Brief Reports

Association Among Visual Hallucinations, Visual Acuity,

and Specific Eye Pathologies in Alzheimers Disease:
Treatment Implications
Fiona M. Chapman, F.R.C., Ophth., Jane Dickinson, M.R.C.P., F.R.C., Ophth.,
Ian McKeith, M.R.C.Psych., M.D., and Clive Ballard, M.R.C.Psych., M.D.

Objective: Studies suggest a link between visual acuity and visual hallucinations in dementia, but links with specific eye pathologies have not been evaluated. Method: Fifty patients (20 with visual hallucinations, 30 without) with probable Alzheimers disease had an
evaluation of psychotic symptoms. Visual acuity was measured before and after refractions, and ophthalmological examinations included standardized assessments for cataracts and macular degeneration. Results: Impaired visual acuity and the severity of cognitive impairments were significantly associated with visual hallucinations. No patients with
normal acuity (6/5 or 6/6 on the Snellen chart) experienced these symptoms. Impaired acuity improved with refraction in 60% (N=12) of the patients with visual hallucinations. Of specific eye pathologies, only cataracts were significantly associated with visual hallucinations.
Descriptive follow-up information suggests that an opticians assessment for glasses improves outcome. Conclusions: Glasses and cataract surgery need evaluation as prophylactic or adjunctive treatments for visual hallucinations in patients with probable Alzheimers
disease.
(Am J Psychiatry 1999; 156:19831985)

any (more than 20%) of the patients with Alzheimers disease experience visual hallucinations.
They are distressing (1), precipitate admission to residential care (1), and are associated with more rapid
cognitive decline (2). Reports (1, 3) suggest a link between visual hallucinations and visual impairment, although impaired acuity was inferred from clinical interviews in two studies. This report examines the
association among visual hallucinations, acuity, and
specific eye pathologies in 50 patients with probable
Alzheimers disease.

Received Sept. 1, 1998; revision received Jan. 14, 1999;

accepted March 4, 1999. From the Royal Victoria Infirmary, Newcastle, United Kingdom; and the Neurochemical Pathology Unit,
Medical Research Council, Newcastle General Hospital. Address
reprint requests to Dr. Ballard, Neurochemical Pathology Unit,
Medical Research Council, Newcastle General Hospital, Newcastle Upon Tyne NE4 6BE, United Kingdom; c.g.ballard@ncl.ac.uk
(e-mail).

Am J Psychiatry 156:12, December 1999

METHOD
Consecutive patients with dementia were included in a case registry. The History and Aetiology Schedule (4) was used for the study;
it records psychiatric and past medical history, medication, and the
results of a standardized physical examination. Psychotic symptoms
were rated with the Columbia University Scale for Psychopathology
in Alzheimers Disease (5), from which operationalized diagnoses of
visual hallucinations, delusions, and delusional misidentification
were made (6). An appendix rated the minutes of visual hallucinations over the week before the assessment. Cognitive assessments
were made with the cognitive section of the Cambridge Examination
for Mental Disorders of the Elderly, section B (7). A diagnosis of
probable Alzheimers disease was made according to the criteria of
the National Institute of Neurological and Communicative Disorders and Stroke and the Alzheimers Disease and Related Disorders
Association (8).
Postmortem examinations were obtained from 50 of the 338 case
registry patients. The positive predictive value for probable Alzheimers disease in a clinical setting against a neuropathological diagnosis was 80% (9).
Fifty patients with probable Alzheimers disease were selected for
ophthalmological evaluation (20 with visual hallucinations, 30 without). Patients and caregivers were shown an information sheet that

1983

BRIEF REPORTS

TABLE 1. Visual Acuity in Patients With Probable Alzheimers

Disease Who Did and Did Not Experience Hallucinationsa
Score on
Cognitive Section
of the Cambridge
Patients
Patients
Examination for
With
Without
Mental Disorders
of the Elderly
Visual Acuity Hallucinations Hallucinations
(N=20)
(N=30)
(N=50)
per the
Snellen Chart N
% N
% Mean
SD
6/5
6/6
6/9
6/12
6/18
6/24
6/36
6/60

0
0
4
5
3
4
0
4

0
0
20
25
15
20
0
20

4
7
7
5
2
2
1
2

13
23
23
17
7
7
3
7

76.3
64.0
58.3
56.1
59.6
43.7
59.0
43.0

13.3
22.4
12.9
16.8
12.7
11.3
0
33.5

a The

1-year follow-up was completed by 16 of the 20 hallucinating

subjects.

explained the study in full. If they wished to participate, written consent was obtained from the patient and written assent from the next
of kin. Approval was obtained from the relevant ethical committee.
Binocular acuity with existing glasses was measured by the
Snellen chart. All patients were refracted by the study optometrist
and examined by an ophthalmologist (F.M.C.) who was blind to the
subjects hallucination status. Assessments included the visual field
evaluation to confrontation and the slit lamp biomicroscopy before
and after pupil dilation. Cataracts were defined by a simplified Oxford cataract grading system (10). Age-related macular degeneration
was graded by using photographs from the Wisconsin age-related
macular degeneration grading system (11) and scored when visually
significant.
Visual acuity and cognitive impairment were compared among
patients with and without visual hallucinations by using the MannWhitney U test. Cataracts were compared between the two groups
by using chi-square analysis. Statistical analyses were made with the
SPSS computer software.

RESULTS

Sixty-two case registry patients with probable Alzheimers disease were living at the time of the study. All
20 with visual hallucinations and 30 who were randomly selected from the 42 without hallucinations were
enrolled. Mean age at assessment was 81.7 years for
hallucinators and 79.2 years for nonhallucinators. Seventeen of the 20 hallucinators were women, compared
to 17 of the 30 nonhallucinators (2=4.1, df=1, p=
0.04). Hallucinators had significantly worse mean
scores than nonhallucinators on the cognitive section of
the Cambridge Examination for Mental Disorders of
the Elderly (48.6 and 62.7) (Mann-Whitney U, z=2.6,
p=0.009). Visual acuity was also significantly more impaired in hallucinators (Mann-Whitney U, z=3.0, p=
0.003) (table 1). No patients with visual hallucinations
had normal acuity (6/5 or 6/6 on the Snellen chart).
Hallucinators with a visual acuity of 6/12 or worse
had 33.7 minutes of visual hallucinations in the week
before the assessment compared to 3.3 minutes for the
hallucinators without impaired visual function, and
eight of 13 (62%) of the hallucinators with poor visual
acuity (6/12 or worse) who completed the follow-up
1984

still had visual hallucinations at 1 year compared to

one of four (25%) of the hallucinators without impaired visual function.
Delusions were also significantly associated with impaired visual acuity (Mann-Whitney U, z=2.3, p=
0.02), and there was a trend toward an association
with delusional misidentification (Mann-Whitney U,
z=1.8, p=0.06).
Medications likely to influence visual hallucinations
or visual acuity were not substantially different in patients with or without visual hallucinations (hallucinators: tricyclic antidepressants=15% [N=3], anticholinergics=5% [N=1], neuroleptics=25% [N=5], steroids=
0% [N=0]; nonhallucinators: tricyclic antidepressants=7% [N=2], anticholinergics=7% [N=2], neuroleptics=13% [N=4], steroids=7% [N=2]; no patients
were taking tamoxifen, chloroquine, or antituberculosis medications).
Logistic regression analysis examined cognition, visual acuity, and gender as associates of visual hallucinations; only impaired visual acuity (Wald 2=4.2, df=
2, p=0.04) was entered into the equation.
Eye pathology was identified in 13 (65%) of the hallucinators and 13 (43%) of the nonhallucinators. Cataracts (45%, N=9 versus 10%, N=3) were significantly
more common among hallucinators (p=0.006, Fishers
exact test). The rates of glaucoma (hallucinators, 10%,
N=2; nonhallucinators, 17%, N=5), macular degeneration (10%, N=2 and 13%, N=4, respectively), and
corneal scars (0%, N=0 and 3%, N=1, respectively)
were similar. Confrontational visual field evaluations
showed one (5%) of the hallucinators had reduction
(retinal arterial occlusion), whereas three (10%) of the
nonhallucinators had constriction (two with glaucomatous and one with aphakic lenses in their glasses).
Twelve (60%) of the hallucinators had their acuity
improved by the refractions. Optician referral was instigated for six patients with visual hallucinations and
impaired acuity who were followed up for 1 year. Four
of six (67%) of these patients were free of hallucinations at follow-up, compared to only one of six (17%)
who had no action taken.
A modest correlation was seen between scores on
the cognitive section of the Cambridge Examination
for Mental Disorders of the Elderly and visual acuity
(rs=0.30, N=50, p=0.03); the relationship is illustrated
in table 1.
DISCUSSION

An association was demonstrated between visual

hallucinations and impaired acuity; visual hallucinations may be more persistent and more severe in patients with these conditions. Furthermore, preliminary
information from follow-up examinations indicates
that referral to an optician may improve the outcome
of visual hallucinations. Of the specific eye pathologies, only cataracts were significantly associated with
visual hallucinations. There was some evidence that
Am J Psychiatry 156:12, December 1999

BRIEF REPORTS

impaired visual acuity may be associated with other

forms of psychosis.
An association was seen between visual acuity and
scores on the cognitive section of the Cambridge Examination for Mental Disorders of the Elderly. The
main variability was between patients with absent impairment and mild impairment of visual acuity who
were not experiencing visual hallucinations. Visual
acuity was also independently associated with visual
hallucinations in a logistic regression analysis.
Cataract treatment and interventions to improve visual acuity may be important adjuncts to antipsychotic
therapy in those suffering from dementia and may have
a prophylactic role. Controlled trials are indicated.
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