Journal of Neuro-Ophthalmology, December 1992, Volume 12, Issue 4

Visual hallucinations on eye closure after cardiovascular surgery.

Visual hallucinations on eye closure are very uncommon. The underlying mechanism remains controversial. We report on a new case after carotid endarterectomy and coronary artery bypass graft surgery. The hypothesis of a temporal lobe epilepsy is discussed.

Journal of Clinical Neuro- ophthallllology 12( 4). 242- 244, 1992. Visual Hallucinations on Eye Closure After Cardiovascular Surgery Patrice Laloux, M. D. and Michel Osseman, M. D. © 1992 Raven Press, Ltd., New York Visual hallucinations on eye closure are very uncom­mon. The underlying mechanism remains controversial. We report on a new case after carotid endarterectomy and coronary artery bypass graft surgery. The hypothe­sis of a temporal lobe epilepsy is discussed. Key Words: Hallucinations- Vision- Epilepsy- Tem­porallobe. From the Department of Neurology, Mont- Godinne Univer­sity Hospital, University of Louvain, Yvou, Belgium. Address correspondence and reprint requests to Dr. Patrice Laloux at Department of Neurology, Mont- Godinne University Hospital, University of Louvain, B- 5530 Yvoir, Belgium. 242 Visual hallucinations on eye closure have been only reported in two cases by Fisher ( 1,2). The fre­quency of this peculiar clinical phenomenon in fully alert patients is probably overlooked. The un­derlying mechanism remains unknown. We report on a new case in whom the cause could be a tem­poral lobe epilepsy. CASE REPORT A white 60- year- old woman, with history of hy­perlipidemia and moderate hypertension, was ad­mitted for carotid endarterectomy and coronary ar­tery bypass graft surgery. Three months earlier, she had reported a transient ischemic attack char­acterized by a 30- minute right hemiparesis. Neu­rological and general examination were normal, except for a bilateral carotid bruit. Blood pressure was 160/ 80 mmHg. Brain computed tomography ( CT) was normal. Selective carotid angiogram demonstrated a 90% stenosis in the left internal carotid artery and a 70% ulcerated stenosis in the right internal carotid artery. Heart investigations revealed no emboligenic cardiopathy, but a severe asymptomatic coronary disease. Therefore, a left­sided carotid endarterectomy as well as a coronary artery bypass graft surgery were performed. The immediate postoperative course was uneventful. Medical treatment was aspirin 100 mg/ day, raniti­dine 300 mg/ day, molsidomine 12 mg/ day, and so­talol 160 mg/ day, which replaced celiprolol, usu­ally taken before the entry. Two days after sur­gery, at 9 p. m., the patient experienced visual hallucinations, occurring only on eye closure. She saw her room, in which the architecture was com­pletely modified. In this scene, the furniture and other objects were upside down and motionless. The images were colored and not distorted in shape or size. There were neither geometric, col­ored, or scintillating shapes, nor colored flashes. VISUAL HALLUCINAnONS ON EYE CLOSURE 243 She saw no figures like people, faces, or animals. The visions were not confined in one eye or one hemifield. On eye opening, they immediately dis­appeared. The visual hallucinations were associ­ated with a feeling of lightness and floating, with­out real vertigo. She had no auditory hallucina­tions or " racing thoughts," nor did she feel forced to keep her eyes closed. Always well aware of the visual phenomenon, she could exactly describe it to nurses. Unable to control it, she was worried and somewhat frightened to fall asleep. No signs of confusion were noted. This phenomenon per­sisted for about 2 hours and recurred on the 2 fol­lowing days in the evening. The patient had no history of previous visual hallucinations, migraine, or epilepsy. Neurological and general examination remained entirely normal. Blood pressure was 130/ 80 mmHg. Ambulatory 24- hour electrocardiogram ( ECG) showed no cardiac arrhythmia during the second visual episode. Two days after the last vi­sual hallucinations, the patient suddenly experi­enced a complex partial seizure secondarily gener­alized. The immediate postictal neurological exam­ination and electroencephalogram ( EEG) were normal. The serum prolactin level increased up to 731 .... U/ ml ( normal level: 35- 357 .... U/ ml) and de­creased 7 days later at 479 .... U/ ml. The patient un­derwent a 24- hour EEG monitoring with sleep study. No epileptic activity was recorded. The sleep pattern and REM latency were normal. The following investigations were unremarkable: neuropsychological testing, brain CT, extracranial and transcranial Doppler ultrasonography, HMPAO single photon emission computed to­mography. Magnetic resonance imaging ( MRI) could not be obtained. Without antiepileptic med­ications, the seizures did not recur during a period of 6 months. DISCUSSION In our patient, visual hallucinations were com­plex and binocular ( 3). Vision was normal without distortion of images that excluded visual illusions. Unlike Fisher's description, our patient reported neither " racing thoughts" nor moving figures, but images were similarly colored and not lateralized. Psychoactive drugs cannot be incriminated in our case ( 3). Although visual hallucinations may be induced by some beta- blockers, they are com­monly associated with confusion ( 4). Sotalol in two doses of 80 mg do not usually cause visual hallu­cinations. Even if ranitidine may be responsible for confusion and visual hallucinations in elderly pa­tients with severe disease ( 4), it seems unlikely here. Aspirin and molsidomine are not known to be toxic to the central nervous system ( 4). Meta­bolic abnormalities were excluded by laboratory tests. Repeated visual hallucinations only occur­ring on eye closure have not been reported as symptoms of transient ischemic attacks ( 5). Fur­thermore, the absence of carotid restenosis or car­diac arrhythmia during the visual episode is not in favor of a cerebral hemodynamic deficiency. Visual hallucinations on eye closure may be interpreted as narcoleptic hypnagogic hallucinations of sleep onset ( 6). However, our patient had no history of hypnagogic hallucinations and did not complain of other narcoleptic symptoms like cataplexy, hyper­somnia, or sleep palsy. The normal sleep study definitely excluded narcolepsy. Complex visual hallucinations can occur in migraine ( 3). But, in our case, the visual hallucinations did not progress slowly across the visual field and there were no previous migraine attacks or associated headache. Visual hallucinations and feeling of giddiness have been described as visual and vertiginous partial seizures originating from the posterior part of the temporal lobe ( 7,8). In our patient, despite several normal EEGs, the early occurrence of a partial complex seizure, secondarily generalized after the visual experiences, suggest an epileptic mecha­nism for the visual hallucinations. Moreover, elic­iting factors such as light stimulation ( 9) or eye closure ( 10) have been reported in some cases of reflex epilepsy. Medication overdosage or meta­bolic disorders were not the cause of seizures. Even if brain CT was normal, small embolic cere­bral infarcts after carotid endarterectomy ( 11) and heart surgery ( 12) could be incriminated. How­ever, MRI could not be obtained to demonstrate the presence of cortical infarcts in the temporal lobe. This case stresses the need for further reports to understand the mechanism of visual hallucina­tions on eye closure. REFERENCES 1. Fisher CM. Visual hallucinations and racing thoughts on eye closure after minor surgery. Arch NeuroI1991; 48: 1091- 2. 2. Fisher CM. Visual hallucinations on eye closure associated with atropine toxicity: a neurological analysis and compar­ison with other visual hallucinations. Can JNeurol Sci 1991; 19: 1~ 27. 3. Burde RM, Savino PI. Trobe JO. Visual illusions and hallu­cinations. In: Kist KM, ed. 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