. As there are no studies that describe the quality of the phantom eye pain, the comparison is made with studies about phantom pain in amputated limbs, and in those cases, the phantom limb pain is often described as shooting, stabbing, penetration, cramps, pinch, burning, crushing, shocking, sticking, and cramping [ 23 , 24 , 28 , 40 ].

Most patients with phantom pain present intermittent pain, with intervals varying from one day to several weeks. Even intervals over a year have been reported. The pain often presents itself in the form of attacks that vary in duration from a few seconds to a few minutes or hours [ 23 , 24 ]. Phantom pain after eye amputation is relatively common and patients should be informed about potential complications before surgery.

4.3. Phantom Sensations

Phantom sensation is any sensation (paresthesia, dysesthesia, and hyperpathia) of the missing limb except pain [ 41 ], which has been accepted as normal sequel to amputation [ 40 ]. It usually manifests as kinetic, kinesthetic, or exteroceptive perceptions [ 23 ].

The phantom sensation is experienced by almost everyone who undergoes limb amputation, but it is rarely a clinical problem [ 24 ]. Immediately after amputation, phantom limb generally resembles the preamputated limb in shape, length, and volume. The sensations can be very vivid and usually include sensations of posture, movement, heat, and tingling. Nonpainful sensations are not observed immediately after surgery. Their incidence is generally highest 2–12 months postoperatively. Over time the phantom sensation may disappear [ 11 , 23 , 24 ].

The eye not only has rich somatosensory innervations, predisposing for the development of phantom sensations, but also is the most important sensory organ with the largest cortical representation in humans [ 12 ]. However, the incidence of phantom sensations in anophthalmic cavity is low and manifests as itching around the eyes, feeling of nonexisting eyelids, and sensation of opening and seeing with both eyes [ 8 ].

Initial information should try to reassure the patient that the sensations and pains that they experience are normal, are not imagined, and do not necessarily signify the occurrence of any complicating conditions or reemergence of a past disease [ 40 ].

4.4. Treatment

Prevention of phantom eye syndrome is important and whether the benefit expected with this enucleation overcomes the drawbacks resulting from the syndrome must be assessed [ 8 ].

The management of phantom phenomena is challenging because the response to most drugs remains unpredictable despite attempts to develop a more rational therapeutic approach [ 21 ].

Nevertheless, pharmacologic therapy represents the most noninvasive option for treatment of phantom pain. Optimum treatment of this challenging condition may involve combinations of pharmacologic and nonpharmacologic treatments [ 20 ]. Surgery, drug therapy, and psychological approach are suggested as treatments for phantom limb syndrome [ 27 ]; however, when it comes to phantom eye syndrome, the literature is limited and does not point out a treatment protocol.

Some drugs are associated with the treatment of phantom phenomena, such as antidepressants [ 22 , 23 , 25 , 28 , 42 , 43 ], anticonvulsants [ 20 , 22 – 24 , 28 , 42 , 44 , 45 ], sodium channel blockers [ 11 , 12 , 17 , 25 , 31 ], N-methyl-D-aspartate receptor antagonists [ 21 – 24 , 28 , 42 , 44 , 46 – 48 ], and opioids [ 21 – 24 , 28 , 42 , 43 , 45 , 49 ], but other medications are also reported ( Table 2 ) [ 22 – 24 , 28 , 42 , 50 – 52 ].

Drugs used in the treatment of phantom phenomena.

x Drugs with reports of improvements in the clinical aspect of the phantom phenomena.

Despite such suggestions, efforts are needed in order to recover the patient with this syndrome. This recovering implies improved quality of life and reintegration into social life.

Anophthalmic patients have a lower quality of life in comparison with the general population [ 53 ], given the central role of the eyes in communication and physical attractiveness [ 54 ]. Eye amputation can result in emotional devastating problems such as insecurity, rejection, inferiority complexes, and fear of social marginalization.

Some studies relate that patients who underwent surgical removal of the eye reported that depression was overcome after installation of ocular prosthesis [ 55 ]. The main function of this prosthesis is to keep the socket continuing to perform many of the functions of a normal eye socket, such as blinking, winking, and even shedding tears, since the lids and tear glands are still in working order [ 56 ]. Therefore, besides restoring aesthetics and protecting the damaged area, the prosthesis can promote psychological restructuring in a certain degree, which may lead to resolution of some disorders; however for the great psychic trauma, individualized psychological support is essential [ 57 ].

Ahn et al., in 2010, highlighted the need for attention directed towards improving the quality of life and reducing anxiety and depression in patients affected, requiring, in addition to medical support, psychological support to deal with this condition. The mental health of anophthalmic patients should be measured initially and checked regularly to assure that there is no development of anxiety or depression disorders. If additional professional help is necessary, patients should be referred to psychiatrists for a deeper consultation and appropriate treatment strategies [ 1 ].

5. Final Considerations

From the literature review it can be concluded the following.

  • The phantom eye syndrome has as etiology the evisceration, enucleation, or exenteration of one or both eyes, affecting sensory and motor nerves.
  • The symptoms often related to this syndrome are visual hallucinations, phantom pain, and phantom sensations.
  • This syndrome has a great impact on the quality of life of patients, and psychological support before and after the amputation of the eyeball as well as a complementary treatment of the syndrome is recommended.
  • Drug therapy is greatly associated with this type of syndrome, although not providing satisfactory results in all cases.
  • A psychological approach associated with drug therapy should be indicated as treatment for patients with phantom eye syndrome.

Conflict of Interests

The authors declare that there is no conflict of interests regarding the publication of this paper.

Charles Bonnet Syndrome

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Phantom Vision: Common But Neglected

Imagine the following scenario: You are 66 years of age, vision-impaired and at home. You enter the bathroom and are astonished to discover a bizarre character wearing an exotic headdress is sitting in the sink. At first you are startled, and perhaps frightened.

Jester in a bathroom

The figure in the wash basin appears to be just as real as the shower recess and towels.

Your everyday impoverished vision is typically lacking in clarity and colour, but surprisingly this figure is vivid and detailed. You blink your eyes several times, but the unnerving vision persists. You are seized by an unwavering thought: “What on earth is happening to me?”

Upon leaving the bathroom the disturbing vision eventually disappears. Relief, and nothing more for the rest of the day. However, over the coming days, this unwanted visitor suddenly reappears in the kitchen, and later while watching TV.

This situation stretches out to weeks. The mind has been racing and a prominent thought – “First I lost my vision, am I now losing my mind?” – just will not let up.

What is worse is that you keep all this very much to yourself. You are too frightened to tell anyone – certainly not the optometrist or GP – lest you be ridiculed or, even worse, referred to a psychiatric service.

Welcome to the peculiar world of Charles Bonnet Syndrome (CBS). Though it was first clinically identified in 1760, CBS unfortunately remains at the periphery of eye healthcare awareness.

To the surprise of many it is not at all a rare condition. It is currently estimated that approximately 40% of all those who acquire vision loss will develop CBS. That translates to an utterly staggering number of people affected.

What is CBS? It is the experience of recurrent phantom images in a vision-impaired person who is otherwise of sound mind. The syndrome is not associated with mental illness or dementia. Rather, it is a quirky side effect of vision loss comparable to the phenomenon of phantom limbs.

The vast majority of people affected by CBS are over the age of 55, however the condition can, and does, strike at any age, even among children. It often occurs following a sudden drop in one’s vision. Currently there is no effective treatment, let alone a cure.

Any form of eye disease can result in CBS. This includes macular degeneration, cataracts, glaucoma and diabetic retinopathy. The range of images encountered is vast: from coloured blobs and geometric patterns, right through to buildings, flowers, figures in old-fashioned attire and even full landscapes. CBS images usually appear for seconds to a few minutes but can sometimes extend for much longer periods.

The images are always silent and the person usually comes to realise quite early on that the images are not, or simply cannot, be real. The person is not deceived by what they ‘see’.

Even so, having to contend with intrusive and often unwanted Bonnet images tends to negatively affect a person’s quality of life. It can lead to isolation and loneliness. Additionally, this is on top of the disruptions to life that typically occur due to sight loss, such as reduced driving, reading ability, and self-confidence.

A 2018 study found that 55% of Canadian GPs had never heard of CBS and a further 20% had only scant knowledge. Presumably, comparable results also exist within an Australian context. Additionally, those working in low vision settings are typically not screening for, or forewarning of, CBS. Hence it is being clinically missed and, in turn, under-appreciated in terms of its sizeable impact upon patient care.

It is envisaged that one day it will become mandatory for healthcare practitioners to screen for CBS among their vision-impaired patients. Steps towards this have already begun. RANZCO has already developed an excellent CBS position statement, the Royal College of GPs (UK) has identified CBS as a clinical priority, and in June this year the World Health Organization recognised CBS in its International Classification of Diseases.

Ophthalmic practitioners are encouraged to learn more about this peculiar perceptual disorder and consider broaching the topic with patients. It has been found that in about 70% of cases, once the practitioner explains the syndrome to the patient and allays fears of impending insanity, enormous relief follows.

This reassurance is often the single most important treatment of all.

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  • Volume 106, Issue 11
  • Phantom vision after eye removal: prevalence, features and related risk factors
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  • http://orcid.org/0000-0003-3836-7126 Arnaud Martel 1 ,
  • Stephanie Baillif 1 ,
  • Pierre Thomas 2 ,
  • Fabien Almairac 3 ,
  • Olivier Galatoire 4 ,
  • Mehrad Hamedani 5 ,
  • Denys Fontaine 3 ,
  • Michel Lanteri-Minet 6
  • 1 Ophthalmology , University Hospital Centre Nice , Nice , Provence-Alpes-Côte d’Azur , France
  • 2 Neurology , University Hospital Centre Nice , Nice , Provence-Alpes-Côte d’Azur , France
  • 3 Neurosurgery , University Hospital Centre Nice , Nice , Provence-Alpes-Côte d’Azur , France
  • 4 Oculoplastics , Fondation Rothschild , Paris , Île-de-France , France
  • 5 Hôpital Ophtalmique Jules Gonin , Lausanne , VD , Switzerland
  • 6 Pain Evaluation and Management Department, University Hospital of Nice, Fédération Hospitalo-Universitaire InovPain, Cote d’Azur University , University Hospital Centre Nice , Nice , Provence-Alpes-Côte d’Azur , France
  • Correspondence to Dr Arnaud Martel, Ophthalmology, University Hospital Centre Nice, Nice, Provence-Alpes-Côte d’Azu, France; arnaudmartel{at}hotmail.fr

Aim Phantom eye syndrome is a poorly understood and underestimated complication of eye removal (ER). Seeing with the amputated eye, referred to as phantom vision (PV), is undoubtedly the most intriguing and confusing complication experienced by anophthalmic patients. The aim of the study was to assess PV prevalence, clinical features and risk factors after ER.

Methods A multicentric questionnaire-based study was conducted between April 2016 and July 2017. Patients >18 years who underwent ER >3 months ago had a socket examination before inclusion. Data recorded included patients’ demographics, and preoperative, surgical and postoperative features.

Results One hundred patients (53 men) with a mean age of 65.1 years (29–92; SD=13.0) were included. ER indications were: uveal melanoma (n=24, 24%), trauma (n=20, 20%), retinal detachment (n=20, 20%), glaucoma (n=14, 14%) and endophthalmitis (n=12, 12%). Thirty (30%) patients experienced PV. Elementary and complex visual hallucinations were experienced by 80% and 20% of patients, respectively. PV usually appeared within the first postoperative month and tended to decrease over time. Risk factors for PV were the preoperative use of proton beam therapy (p=0.006), uveal melanoma (p=0.014), enucleation (p=0.015), anxiety with a Hospital and Anxiety Depression (HAD) score ≥8 (p=0.042), depression with a HAD score ≥8 (p=0.030), phantom eye pain (p=0.044) and phantom eye sensations (p=0.002).

Conclusion PV was reported by one-third of our patients. Despite being widely misunderstood, ophthalmologists and neurologists should be aware of this complication to adequately reassure patients.

  • visual perception
  • treatment surgery

Data availability statement

No data are available. none.

https://doi.org/10.1136/bjophthalmol-2021-319091

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Introduction

Eye removal (ER) is experienced as a psychological and anatomical trauma by the patients. 1–3 Removing the eyeball may be necessary to relieve pain and/or in case of non-aesthetic blinded eyes following trauma, retinal detachment, glaucoma or to manage aggressive intraocular malignancies. 4–6 Cosmetic rehabilitation is usually achieved with ocular prosthesis or epithesis delivery. 7 8 Despite this, the psychological impact of ER is widely underestimated. 9 10 Unlike very well-known complications such as the postenucleation syndrome, 11 phantom eye syndrome (PES) is a poorly understood complication of ER. 12 PES includes at least one of the following characteristics: phantom eye pain (PEP), phantom vision (PV) and phantom eye sensations. PES is associated with elevated anxiety and depression rates as well as an impaired quality of life and thus should be further investigated. 1 3 10 13 14 In a previous study, we have found that 47% of patients experienced PEP defined as any pain felt in or around the amputated eye. 9 However, some studies have highlighted that several conditions such as dry socket or poor prosthesis aftercare could lead to chronic socket pain often misdiagnosed as PEP. 15 16 In our opinion, PV is less likely to be misdiagnosed with other differential diagnoses and would therefore better reflect the real prevalence of PES. PV is often reported by the patients as the most intriguing and sometimes terrifying symptom following ER.

The aim of this study was to assess the prevalence, features and risk factors of PV in patients who underwent ER.

Patients and method

Study design.

A multicentric international study was conducted between April 2016 and July 2017 in three oculoplastic departments in Nice University Hospital (Nice, France), the Rothschild Foundation (Paris, France) and the Jules Gonin Eye Hospital (Lausanne, Switzerland). All the patients gave their informed consent.

Inclusion criteria and data collected

Patients >18 years, who underwent ER ≥3 months ago, and wore an acrylic eye prosthesis were invited to participate in the study. There were no limitations regarding the follow-up duration. Socket examination was systematically performed by an oculoplastic surgeon or an ocularist before inclusion. Patients with socket abnormalities (eg, implant exposure, infection, granuloma, shallow fornices, ocular prosthesis instability), or neurological disorders such as cluster headaches or ophthalmic zona were excluded. Patients who reported visual hallucinations related to Charles Bonnet syndrome (CBS) or to another neurological disorder before ER were also excluded. Sociodemographic and medical data were collected by reviewing the medical charts of the three participating oculoplastic centres. Data collected included: age, gender, aetiology of ER, time between ER and the questionnaire completion, prior treatments (ie, surgery, proton beam therapy), surgical details (surgeon experience, surgical technique, reconstruction of the anophthalmic socket, retrobulbar anaesthetics administration, surgery duration), postoperative course (adjuvant radiotherapy, metastatic status) and follow-up. A surgeon was considered an oculoplastic surgeon if he/she belonged to the French Ophthalmic Plastic Reconstructive and Aesthetic Society.

Questionnaire

At the end of the baseline visit, a prestamped questionnaire was given to the patients who were asked to fill it at home. The intrinsic validity of the questionnaire had been previously confirmed in five patients. The questionnaire was returned to and centralised in Nice University Hospital where the data were anonymised. The questionnaire included 17 pages with 21 to 66 questions divided into five different sections. Most questions were presented as fixed answers. Only few questions were presented as a free text.

PES was diagnosed based on the following definitions: (1) PEP was defined as any pain felt in or around the amputated eye, 9 17 (2) PV was defined as any vision occurring without visual stimulation of the amputated eye and (3) phantom eye sensation was defined as any tactile sensation felt in or around the eye (ie, unexplained itching, and the sensation that the amputated eye or the eyelids were still present). 2 PV was divided into elementary visions (ie, lightning, black dots, colours) or complex visions (faces, objects, landscapes) as previously described. 18 19

The following data were also collected: medical history (migraine or non-migraine headache assessed using the International Headache Society questionnaire, depression, cancer, diabetes), preoperative eye and head pain, anxiety and depression based on the Hospital and Anxiety Depression (HAD) scale and the quality of life based on the EQ-5D-3L scale and Visual Analogue Scale (VAS).

The HAD scale is an internationally validated scale comprising 14 items used to assess anxiety and depression. 20 The diagnosis of anxiety and/or depression was based on a score ≥8 as previously described. 1 Its French translation has been previously validated. 21

The EQ-5D-3L is a standardised and reliable health-related quality of life scale developed by the EuroQol group in 1990. The EQ-5D-3L comprises five dimensions: mobility, self-care, usual activities, pain/discomfort and anxiety/depression. The EQ VAS records the patient’s self-rated health on a vertical VAS. The scores are obtained using a French weighting matrix edited by the Haute Autorité de Santé and range between −0.51 and 1. The higher is the score, the better is the health status of the patient. The EQ-5D-3L scale and its French translation 22 have been previously validated in the ophthalmic literature. 23 24

Main outcome measures

The aims of the study were to assess: (1) the prevalence of PV, (2) the features of PV and (3) the risk factors for PV in patients who underwent ER.

Descriptive statistics are presented as counts and percentages for categorical variables and a mean±SD for continuous variables. Analyses were performed using Fisher’s exact and Mann-Whitney tests to compare qualitative and quantitative data, respectively. A multivariate analysis was performed using a logistic regression. SPSS software V.25 (IBM) was used and a p<0.05 was considered statistically significant.

Patients’ characteristics

Of the 185 questionnaires provided, 115 (response rate: 62%) were returned and a further 15 were excluded due to numerous missing data. Finally, 100 patients (53 males) with a mean age of 65.1 (29–92) years were included in the study. Patients’ characteristics are presented in table 1 . Choroidal melanoma was the most common indication of ER (n=24, 24%) followed by trauma (n=20, 20%) and retinal detachment (n=20, 20%). The main reason that patients with retinal detachment, glaucoma or uveitis required surgery was intractable pain or poor aesthetics in a blind and non-functional eye. Among the patients treated for eye or orbital malignancies (n=29, 29%), 15 (52%) underwent radiotherapy (mainly proton beam therapy) prior to ER. The mean time between surgery and the questionnaire completion was 49 months (3–264; SD=64.0). The mean score for aesthetic discomfort related to the prosthesis reported by the patients was 3.2 (SD=2.5) on a 0–10 scale. Anxiety, based on a HAD score ≥8, was diagnosed in 34 (34%) patients. Depression was diagnosed in 42 (42%) patients. The mean EQ-5D-3L and EQ-5D-VAS scores were 0.8 (SD=0.2) and 68 (SD=22), respectively.

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Baseline patients’ characteristics

PV prevalence

PES was diagnosed in 68 (68%) patients. Forty-seven (47%), 30 (30%) and 38 (38%) patients experienced PEP, PV and phantom eye sensations, respectively.

PV clinical features

PV features are presented in table 2 . Among the 30 patients experiencing PV, about half reported having experienced PV in the first postoperative month. Only four (13.5%) patients reported delayed symptoms (>1 year). Twenty-four (80%) and six (20%) patients reported elementary and complex visual hallucinations, respectively. Examples of elementary and complex visual hallucinations experienced by the patients are shown in figures 1 and 2 , respectively. PV usually occurred every day (n=12; 40%) at any time of the day (n=19; 62.5%). PV spontaneously disappeared in 5 (17%) patients. Even if PV was usually experienced for a few seconds (n=11; 36.5%) or minutes (n=8; 27%), almost one-quarter of the patients reported having continuous symptoms. PV essentially improved with time (n=13; 43%) and a worsening was exceptional (n=2; 7%). Stress and intense lightning were reported as triggering factors whereas rest and darkness were considered relieving factors. About half and one-third of the patients wanted to receive a medical and even surgical treatment to relieve PV symptoms.

Phantom vision (PV) features

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Elementary visual hallucinations experienced by three different patients.

Horrific complex visual hallucination drawn by the patient herself. English translation of the text: ’an image appears, as drawn in charcoal, on a light background; this image is moving towards me with a wide open eye, turns left (always) and disappears. Another time, (I saw) a male bare chest holding two babies against him’.

Risk factors for PV

As shown in table 3 , the risk factors for developing PV identified in the univariate analysis were the preoperative use of proton beam therapy (p=0.006), uveal melanoma (p=0.014), enucleation (p=0.015), anxiety with a HAD score ≥8 (p=0.042), depression with a HAD score ≥8 (p=0.030), experiencing concomitant PEP (0.044) and phantom eye sensations (0.002). The multivariate analysis failed to identify any risk factors.

Risk factors for developing phantom vision

PES is a poorly understood and underestimated complication of ER. 2 9 In our study, 68% of our patients experienced PES symptoms which is in line with previous studies ( table 4 ). Among all PES features, PV is probably the most worrying and confusing complication for the patients. Visual hallucinations are very well known by ophthalmologists and neurologists faced with CBS or Lewy body dementia, respectively. 25 26 Visual hallucinations have been classified as elementary and complex. 19 PV definition is well established and recognised. PV is defined as the occurrence of visual hallucinations following ER in the absence of any external visual stimulus. 3 18 27 28 In our opinion, PV better reflects the real prevalence of PES than PEP. Indeed, PEP may be overestimated due to numerous differential diagnoses (socket dryness, prosthesis discomfort). Overall, 30% of our patients experienced PV. As shown in table 4 , this result is in accordance with previous studies. Nicolodi et al have found a higher PV rate (up to 71%). 27 This could be explained by the fact that they have only included patients who underwent enucleation. In the present study, we found that uveal melanoma and enucleation promoted the occurrence of PV. Surprisingly, no differences were found between studies based on a questionnaire (ours and Hope-Stone et al ) or an interview (Rasmussen et al and Sörös et al ). We hypothesised that interviewed patients would less likely report their visual hallucinations due to the fear to be considered mentally disabled by their physician. 18 In our study, 80% of PV patients experienced elementary visual hallucinations (eg, lightning, seeing with both eyes) which is in line with previous studies ( table 5 ). Complex visual hallucinations mainly include seeing faces, landscapes or writing. 18 As in our study, some patients have already drawn their complex visual hallucinations. 29 Forty per cent of our patients experienced daily symptoms, a higher rate than that reported by Rasmussen et al (14%) and Hope-Stone et al (28.7%) without clear explanation. In accordance with other studies on visual hallucinations, PV tended to decrease and even disappear over time. 30 Worsening of symptoms is very unlikely and should be studied with orbital imaging to rule out any differential diagnosis (optic or ciliary neuroma). Unlike other studies on PV 3 28 and without clear explanation, darkness was not considered a triggering factor but was rather a relieving factor in our study. Unlike us, Rasmussen et al and Hope-Stone et al have sometimes identified noisy sounds as triggering factors. 3 18 This phenomenon called the ‘sound-induced phosphene illusion’ or ‘visual synesthesia’ was first described by Bolognini et al by delivering a noisy stimulus in combination with a targeted occipital transcranial magnetic stimulation. 31 Despite the use of different measurement methods depending on the studies, PV is usually not considered very disturbing. 3 18 Terrifying visual hallucinations are exceptional but have already been reported by Rasmussen et al , as in our study ( figure 2 ).

Phantom eye syndrome (PES) prevalence and related features in the literature

Comparison of studies on phantom vision (PV)

As shown in table 5 , the risk factors for PV are debated. PEP has been shown to be the most reliable risk factor for developing PV. 3 28 Unlike previous studies, the age was not associated with PV in our study. Hope-Stone et al and Sörös et al have found that patients younger at the time of surgery were at higher risk of PV. 3 28 Conversely, Rasmussen et al have found that the sensation of seeing with both eyes was increased in older amputated patients. 18

For the first time, we reported an association between PV, uveal melanoma and its related treatments (ie, proton beam therapy and enucleation). However, a recent study has shown that 60% of patients who received proton beam therapy for choroidal melanoma experienced phosphenes during the sessions. 32 These visual phenomena are not fully understood. 33 It could be assumed that some patients confused PV with phosphenes related to proton beam therapy. The time between surgery and our questionnaire completion ranged between 3 months and up to 240 months, but the mean and median times were 49 and 23.5 months, respectively, reducing the risk of bias. It is still unclear in the literature whether sectioning the optic nerve during enucleation could promote PV or not. For the first time, we demonstrated that anxiety and depression were associated with PV.

PV pathophysiology is not yet elucidated. Many theories have been advocated: the hyperactivation of the cortical visual areas, 31 the activation of the neuromatrix network, 34 the deafferentation theory 35 or the neurobiological theory. 36 Several studies have shown a cortical reorganisation and alteration of the anterior visual system after enucleation in patients with retinoblastoma. 37 38 The pathophysiology is assumed to be multifactorial. 19

It could be assumed that PV could be classified as a subtype of CBS. CBS was first described by the Swiss naturalist Charles Bonnet as occurring in: (1) an elderly patient with intact cognition, (2) with an eye disease and (3) with visual hallucinations with preserved insight. 19 Nowadays, CBS definition is widely debated. 25 Some authors consider that CBS can only be related to ophthalmological disorders (eg, secondary to age-related macular degeneration, glaucoma…) whereas others also include visual hallucinations due to brain disorders. 39 40 Of interest, some authors only include complex visual hallucinations whereas others include both complex and elementary visual hallucinations. 41 These controversies could explain why complex visual hallucinations are more prevalent in CBS (71.6% according to the literature review conducted by Khan et al 30 ) compared with PV studies ( table 4 ).

To date, no study has investigated PV treatment. Based on our findings, reassurance and explanations on the natural course of PV are the mainstay of treatment. The use of antiepileptics has already been described in CBS with conflicting outcomes. 25

In the present study, we tried to reduce all the confusing biases. All our patients were examined by an oculoplastic surgeon or an ocularist before inclusion to rule out any socket abnormality. We also excluded the patients who experienced visual hallucinations prior to surgery that could be related to the underlying trauma, medications, previous proton beam therapy or a mental illness. 18

This study has some limitations including: (1) the fact that the mean and median times between ER and the questionnaire completion were 49 and 23.5 months, respectively. As discussed above, some patients could have confused phosphenes induced by previous proton beam therapy with PV (recall bias). However, about 70% of patients reported having experienced PV at least once a month ( table 2 ) which was not compatible with phosphenes induced by proton beam therapy; (2) the response rate was 62% in our study. Although this result is in line with previous studies, 3 28 it could be assumed that patients experiencing PV were more likely to fill the questionnaire, resulting in an overestimation of the real PV prevalence; (3) 22% of our patients had a medical history of depression (HAD score ≥8). Several antidepressants are known to induce visual hallucinations and could have induced a confusing bias; (4) no orbital imaging was performed in our study. The diagnoses of PES and even phantom limb syndrome are only based on clinical findings. 2 42 However, an imaging and histopathology study reported that 20% of amputated patients had neurinomas at the optic nerve/orbital implant junction. 43 It could be assumed that neurinomas could trigger visual hallucinations and be responsible for pseudo-PV. However, as highlighted by this article, most neurinomas were only diagnosed on histopathologic examination. Therefore, we recommend to routinely perform orbital imaging before making the diagnosis of PES 9 even if normal imaging does not always rule out an organic aetiology; and (5) the visual acuity of the remaining eye was not assessed in our study. A bilateral visual impairment or a marked decrease in visual contrast sensitivity is known to promote CBS. 19 44 To our knowledge, only one of our patients experienced bilateral blindness.

Seeing with the amputated eye is undoubtedly the most intriguing complication experienced by patients who underwent ER. Ophthalmologists and neurologists should be aware of this underreported complication that affected one-third of our patients in order to provide adequate explanations and reassurance. Further brain imaging studies are needed to better understand and manage PV.

Ethics statements

Patient consent for publication.

Not required.

Ethics approval

This study was conducted in accordance with the principles outlined in the 1964 Declaration of Helsinki and its further amendments. The study was approved by the French authorities and all the data were anonymised accordingly (National Registration Number: 2003886).

Acknowledgments

To M. Billard, M. S. Pyelong and M. Jaupart for their help in collecting all the data.

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Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Competing interests None declared.

Provenance and peer review Not commissioned; externally peer reviewed.

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  • Highlights from this issue Highlights from this issue Frank Larkin British Journal of Ophthalmology 2022; 106 i-ii Published Online First: 20 Oct 2022. doi: 10.1136/bjo-2022-322666

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Phantom Vision

Washington, DC From the Department of Neurology, Howard University Medical School, Washington, DC.

Phantom vision was manifest by the transient belief that visual sensations were present in the absent eye. This phenomenon was never spontaneously divulged; in all instances the visual sensations had to be specifically elicited. Because of the unanimity of these findings, it is believed that phantom vision is a common and persistent phenomenon in patients who have suffered traumatic enucleation of one or both eyes. These phantom visions appear to be behaviorally related to the somatosensory phenomenon of "phantom limb" resulting from the total loss of an extremity, or parts of an extremity.

Cohn R. Phantom Vision. Arch Neurol. 1971;25(5):468–471. doi:10.1001/archneur.1971.00490050102009

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  • Published: 26 September 2023

Prevalence, temporal course and risk factors for phantom eye symptoms in uveal melanoma

  • Stephen L. Brown   ORCID: orcid.org/0000-0002-6142-0995 1 , 2 ,
  • Laura Hope-Stone 2 , 3 ,
  • Rumana N. Hussain 3 ,
  • Heinrich Heimann 3 ,
  • Nicola van der Voort 3 &
  • M. Gemma Cherry 2  

Eye ( 2023 ) Cite this article

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  • Eye manifestations

Phantom eye symptoms (PES), particularly phantom visual sensations (PVS) and phantom eye pain (PEP), are common in enucleated patients and can lead to psychological distress. Current cross-sectional studies cannot examine the temporal course of symptoms, nor can they identify dynamic risk factors or consequences of PES.

Cohort study of 105 enucleated uveal melanoma patients returning self-report questionnaires, within 4 weeks of diagnosis and 6-, 12- and 24-months post-treatment. Questionnaires measuring PVS and PEP symptoms in the week prior to completion, pain severity, Hospital Anxiety and Depression Scale scores and the Functional Assessment of Cancer Therapy scale (FACT-G) measuring quality of life.

PVS and PEP emerged after 6 months, were relatively stable over the study and did not remit. PVS showed 6-, 12- and 24-month prevalence rates of 44.6%, 48.2% and 30.2%, and PEP 16.1%, 18.4% and 17.5% respectively. PVS were generally elementary, with only 10–15% of the total cohort experiencing complex sensations. PEP was generally neither prolonged nor intense, except in a small proportion. PVS and PEP were showed moderate associations but did not predict each other prospectively. Anxiety within 4 weeks of diagnosis was a risk factor for the initiation of PEP. Neither PVS nor PEP prospectively predicted anxiety, depression or quality of life.

Conclusions

PES were prevalent and non-remitting, beginning within 6 months of enucleation. PVS and PEP may not represent symptoms of a coherent syndrome. We discuss findings with reference to theories of phantom sensations, and directions for clinical practise and research.

Introduction

Uveal melanoma (UM) is the most common intraocular tumour in adults. Approximately 30% of UM patients are treated by enucleation [ 1 ]. Enucleation is commonly experienced as traumatic, and is associated with pain, adverse physical and functional consequences, psychological distress and poorer quality of life (QoL) [ 2 ].

Additionally, UM patients may experience phantom eye symptoms (PES) [ 3 ]; pain or visual sensations that appear to emanate from the removed eye. Clinical characteristics and correlates of PES have been documented across populations of UM, eye infection and eye injury amputees [ 4 , 5 , 6 ]. Phantom visual sensations (PVS) are reported by 30–42% of patients; including unstructured phenomena, such as colours or shapes, and, less frequently, meaningful images such as faces or animals. About a quarter of patients report ‘seeing’ from the absent eye [ 3 ]. Phantom eye pain (PEP) is reported by 23–47%, and phantom tactile sensations by 2%. PES are often perceived as disturbing and are associated with elevated anxiety and depression [ 3 , 5 , 6 ].

PES is yet to be fully described, because previous studies are cross-sectional and identify neither the temporal course nor precursors or consequences of PES. This limits the interpretation of findings in four ways. First, PES symptom timelines, initiation, consistency and remission, are unknown. Second, it is unclear how symptoms are temporally linked. Initially PES was considered a unique syndrome [ 2 ], but PVS and PEP are not strongly linked in cross-section [ 3 , 5 ]. It is unclear, though, whether PVS and PEP form part of a syndrome with links at some timepoints and divergences at others, or whether PVS and PEP are sequentially linked such that one precedes the other.

Third, PEP is associated with pre-amputation eye pain [ 3 , 5 ]. In the phantom limb pain literature, such associations are cited as evidence of maladaptive neural plasticity [ 7 ] or prior learning [ 8 ]. However, cross-sectional studies assess pre-amputation pain simultaneously with PEP measures, overlooking the possibility that recall of prior pain may be influenced by post-amputation PEP. Fourth, PES, particularly PEP, are cross-sectionally associated with elevated anxiety and depression [ 3 , 5 , 6 ]. The direction of this association is unknown. Psychological distress may cause, phantom limb pain [ 9 ]. Equally plausibly, pain is a well-established cause of psychological distress [ 10 ]. PES are subjectively disturbing [ 2 , 3 ] and may cause anxiety and depression.

To overcome the problems of cross-sectional studies, we conducted a two-year prospective cohort study of UM patients. We aimed to identify the putative course, precursors and consequences of three major PES symptoms; PVS, ‘seeing’ and PEP. Our first aim was to establish symptom prevalence at 6, 12 and 24 months post-diagnosis, and intra-individual symptom consistency. Our second aim was to establish whether PES are prospectively predicted by other PES symptoms, pain, anxiety, depression or QoL. Our third aim was to determine whether PVS and PEP prospectively predict anxiety, depression or QoL.

Ethical oversight

The conduct of the study was approved by the Liverpool Central NHS Ethics Committee (03/06/072/A).

Study design

Open cohort study with return-paid questionnaires administered at baseline (within 4 weeks of diagnosis), and 6-, 12- and 24-months later. Anxiety and depression were measured at all timepoints and PVS, PEP and QoL at 6-, 12- and 24-months. Clinical and demographic variables were controlled.

Participants

We recruited consecutive adult UM patients treated by enucleation at the Liverpool Ocular Oncology Centre (LOOC) for UM (choroid and ciliary body) tumours between July 2015 and July 2020. At LOOC, patients are treated by enucleation if eye-conserving procedures are not clinically indicated or by patient preference [ 11 ]. All patients who gave written consent for this study were posted the self-report questionnaire with enclosed postage-paid envelopes 4 weeks 6, 12 and 24 months following diagnosis. Analyses were confined to participants who returned questionnaires at two or more timepoints.

Socio-demographic and clinical data were available from clinical records for all participants. Clinical data included affected eye, visual acuity, tumour diameter, extra-ocular extension and prognostic testing outcomes. Visual tests used the Snellen method converted to logMAR scores. Extra-ocular extension is tumours that extend beyond the eye and are often treated by external beam radiotherapy to the socket following enucleation. Prognostic testing outcomes were also included. About 40% to 50% of UM patients will develop metastatic disease within 10 years, for which treatment rarely pro-longs life [ 12 ]. Metastatic risk and all-cause mortality are predicted by multiple clinical, histological and tumoural genetic risk factors; the strongest predictive factor involves a mutation deletion of one of the pair of chromosome 3 alleles (Monosomy 3-M3) [ 13 ]. LOOC offers prognostic testing with outcomes communicated within six weeks. Testing outcomes include M3, Disomy 3 (D3 - absence of mutation) or unknown (patient did not accept testing offer or test failed).

PVS and PES were measured using questionnaire items derived from those of Rasmussen et al. [ 6 ], Martel et al. [ 5 ] and Hope-Stone et al. [ 3 ]. To normalise what some may see as unusual or discomforting sensations 4 , we provided the following statement on the questionnaire; ‘Some people experience visual sensations and pain that feel as though they come from the removed eye’. Participants were then asked to report if they experienced ‘visual sensations in the removed eye’ during the past week. If so, they were asked if these sensations resembled the following; visual patterns, flashing lights, shapes, kaleidoscopes, colours, people, animals or other (taken from Hope-Stone et al. [ 3 ]). Participants were then asked to report if they felt that they could ‘see through the removed eye’ during the past week (yes/no), and an open text question concerning what they ‘saw’. Participants were asked if they had experienced pain in the last week (yes/no), and if so for what duration (few minutes/few hours/few days/whole week). They were also asked to indicate the worst pain during that week, on a 1–10 scale anchored by the terms ‘no pain’ and ‘as bad as you can imagine’. Previous studies have found pain to be associated with reports of pre-surgical pain in the eye. Thus, we asked participants if they had experienced pain in the eye before removal (yes/no).

Anxiety and depression were assessed using subscales of the Hospital Anxiety and Depression Scale (HADS) [ 14 ]. Each has seven items scored from 0 to 3 with higher scores signifying greater symptomology (range = 0–21). Both subscales predict diagnosed cases with good sensitivity and specificity [ 15 ].

QoL was measured using the total score from the Functional Assessment of Cancer Therapy scale (FACT-G) [ 16 ]. The FACT-G is a 28 item, five-point scale from 0 (not at all) to 4 (very much). Item scores are summed with a range of 0–108, with higher scores indicating better QoL.

Temporal courses of PVS and PEP were inferred from prevalence rates at each time-point. We examined consistency of symptom reporting by calculating percentages of participants reporting symptoms across timepoints.

Using binary logistic regressions, PVS and PEP outcomes at 12 and 24 months were regressed onto PEP, PVS and QoL measured at 6 and 12 months respectively, and from anxiety and depression at each timepoint. As shown in Table  1 , ‘seeing’ was uncommon and all patients who reported ‘seeing’ also reported PVS. Thus, we did not conduct separate analyses to predict ‘seeing’. Initial values of the outcome variable were controlled. Odds ratios and 95% upper and lower confidence intervals (CIs) are reported.

We used linear regression, to predict 12- and 24-month anxiety and depression from PVS and PEP at 6 and 12 months.

Statistical controls

To eliminate confounding, we examined the association between demographic and clinical variables and PVS and PEP. None predicted PVS or PEP, and thus none were used as control variables.

Missing data

Aim 1 analyses used returned data with no data replacement. For Aim 2 analyses, missing data were replaced by multiple imputations. Ten imputations were used to replace missing data. Eleven participants died during the study, 2 between 6 and 12 months and none between 12 and 24 months. Missing data due to death was addressed by creating a covariate representing time points (from 2–4) for which patients were alive for imputation, we then deleted all imputations made after death [ 17 ].

During the recruitment period, 224 patients were enucleated, with 121 returning at least one questionnaire. Of the 121, 105 met the criterion of having returned questionnaires at two or more time points. Demographic and clinical data were available for all 105 patients. The baseline questionnaire was returned by 86 (81.9%), 6-month return was 89 (84.8%), 12-month return was 93 (88.6%, two patients died before this time point) and the 24-month return was 64 (61.0%, another nine patients died before this time point). Attrition analysis showed that a 24-month dropout (not attributable to death) was not predicted by any study variable. Table  2 shows distributions of demographic and clinical characteristics.

Aim 1: PES emergence, temporal course and consistency over time

Phantom visual sensations.

Table  1 shows consistent prevalence rates across timepoints, with symptoms commencing before 6 months, and a non-significant reduction between 12 and 24 months. PVS were mainly elemental perceptions of flashing lights, shapes or kaleidoscopes, with a minority perceiving meaningful images of people or animals. Of 96 participants responding to the PVS item at two or more time points, 25 (26.04%) reported visual sensations at all time points (13 at three time points, 7 at two time points), and 38 (39.6%) reported visual sensations at some time points but not others. Thirty-three did not report visual sensations at all (23 at three time points, 10 at two time points). No participant who reported PVS after six months showed spontaneous remission, defined as no PVS during the subsequent two time points.

About 10–12% of participants reported ‘seeing’ from the eye. Open text responses were evenly split between elementary or complex images similar to PVS (all of whom also reported PVS) and a non-specific feeling ‘as though the eye was still there’. As the former category fully overlapped PVS, we included these in that category. This left 3–5 participants who felt as though the eye existed but did not report specific visual sensations. This category was too small for meaningful analyses.

PES prevalence rates were consistent across time points but lower than PVS; 16.1% at 6 months, 18.4% at 12 months, and 17.5% at 24 months. The modal experience of pain lasted only minutes and mean pain intensity was generally low at just over one on the 10-point scale. Spearman rank-order correlations showed pain intensity and duration to be significantly linked; 6-month rho  = 0.50, p  = 0.080, 12-month rho  = 0.56, p  < 0.01, 24-month rho  = 0.69, p  < 0.01. This suggests a small number of participants reporting pain that was both more prolonged and of higher intensity that others in the sample. Of the 101 who responded to the PEP item at two or more time points, 8 (7.9%) reported pain at each time point (2 at three time points and 6 at two time points) and 35 (34.7%) reported pain at some time points and not others. 58 reported no pain at any time point (39 at three time points, 19 at two time points). No participant reported spontaneous remission.

Visual sensations and pain were moderately cross-sectionally linked at each timepoint: Timepoint 1, Φ = 0.24, p  < 0.05; Timepoint 2, Φ = 0.33, p  < 0.01; Timepoint 3, Φ = 0.33, p  < 0.05.

Prevalence estimates were unlikely to be biased by the high dropout between 12 and 24 months (Table  1 ). In logistic regression analyses predicting retention at 24 months, neither 12-month PVS (Odds ratio = 1.24, 95% CI = 0.44, 3.133) nor PEP (Odds ratio = 1.35, 95% CI = 0.37, 4.88) predicted retention.

Aim 2: prospective predictors of PVS and PEP

Prior observations of PEP and did not predict PVS and prior observations of PVS did not predict PEP (Table  3 ). Thus, PVS and PEP were not sequentially linked. PEP was not predicted by pre-amputation eye pain. The initiation of PEP at 6 months was predicted by higher levels of baseline anxiety but not baseline depression (see Table  3 ). Neither PVS nor PEP were predicted by anxiety, depression or QoL at any time points subsequent to 6 months.

Aim 3: PVS and PEP as predictors of anxiety, depression and poorer QoL

Table  4 shows that neither PVS nor PEP predicted later depression, anxiety or poorer QoL.

PVS and PEP were relatively common in newly enucleated UM patients, emerging before 6 months and largely persisting over 24 months. PVS were experienced by about a third to a half of participants and were generally elementary with only about a quarter of sensations consisting of meaningful images. PEP was experienced by 11–16% of participants. For most, PEP was neither prolonged nor intense, although for a small proportion of participants length of pain was related to intensity. PVS and PEP were not sequentially related. PEP was more likely to occur in patients who reported elevated pre-treatment anxiety but not elevated depression or poorer QoL. Anxiety probably constitutes a risk factor for the emergence of PEP, but does not influence its course. We found no evidence that PVS or PEP may cause elevated anxiety, depression or poorer QoL. We discuss the importance of all findings with reference to theoretical and clinical implications.

PVS prevalence of 30–48% is generally in line with previous studies [ 2 , 3 , 4 , 5 , 6 ], although one detected prevalence rates of up to 60% [ 18 ]. Our estimate may be slightly low because we asked participants to report only symptoms during the previous week. Previous studies imposed no truncation. Consistent with previous studies, PVS mainly consisted of elementary shapes and colours, with few complex or meaningful sensations such as people or animals [ 3 , 4 , 5 , 6 ]. Evidence of intra-individual consistency comes from the high likelihood that those reporting PVS did so at the previous time point, and that 26% of participants reporting sensations at all time points. Nonetheless, almost 40% of participants reported PVS at some time points and not others. Taken together, these findings suggest that PVS is episodic, sometimes abating for a week or more, but endures at least 2 years after surgery. Symptom persistence is consistent with cross-sectional studies showing PVS many years post-surgery [ 3 , 5 ]. Although previous studies show that PVS can be discomforting and frightening [ 3 , 4 , 5 ], findings indicate that PVS probably do not cause elevated anxiety or depression symptoms or affect QoL.

‘Seeing’ with the amputated eye

Less than 12% of participants felt that they could ‘see’ with the removed eye, compared with 28–40% in previous studies [ 3 , 4 , 19 ]. Truncating symptom reporting to may reduce prevalence estimation. Qualitative data raised the question of what is meant by ‘seeing’. About half of the responses pertained to elementary or complex visual sensations similar to PVS, and all of these participants also reported PVS. Others described non-specific ‘seeing’ with both eyes. The meaning of this is unclear. Participants may have experienced a form of sensory embodiment, whereby fellow eye vision is perceived to derive from the amputated eye [ 20 ].

Phantom pain

The 16–18% prevalence rate of patients who reported PEP was lower than previous literature [ 3 , 5 , 6 ]. Again, this may be attributable to limiting the reporting period to the past week. Prevalences of PEP were lower than PVS, but again reasonably stable over the study. Similar to PVS, about 35% of participants reported PEP at some but not other time points, suggesting that PEP is also episodic. Fortunately, episodes were generally brief and pain mild. About 75% of participants experienced PEP for minutes or hours rather than days or weeks, and mean ratings were about one point on a ten-point scale. Nonetheless, strong associations between PEP duration and intensity existed in a small number of participants. It is unclear whether their prolonged and intense PEP merely quantitatively differs to others, or whether it had a separate aetiology. This could be a focus of future research. Also, we cannot be sure that pain represents true PEP, as we did not examine socket or adjacent structures for causes of pain.

Anxiety preceded PEP, and may cause its initiation. There was no evidence that anxiety was prospectively associated with PEP after 6 months, thus anxiety may initiate rather than maintain PEP. Depression showed a similar link although this was not statistically significant. Elevated anxiety may be a risk factor for PEP. It is unclear whether the heightened anxiety that precedes PEP is attributable to UM, or whether participants were anxious before diagnosis. Contrary to previous studies [ 3 , 5 , 6 ], we did not find that pre-operative eye pain predicted PEP at any time point. We did not find evidence suggesting that pain causes elevated anxiety, depression or reduced QoL.

Is PES a syndrome?

The term ‘syndrome’ implies common cause of symptoms, with a strong empirical association between them. Similar to previous studies [ 3 , 4 ], PEP and PVS were not strongly cross-sectionally related. Prospectively, we found no evidence of sequencing (e.g., one preceding the other) as part of any developmental pathway. As neither cross-sectional nor longitudinal studies have found PVS and PEP to be strongly linked, we find it unlikely that a common pathological process underlies PVS and PEP.

Strengths and limitations

This study is the first to directly observe the temporal development of PES and make a prospective assessment of risk factors. The study also benefits from a homogenous group of participants, enucleated UM patients, who are at higher risk of PES than other enucleated patients [ 5 ]. We asked patients only to report symptoms occurring during the past week to minimize recall error, but this bracketing of the recall period can lead to prevalence underestimation.

The main drawback of the study is the lack of power afforded by 105 participants. This is particularly important because change is modeled through statistical control of the autocorrelation. Although providing a rigorous test of sequence, controlling the autocorrelation reduces power. A further problem is that 105 of 224 eligible patients were recruited, which may cause unidentified sampling bias. We also note the temporal limitation of being unable to describe trends beyond the two years of the study. We did not conduct socket examinations, and thus cannot definitively eliminate anatomical explanations for PES. Nor did we eliminate sub-clinical phenomena at the local level (e.g., neuroma of the optic nerve) or discomfort related to prostheses, and thus acknowledge limitations of any interpretations based on broader neural systems. Caution in generalising findings to other eye amputation patients is advised due to the unique demographic, medical, and psychological characteristics of both UM patients and patients undergoing enucleation. In relation to the latter, we note that previous studies have not found consistent differences between enucleated and eviscerated patients in PES prevalence or characteristics [ 2 , 5 , 6 , 10 ].

Theoretical implications

A number of theoretical explanations for phantom sensations have been proposed, most derived from the phantom limb and medically unexplained pain literature [ 9 ]. Probably the most relevant to our findings are constructivist theories that attribute symptom experience to the ways in which past experience influences the perception of afferent sensation [ 20 , 21 ]. Neural systems are viewed as trained units that continually generate, test, and refine hypotheses about afferent inputs. For example, neuromatrix theories [ 20 ] describe perception as deriving from the processing of afferent sensory input through sub-systems relating to temporospatial positioning, emotional excitation and cognition. The neural matrix is trained in the sense that sub-systems are sharpened and differentiated in a neural system where the amputated body part existed [ 20 , 21 ]. Systems are resilient to disruption because the matrix ‘fills in’ for the absence of expected, but no longer available, sensory inputs by reconstructing those inputs. ‘Filling in’ is seen to create phantom sensations [ 22 ].

These theories help to elucidate two of our findings. PVS and PEP may not be strongly related because visual and pain sensations involve differing neural systems. This would also explain why PVS is more common than PEP; visual sensations are more common in normal functioning than pain sensations and thus are likely to create stronger expectations. Further, neuromatrix theories of PEP describe emotional activation as an important determinant of perception, particularly pain perception, prior to amputation [ 20 , 21 , 22 ]. This may explain why pre-existing anxiety constitutes a risk factor for PEP. We emphasise, though, that this link could also be explained by attentional, resource depletion, and cognitive-behavioural accounts of pain [ 9 ].

Two findings, though, are inconsistent with constructivist accounts. First, phantom sensations should decline as neural systems gradually change to accommodate the loss of afferent input [ 9 ]. We found little evidence of decline over two years. Further, cross-sectional studies examining longer post-surgical periods have not found negative associations between PVS, PEP and time elapsed since treatment [ 3 , 5 ]. Second, experience of pre-surgical eye pain should predict PEP, as it does with other forms of phantom pain, because this would help may train neural expectations for eye pain [ 7 , 8 , 9 ]. Cross-sectional studies have observed this, but our prospective study did not.

Clinical implications

Although PES may not influence anxiety, depression or QoL, phantom sensations can be disturbing particularly when they are poorly understood by patients [ 3 , 5 , 6 ]. As PVS or PEP appears to lack clear risk factors, it highlights the importance of informing every patient that PES may occur, are normal and that PES are usually not harmful. A number of studies document triggers for PES and strategies that patients spontaneously use to reduce sensations [ 3 , 6 ]. Whilst triggers and helpful strategies may be specific to individual patients, patients should be encouraged to try as many as possible to see what is helpful in their case. It is notable that anxiety precedes and may be causally-related to PEP. Thus, treating anxiety at 6 months may help to reduce PEP.

A small number of participants experienced intense non-transient pain, although it is possible that this pain originates from damaged extra-orbital structures which does not represent phantom pain. Early research in other areas of PEP is starting to show the efficacy of surgical and behavioural strategies that reduce pain through therapies such as mirroring [ 23 ], transcranial magnetic stimulation [ 24 ] and sensory feedback [ 25 ]. These are not currently directed toward PES, and will have to be adapted because mirroring and feedback techniques are primarily visual. Nonetheless, these represent a start and researchers could adapt and trial some for PES.

What was known before

Phantom visual sensations and pain are known to be common in enucleated patients. Phantom sensations and pain are disturbing and are associated with anxiety and depression. Studies are cross-sectional and cannot identify the temporal course of symptoms or potential causes or consequences.

What this study adds

Phantom symptoms are episodic and endure at least two years after enucleation. There is little evidence that symptoms represent a coherent syndrome. Higher anxiety scores may be a risk factor for phantom pain, but there is little evidence that phantom symptoms cause anxiety, depression or reduce quality of life.

Data availability

Data is available from the first author subject to ethical oversight of its use.

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Tracey I. Getting the pain you expect: mechanisms of placebo, nocebo and reappraisal effects in humans. Nat Med. 2010;16:1277–83. https://doi.org/10.1038/nm.2229 .

Giummarra MJ, Gibson SJ, Georgiou-Karistianis N, Bradshaw JL. Central mechanisms in phantom limb perception: the past, present and future. Brain Res Rev. 2007;54:219–32. https://doi.org/10.1016/j.brainresrev.2007.01.009 .

Nardone R, Versace V, Sebastianelli L, Brigo F, Christova M, Scarano GI, et al. Transcranial magnetic stimulation in subjects with phantom pain and non-painful phantom sensations: a systematic review. Brain Res Bull. 2019;148:1–9. https://doi.org/10.1016/j.brainresbull.2019.03.001 .

Petrini FM, Bumbasirevic M, Valle G, Ilic V, Mijovic P, Cvancara P, et al. Sensory feedback restoration in leg amputees improves walking speed, metabolic cost and phantom pain. Nat Med. 2019;25:1356–63. https://doi.org/10.1038/s41591-019-0567-3 .

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Acknowledgements

Peter Salmon is thanked for his contributions to study conceptualisation, design, and instrument development.

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Stephen L. Brown

Department of Primary Care and Mental Health, University of Liverpool, Liverpool, UK

Stephen L. Brown, Laura Hope-Stone & M. Gemma Cherry

Liverpool Ocular Oncology Centre, Liverpool University Hospital NHS Foundation Trust, Liverpool, UK

Laura Hope-Stone, Rumana N. Hussain, Heinrich Heimann & Nicola van der Voort

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SLB and LHS developed the idea for the project and developed the methods; NvdV acted as data custodian and facilitated data access; LH-S provided oversight of data collection and custody; SLB preformed data analysis; all authors engaged in analysis interpretation; HH and RNH provided specialist medical input; all authors contributed to manuscript production and review.

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Correspondence to Stephen L. Brown .

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Brown, S.L., Hope-Stone, L., Hussain, R.N. et al. Prevalence, temporal course and risk factors for phantom eye symptoms in uveal melanoma. Eye (2023). https://doi.org/10.1038/s41433-023-02756-w

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phantom vision eyes

phantom vision eyes

Help DEF Unlock $100,000 Matching Gift

Discovery eye foundation, when you see things that aren’t there, charles bonnet syndrome.

“Do you ever see anything you know is not there but looks real anyway?” I asked Sam Weinberg when he came to the Low Vision Living program.

“No.” he said, looking at his wife, Rachel, and fidgeting with his sweater.

“Oh”, I said casually, “I just asked because many people with macular degeneration see things they know are not there. I call it phantom vision, but the technical term is Charles Bonnet Syndrome.”

“Is this syndrome an early sign of Alzheimer’s?” Sam asked pointedly, still looking at Rachel. . .

“Absolutely not”, I said firmly. “Charles Bonnet Syndrome has nothing to do with mental agility or stability. When you have phantom vision, your mind is fine; it is your eyes that are playing tricks on you. It’s a side effect of low vision.”

“Well,” Sam admitted quickly, “I see little monkeys with red hats and blue coats playing in the front yard. I’ve seem them for eighteen months.”

“What!” Rachel’s eyes about popped out of her head. “Little monkeys in the front yard?”

“Well. . .um,” Sam continued, “sometimes I see them in the living room too.”

What is Charles Bonnet Syndrome (CBS)? Charles Bonnet was an eighteenth century Swiss naturalist and philosopher. . . who described his grandfather’s curious experience of seeing men, women, birds and buildings that he knew were not there. Later in his life, Bonnet’s own vision deteriorated and he experienced phantom visions similar to his grandfather’s. . . .Charles Bonnet’s discovery didn’t capture medical attention at the time. But 150 years later, in the 1930’s, his files were dusted off, and he was credited with being the first person to describe the syndrome that came to be named for him.

Image seen by someone with CBS

How common is CBS? This syndrome is very common. Studies place the number somewhere between 10 and 40 percent of people with low vision. Twenty percent of my low vision patients have Charles Bonnet Syndrome. . . To determine whether or not you are experiencing phantom vision: Do the images that appear to you have the following six characteristics?

  • They occur when you are fully conscious and wide awake, often during broad daylight
  • They do not deceive you; you are aware that they are not real.
  • They occur in combination with normal perception. For example, you may see a sidewalk clearly but find it covered with dots, flowers, or faces.
  • They are exclusively visual and do not appear in combination with any sounds or bizarre sensations.
  • They appear and disappear without obvious cause.
  • They are amusing or annoying but not grotesque.

An image described by a person with CBS

What do people with CBS see? My patients. . . have reported seeing cartoon characters, flowers in the bathroom sink, hands rubbing each other, waterfalls and mountains, tigers, maple trees in vibrant autumn foliage, yellow polka dots, row houses, a dinner party and brightly colored balloons. . . One of the most remarkable qualities of these figures is that they almost always wear pleasant expressions. . . Menacing behavior, grotesque shapes and scenes of violent conflict are not, to my knowledge, a part of this syndrome.

Usually the same image or set of images reappears to each person. Sam’s monkeys usually materialized around sunset. . .They stayed for 10 or 20 minutes several times a week for two years and then began to appear less frequently. Some times the images change of multiple images appear. . .

Little girls dancing in the yard

Dolly Kowalski’s Little Girls with Pink Bows ‘I see little girls with pink bows playing in my yard. At first, there was only one little girl. But after a while, she had several playmates. Now they come almost every evening for fifteen minutes. . .They are so delightful, so cheerful, so active. Their little white dresses and pink bows blow in the wind. I see them so incredibly clearly, much more clearly than I see anything else now. . . .I know they aren’t real, but you wouldn’t believe how realistic they seem. . . . I wish you could see them the way I do.’”

Further note by Lylas Mogk, MD Fortunately, most people, like Dolly, find the images of CBS largely untroubling and many actually find them amusing or enjoyable, as they are usually pleasant and they are crystal clear. There is no drug treatment for CBS, but it is associated with sensory deprivation, so the more active and engaged one is the less likely it is to occur. That’s one reason why vision rehabilitation to empower individuals to accomplish their daily activities in spite of vision loss.

Excerpts were used from Macular Degeneration: The Complete Guide to Saving and Maximizing Your Sight , by Lylas G. Mogk, MD and Marja Mogk, PhD, New York: Ballantine Books, 2003, Chapter 8, pp. 236-252.

Mogk_Lylas_11C[1]

  • ← The Costs of Eye Care
  • Beyond Eating Green →

Phantom eye syndrome: a review of the literature

Affiliation.

  • 1 Department of Dental Materials and Prosthodontics, Araçatuba Dental School, São Paulo State University (UNESP), José Bonifácio 1193, 16015-050 Araçatuba, SP, Brazil.
  • PMID: 25548790
  • PMCID: PMC4273592
  • DOI: 10.1155/2014/686493

The purpose of this literature review was to describe the main features of phantom eye syndrome in relation to their possible causes, symptoms, treatments, and influence of eye amputation on quality of life of anophthalmic patients. For this, a bibliographical research was performed in Pubmed database using the following terms: "eye amputation," "eye trauma," "phantom eye syndrome," "phantom pain," and "quality of life," associated or not. Thirteen studies were selected, besides some relevant references contained in the selected manuscripts and other studies hallowed in the literature. Thus, 56 articles were included in this review. The phantom eye syndrome is defined as any sensation reported by the patient with anophthalmia, originated anophthalmic cavity. In phantom eye syndrome, at least one of these three symptoms has to be present: phantom vision, phantom pain, and phantom sensations. This syndrome has a direct influence on the quality of life of the patients, and psychological support is recommended before and after the amputation of the eyeball as well as aid in the treatment of the syndrome. Therefore, it is suggested that, for more effective treatment of phantom eye syndrome, drug therapy should be associated with psychological approach.

Publication types

  • Eye / pathology*
  • Phantom Limb / drug therapy
  • Phantom Limb / pathology*

Is eye color surgery the new fad? Interest soars as doctors warn of permanent risks.

phantom vision eyes

These days, there are many ways to get what you want but don’t have. Dimples? Wear cheek clamps . Freckles? Get them tattooed on your face . Different eye color? Just ask an ophthalmologist to laser a chemical dye into your cornea or have a silicone iris surgically implanted instead.

If that sounds dangerous to you, that’s because it is — and eye doctors are desperate to get the message across to the many blue- and green-eyed hopefuls who are being bamboozled by purported success stories online.

Eye color change procedures, none of which are FDA-approved, carry with them risks that include severe light sensitivity, glaucoma, cataracts, corneal disease, vision loss and blindness. Side effects may manifest shortly after a procedure or take years to develop. In many cases, people become depressed as they navigate these consequences, eye doctors told USA TODAY. 

One clinic in New York City is driving much of the social media chatter on permanent eye color change, garnering millions of views per TikTok . Run by ophthalmologist Dr. Alexander Movshovich, KERATO is the first keratopigmentation practice in the U.S. that uses special lasers to insert pigments inside a healthy cornea to cover the eye’s natural color, which lies in the iris. The procedure costs $12,000 and is not covered by insurance. 

Yet the risks and cost doesn't deter some people.

Just before the new year, actor and model Jessica White revealed on Instagram that she permanently changed her eye color with KERATO from dark brown to hazel. In 2014, reality TV star Tameka “Tiny” Harris said she went to Africa to change her eye color with iris implants : the riskiest procedure of them all, ophthalmologists say.

What is an iris implant and is it safe?

During iris implant surgery, a doctor cuts a slit in the cornea and slides a folded, artificial iris made of silicone into it, according to the American Academy of Ophthalmology. The fake iris is then unfolded to cover the natural one. This surgery is illegal in the U.S., so many people get it in other countries. Some experts consider the surgery “malpractice.”  

Dr. Guillermo Amescua , a cornea specialist at the Bascom Palmer Eye Institute within the University of Miami Health System, said he has treated several patients who have experienced serious complications from iris implants and have had to get them removed: an additional surgery that could further damage the eye.

One patient of his is now partially blind; another developed glaucoma — nerve damage that causes vision loss and blindness — so severe they had to get a cornea transplant.  

The resulting mental health effects can be brutal. "When people get their implants, they're super happy and experience a boost in self-esteem," Amescua said. "When they start getting complications, however, they go into denial and then get really bad depression when their implants are removed."

More on eye health: Does driving or grocery shopping make you anxious? Your eyes may be the problem.

Iris implant surgery was originally developed to help people born with missing, undeveloped or damaged irises with symptoms like glare and light sensitivity. (In 2018 the FDA approved the first prosthetic iris in the U.S. for this purpose.) However, the surgery gained popularity as a cosmetic treatment, and despite evidence documenting its risks, people still seek it out, sometimes landing back in doctor’s offices when things go haywire.

“Coming from someone who spends their life trying to restore vision and give people their sight back, it seems cavalier and somewhat silly to me to take on the risk where you could permanently damage your vision,” said Dr. Melissa Daluvoy , an associate professor of ophthalmology at the Duke University School of Medicine. “I would advise any of my patients to really think long and hard if the risks are worth the benefits.” 

Daluvoy agrees that iris implant surgery is the most dangerous way to change your eye color. Once you need a new cornea, which comes from a cadaver, Daluvoy said that you run the risk of rejection like other organ replacements. “And if you’re young, which most people who change their eye color are, then you’ll eventually need another transplant because you will outlive that organ that was donated to you,” Daluvoy said. 

Is keratopigmentation safe? 

Based on available evidence , Daluvoy said that keratopigmentation is “probably the safest of these procedures," but she'd still strongly advise against it. One of her patients required a cornea transplant after they had it done. At the very least, she said, this procedure could limit your peripheral vision because the dye reaches the outer rim of the eye. That said, many people who get keratopigmentation don't experience side effects.

Keratopigmentation may also affect a doctor’s ability to care for other eye problems as a person ages, such as glaucoma and cataracts. “The pigment in the cornea can obstruct the view and make those [conditions] more difficult to diagnose and treat,” Daluvoy said. 

The long-term effects are still unknown. Because the cornea receives its nutrients through fluid in the eye, Daluvoy wonders if dyes, some of which contain metal, could damage the cornea over time.

“I just don't think we have the long term data to know for sure,” she said. 

There’s another eye color change procedure called laser depigmentation of the iris. A doctor uses a laser to diminish the density of the iris’ natural pigment, turning brown eyes blue. But there’s limited research on this method and most doctors don’t recommend it because it can damage the iris, Amescua said, which is critical for controlling how much light enters the eye. 

If you’re interested in changing your eye color, experts recommend talking to an ophthalmologist before undergoing any procedure or considering colored contacts , which require a prescription from an eye doctor.

Oregon State Flag

tag, as divs are not allowed in 's --> Oregon Health Plan (OHP) Eye and Vision Care

OHP covers screening and treatment for medical conditions (such as cataracts, glaucoma, and accident or injury to the eye). It also coversand accident or injury to the eye). It also covers:

OHP covers medical eye exams for any eye condition. Diagnostic services are also covered.

OHP covers routine vision exams for "disorders of refraction and accommodation" (e.g., nearsightedness, farsightedness, astigmatism):

  • Once every 24 months for adults age 21 or older.
  • When clinically appropriate for OHP members under age 21 and pregnant adults.

Glasses or Contact Lenses

OHP covers glasses, fittings for glasses or contact lenses when clinically appropriate for:

  • Pregnant adults (age 21 and older) and
  • Children under age 21.

For non-pregnant adults (age 21 and older), OHP covers glasses or contact lenses for only these specific medical conditions:

  • Aphakia, pseudoaphakia, congenital aphakia, keratoconus; or
  • The natural lenses of the eye are missing; or
  • Has had a keratoplasty surgical procedure (e.g., corneal transplant). For this condition, OHP only covers contact lens services and supplies.

Other vision services need to be approved by OHP or your CCO.

To Get Eye or Vision Care:

If you are in a CCO that covers your physical health care, call your CCO. 

If you are not in a CCO for your physical health care, try these resources:

  • Call OHP Care Coordination at 800-562-4620.
  • Use the online  provider search .  Learn more about using the search .

OHP.Oregon.gov

Member resources.

OHP contacts

OHP handbooks

Words to know

We want to make sure you have the information you need. 

Talk to your CCO

 Not in a CCO? Call 1-800-273-0557 or

 Email us 

How to recognize an official Oregon website

Official websites use .gov.

A .gov website belongs to an official government organization in the United States.

Secure .gov websites use HTTPS

A lock icon ( ) or https:// means you’ve safely connected to the .gov website.

Only share sensitive information on official, secure websites.

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Cucumbers wrapped in plastic package are on display on a grocery stall in Paris, Friday, Dec. 31, 2021. (AP)

Cucumbers wrapped in plastic package are on display on a grocery stall in Paris, Friday, Dec. 31, 2021. (AP)

Katelyn Ferral

No, this cucumber juice recipe won’t restore vision in 7 days

If your time is short.

Good nutrition can contribute to healthy eyesight in some circumstances, for some people, but experts at the National Eye Institute say its effects are limited and won’t restore perfect vision.

Most eye problems stem from vision-impairment caused by genetics, aging or diabetes, one expert said.

A video featuring an artificial intelligence-created physician is claiming that a homemade juice concoction of sliced cucumbers, carrots and garlic will "restore perfect vision in just seven days." 

The virtual physician, with a dubbed voice, explains in a Jan. 4 Facebook reel  how to make what it calls "this miraculous drink" — by chopping and blending with water and fresh garlic carrots for beta carotene and cucumbers for vitamin B6, calcium and magnesium, he says.

"Pour yourself a glass and drink this preparation every morning on an empty stomach for seven days," the AI-generated doctor says before inviting viewers to subscribe to the account or sign up for a "free e-book."

This post was flagged as part of Meta’s efforts to combat false news and misinformation on its News Feed. (Read more about our partnership with Meta , which owns Facebook and Instagram.)

Although real eye doctors agree that a healthy diet can help people maintain good eyesight, this video’s claim that one drink can restore perfect vision in a week is nonsense.

Featured Fact-check

Experts at the National Eye Institute , which is a part of the National Institutes of Health, say that specific foods and supplements can sometimes improve vision for some patients, but the extent of this improvement and how it’s rendered are still being studied. There are a lot of qualifiers there. And, the group offer this big caveat:

"Unfortunately, no amounts of liver, carrots, or bilberries will give you owl-like night vision," an article on the Institute’s website says. (Bilberries are related to blueberries.)

If you wanted to try to improve or maintain your vision through nutrition, however, experts say cucumbers would not top the list of foods that are most beneficial. Carrots are more so — they are rich in beta carotene, a precursor to vitamin A, which helps your eyes adjust to dimness and keeps the eye’s surface, the cornea, moist and healthy. 

But there are many limitations to how and when an increase in beta carotene from carrots specifically can improve vision or prevent vision problems in patients, National Eye Institute investigator Dr. Emily Chew told Scientific American. 

"Most eye problems stem from vision-impairment caused by issues such as genetics, aging or diabetes that cannot be aided with an infusion of beta-carotene," Chew said.

We rate the claim that this  "miracle drink" can "restore perfect vision in seven days" False. 

Our Sources

Facebook reel, Jan. 4, 2023

Scientific American, " Fact or Fiction: Carrots Improve Your Vision?" , June 23, 2014

NVISION, "Beta-Carotene: Does it Actually Affect or Improve Vision?" , Nov. 26, 2022

National Eye Institute, "How to Feast For Your Eyes: Emily Chew has a vision to reduce the risk of eye disease by filling gaps in nutrition, " May 24, 2023

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Every Apple Vision Pro app we've heard about so far

The future is now.

Apple Vision Pro apps

Every confirmed Apple Vision Pro app is designed to work with Apple's unique AR headset, with special controls and UIs. The Apple Vision Pro finally launches in the US on February 2, with other regions set to follow suit, and with that comes a whole host of great apps to get the most out of it. 

With wide support for HDR content, eye tracking, and hand tracking, the Vision Pro is a great-looking headset that focuses on spatial computing. This essentially means it has a huge focus on rendering 3D objects and capturing your environment making it perfect for use in an office setup. 

As part of this, apps have to be specifically designed to fit into what you see in your everyday life so all the above below will be hand-tailored to work on Apple's headset. For $3,500, the Vision Pro comes with two 4K displays, an Apple silicon processor, and some seriously smart software. 

Here are all the apps currently confirmed to be coming to Apple Vision Pro in the future. 

Every confirmed Apple Vision Pro app so far

You can always trust iMore. Our team of Apple experts have years of experience testing all kinds of tech and gadgets, so you can be sure our recommendations and criticisms are accurate and helpful. Find out more about how we test.

The Apple Vision Pro will come with support for Apple's own suite of apps like Safari, Mail, FaceTime, Keynote, Notes, and Mindfulness. The Photos app comes with the ability to run Spatial Video and Apple TV + allows you to stream the best Apple TV Plus movies to whatever size screen you like.  Freeform jumps to Vision Pro too — it's all about collaboration, giving you and members of your team space to sketch ideas, show off plans, and create mood boards. If you are looking to visually represent an idea quickly, this is an excellent choice. 

As well as this, you can play the best Apple Arcade games as the entire library can be played on a virtual screen at any time. 

As for third-party Vision Pro apps, here's what's been publicly announced so far:

Adobe Lightroom — Need to make some quick image edits? Adobe Lightroom lets you quickly touch-up photos taken on your devices, and that's soon to include images shot on Vision Pro, too. It'll be interesting to see if these image edits take 3D composition into account, too.

Cisco Webex — Cisco Webex is a video conferencing app with some smart functions like a whiteboard for team collaboration and calendar functionality, to plan meetings with multiple team members. 

Disney + — Through Disney +, you can stream almost everything Disney owns, from Pixar to Marvel to Star Wars. There are also some great original movies, documentaries, and even everyone's favorite dysfunctional animated family, The Simpsons. 

Fantastical — An award-winning calendar app, Fantastical combines an accessible UI with weather notifications, preset templates to plan your day, and functionality to add social media apps. 

Game Room — We don't actually know anything about the mysterious Game Room other than it is a spatial game designed for Apple Vision Pro. It could perhaps be some sort of introduction to spatial games, with a tutorial on how they work. 

JigSpace — JigSpace is an app for creating and sharing 3D presentations. This would be particularly good if you're in a team working on physical objects or for demonstrations when teaching.

Max — HBO's streaming service, Max, includes HBO original films, TV shows, and documentaries, alongside brand-new movies. It recently just received the Barbie movie so watching that on the big screen of the Vision Pro sounds like a treat.

Microsoft 365 — This is less an app and more a whole suite of apps from Microsoft including Word, Excel, Outlook, Defender, OneDrive, and more. 

Sky Guide — Though it's yet to be publically demoed despite making an appearance in Apple's Vision Pro showcase video and press materials, we're expecting Sky Guide to be able to present the night sky constellations through the headset in your home, opening up the cosmos from the comfort of your sofa. It's already available on iPhone and iPad.

Slack — The ultimate communication platform for teams, Slack comes with the ability to make different chat rooms for different topics, has integration with Google services, and has plenty of ways to customize your experience to be more efficient. 

Super Fruit Ninja — Taking the classic Fruit Ninja formula and letting you play it in your very own living room, the Apple Vision Pro will take advantage of both eye and hand-tracking to let you really feel the fruit you slice your way through.

What the Golf? — A companion to What the Car? , which is currently on Apple Arcade, What the Golf? is a fun, charming, and brilliant little puzzle game all about golf. Using a club, your own body, and a host of other items, you have to get the ball in the hole but it's not nearly that simple. 

Zoom —  Finally arriving on Apple TV just last month, Zoom had a huge surge in users back in 2020 and soon became one of the most popular video-chatting services out there. This should help you organize meetings or game nights with your friends. 

Apple Vision Apps in development

We had the chance to chat with developers working on Vision Pro apps and here are five we know are in development right now: 

Obscura — Obscura is an app designed to get you the most out of your camera, with some very smart controls and settings. In Vision Pro, this could pair with spatial videos excellently. 

PCalc — Simple in concept but likely not in execution, given how complex the Vision Pro is, PCalc is a calculator app that is sure to be valuable in those work meetings. 

Delta — Delta is an emulation app that can transport you into a digital environment like a museum or a park. 

Game Track — Games Track is a tracking system for keeping an eye on all those games you haven't yet made the time to playthrough. In Vision Pro, you can finally start to tackle that backlog. 

Broadcasts —  Broadcasts can be used to stream audio from tonnes of radio stations across the world, which can perfectly accompany whatever Vision Pro environment you find yourself in. 

Apple Vision Pro apps we're hoping to see

Though it is an AR headset designed to work in everyday life and not a traditional VR headset intended for games, we still hope to see a few fun titles on there. The likes of Beat Saber could work great in the confines of your living room and even room-scale experiences like Thrill of the Fight or Tea for God could be enhanced by the Vision Pro's impressive Apple Silicon chip. With how much support Apple has thrown behind Apple to put out both Resident Evil Village and Resident Evil 4 on iPhone 15 Pro, it would be great to see a VR Resident Evil in Apple Vision Pro too. 

Unfortunately, there isn't a native Netflix app from launch but you can run your iPad version of Netflix on it. Hopefully, we'll see the app arrive in the future. Alongside this, apps like YouTube and TikTok will be welcome additions for when you need an entertainment fix. 

Though the headset seems to have some excellent productivity apps so far, it would be nice to see a reason for creatives to check it out too, with optimization for Logic Pro or Procreate. Drawing apps, in particular, could be great for their ability to replicate the feeling of drawing on a real easel. As we approach the launch, we are likely to see the announcement of more apps and future projects. 2024 seems set to be a big year for Apple fans. 

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James Bentley

James is a staff writer and general Jack of all trades at iMore. With news, features, reviews, and guides under his belt, he has always liked Apple for its unique branding and distinctive style. Originally buying a Macbook for music and video production, he has since gone on to join the Apple ecosystem with as many devices as he can fit on his person. 

With a degree in Law and Media and being a little too young to move onto the next step of his law career, James started writing from his bedroom about games, movies, tech, and anything else he could think of. Within months, this turned into a fully-fledged career as a freelance journalist. Before joining iMore, he was a staff writer at Gfinity and saw himself published at sites like TechRadar, NME, and Eurogamer. 

As his extensive portfolio implies, James was predominantly a games journalist before joining iMore and brings with him a unique perspective on Apple itself. When not working, he is trying to catch up with the movies and albums of the year, as well as finally finishing the Yakuza series. If you like Midwest emo music or pretentious indie games that will make you cry, he’ll talk your ear off.

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phantom vision eyes

IMAGES

  1. A new perspective on Phantom Eye Syndrome

    phantom vision eyes

  2. Ep-12 Spectral Eyes, Phantom Vision, Part 2.mkv

    phantom vision eyes

  3. Phantom Eyes

    phantom vision eyes

  4. Phantom Eye by BassLov3r on DeviantArt

    phantom vision eyes

  5. Spectral Eyes, Phantom Vision, Part 1

    phantom vision eyes

  6. Phantom Vision with Headlights

    phantom vision eyes

VIDEO

  1. Eyes Review :)

  2. ALL-SEEING EYE

  3. Phantom Vision

  4. DJI Phantom 2 Vision Camera VS GOPRO 3

  5. Hamburg PHANTOM VISION on Stage December 8,2023

  6. DJI Phantom 2 Vision Very High Altitude 1600m

COMMENTS

  1. Phantom Visions Are Real Aspect of Vision Loss

    People with CBS may have frequent visual hallucinations at first, which can range from simple repeated patterns to complex images of landscapes, people dressed in elaborate costumes or animals. Over time, they usually taper off and may eventually stop. Although CBS is physically harmless, it can be emotionally wearing.

  2. Phantom Eye Syndrome Common After Surgery to Remove Eye

    What is phantom eye? Phantom eye syndrome is somewhat similar to phantom limb syndrome. The brain projects sensory information, making it seem as though it comes from an amputated limb or organ — in this case, an eye that has been removed. However, the reasons behind these sensations remain a mystery to scientists.

  3. What Is Charles Bonnet Syndrome?

    Nov. 15, 2023 Charles Bonnet Syndrome (CBS) is a condition that some people get when they lose some or all their vision. It causes them to have visual hallucinations (seeing things that aren't really there). A new study suggests this condition is surprisingly common among people with certain types of vision loss.

  4. Charles Bonnet Syndrome: Why Am I Having Visual Hallucinations?

    What Is Charles Bonnet Syndrome? Charles Bonnet Syndrome (CBS) is a condition that causes vivid, complex, recurring visual hallucinations, usually (but not only) in older adults with later-life vision loss. It was introduced into the English-speaking psychiatric literature in 1982.

  5. Phantom Eye Syndrome: A Review of the Literature

    However, the incidence of phantom sensations in anophthalmic cavity is low and manifests as itching around the eyes, feeling of nonexisting eyelids, and sensation of opening and seeing with both eyes [

  6. Charles Bonnet Syndrome

    First noted in 1760, Charles Bonnet Syndrome (CBS, also known as phantom vision syndrome) describes the condition in which visual hallucinations are experienced by people of any age living with significant sight loss. It develops in some people, of any age, who have lost over 60% of vision.

  7. Phantom eye syndrome

    The phantom eye syndrome ( PES) is a phantom pain in the eye and visual hallucinations after the removal of an eye ( enucleation, evisceration ). Symptoms Many patients experience one or more phantom phenomena after the removal of the eye: Phantom pain in the (removed) eye (prevalence: 26%) [1] [2] Non-painful phantom sensations [1] [2]

  8. Phantom Vision: Common But Neglected

    It is the experience of recurrent phantom images in a vision-impaired person who is otherwise of sound mind. The syndrome is not associated with mental illness or dementia. Rather, it is a quirky side effect of vision loss comparable to the phenomenon of phantom limbs. The vast majority of people affected by CBS are over the age of 55, however ...

  9. Phantom vision after eye removal: prevalence, features and ...

    Phantom vision after eye removal: prevalence, features and related risk factors Br J Ophthalmol. 2022 Nov;106(11):1603-1609.doi: 10.1136/bjophthalmol-2021-319091. Epub 2021 May 12. Authors Arnaud Martel 1 , Stephanie Baillif 2 , Pierre Thomas 3 , Fabien Almairac 4

  10. Phantom vision after eye removal: prevalence, features and related risk

    Seeing with the amputated eye, referred to as phantom vision (PV), is undoubtedly the most intriguing and confusing complication experienced by anophthalmic patients. The aim of the study was to assess PV prevalence, clinical features and risk factors after ER.

  11. Phantom Vision

    Phantom vision was manifest by the transient belief that visual sensations were present in the absent eye. ... phantom vision is a common and persistent phenomenon in patients who have suffered traumatic enucleation of one or both eyes. These phantom visions appear to be behaviorally related to the somatosensory phenomenon of "phantom limb ...

  12. Flashes of Light in Corner of Eye or Peripheral Vision

    According to the American Academy of Ophthalmology, seeing flashes of light in the corner of your eye can be caused by a variety of factors or conditions. Some causes may be related to your...

  13. Prevalence, temporal course and risk factors for phantom eye ...

    Martel A, Bailif S, Thomas P, Almairac F, Gelatoire O, Hamedani M, et al. Phantom vision after eye removal: prevalence, features and related risk factors Br Journal of Ophthalmol. Published Online ...

  14. When You See Things That Aren't There

    When you have phantom vision, your mind is fine; it is your eyes that are playing tricks on you. It's a side effect of low vision." "Well," Sam admitted quickly, "I see little monkeys with red hats and blue coats playing in the front yard. I've seem them for eighteen months." "What!" Rachel's eyes about popped out of her head.

  15. Phantom Eye Syndrome: A Review of the Literature

    The phantom eye syndrome is defined as any sensation reported by the patient with anophthalmia, originated anophthalmic cavity. In phantom eye syndrome, at least one of these three symptoms has to be present: phantom vision, phantom pain, and phantom sensations.

  16. Phantom eye pain: a multicentric study in 100 patients

    Phantom eye syndrome (PES) is an underestimated complication of eye amputation (EA) characterized by phantom eye pain (PEP), phantom visions and/or phantom sensations. The aim of this study was to assess PEP prevalence, features, risk factors, social and psychological consequences and associated quality of life.

  17. Phantom Eye Syndrome

    Patients undergoing enucleation for uveal melanoma need to be informed of the possibility of phantom eye syndrome (PES). The number with uveal melanoma in PES studies has been small. Aims were to: (1) determine the prevalence, symptoms, and characteristics of PES and to test associations of PES symptoms with sociodemographic and clinical characteristics; (2) examine the interrelatedness of PES ...

  18. Phantom eye syndrome: a review of the literature

    In phantom eye syndrome, at least one of these three symptoms has to be present: phantom vision, phantom pain, and phantom sensations. This syndrome has a direct influence on the quality of life of the patients, and psychological support is recommended before and after the amputation of the eyeball as well as aid in the treatment of the syndrome.

  19. Phantom eye syndrome

    This study presents data on the clinical characteristics and possible mechanisms of the phantom eye syndrome in 112 patients after removal of one eye. The prevalence of phantom eye pain was 26%, nonpainful phantom sensations 29%, and visual hallucinations 31%. ... Phantom vision after eye removal: prevalence, features and related risk factors ...

  20. Apple Vision Pro launch date announced: How to preorder

    Mike Andronico/CNN. Apple's Vision Pro goggles, arguably its most anticipated product of 2024, will be available for users just in time for Valentine's Day. Mere hours before CES 2024 kicks ...

  21. Apple Ran a Vision Pro Ad With Luke Skywalker and Snoopy During the

    I especially love the Obi-Wan Kenobi quote used in the ad: "Let go of your conscious self, and act on instinct." Sure, that's Hollywood, but it's also a pretty good metaphor for using the Vision Pro.

  22. Can you change your eye color? Procedures carry big risks

    Eye color change procedures, none of which are FDA-approved, carry with them risks that include severe light sensitivity, glaucoma, cataracts, corneal disease, vision loss and blindness. Side ...

  23. PDF On the Soviet Nuclear Scent

    2 G-2, OSS, and their British counterparts, under the direction of the two nations' atomic authorities, 3 began with a vigorous campaign to discover which Germans had been recruited for this effort and which

  24. Oregon Health Plan (OHP) Eye and Vision Care

    The natural lenses of the eye are missing; or; Has had a keratoplasty surgical procedure (e.g., corneal transplant). For this condition, OHP only covers contact lens services and supplies. Other vision services need to be approved by OHP or your CCO. To Get Eye or Vision Care: If you are in a CCO that covers your physical health care, call your ...

  25. DLR

    At the national aerospace exhibition Aerosalon MAKS in Zhukovsky in Moscow (27 August to 01 September 2019), which took place for the eighth time, the German Aerospace Center also presented itself. On around 100 square metres, DLR presented concepts and technologies for tomorrow's space travel and aviation. The presentation focused, among other things, on German-Russian cooperation projects.

  26. Aluminium Windows

    Adres: BOSB Mermerciler San. Sitesi 4. Cadde No: 7 34520, Beylikdüzü / İstanbul / TÜRKİYE

  27. No, this cucumber juice recipe won't restore vision in 7 days

    stated on December 13, 2023 in a reel on Facebook: A juice of carrots, cucumbers and garlic will "restore perfect vision in seven days.". Instagram posts. stated on January 2, 2024 in an ...

  28. Every Apple Vision Pro app we've heard about so far

    Every confirmed Apple Vision Pro app is designed to work with Apple's unique AR headset, with special controls and UIs. The Apple Vision Pro finally launches in the US on February 2, with other regions set to follow suit, and with that comes a whole host of great apps to get the most out of it. With wide support for HDR content, eye tracking ...

  29. Tough choices for Israel in US's Middle East vision

    Here was the offer: The Arab leaders would support regional integration, including normalised relations with Israel, in exchange for an end to the Gaza War, and Israel's acceptance of a "clear ...