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OPTOMETRY AND VISION SCIENCE
Copyright * 2013 American Academy of Optometry
Hallucinations, Oliver Sacks.
New York, NY: Knopf; 2012. $26.95
Oliver Sacks, now famous for his highly
accessible neurological case studies, used
to be known for monographs on migraine
and encephalitis lethargica. Interestingly,
his migraine work focused not on the
headache but on the fascinating sensory
hallucinations that herald the condition in
many migraineurs. Sacks argued that It
is in this sense that migraine is enthrall-
ing; for it shows us, in the form of a hal-
lucinatory display, not only an elemental
activity of the cerebral cortex, but an
entire self-organizing system, a universal
behavior, at work. It shows us not only
the secrets of neuronal organization, but
the creative heart of Nature itself.1 In
his new book, Hallucinations, he returns
to migraine illusions, comparing them
with hallucinations seen via pharmaceuti-
cals (including Sacks private experiments
in the sixties), but those varieties of
hallucinogenic experience are just two in
a larger cast of hallucinations induced by
sensory and neural disorders.
A disclosureVyears ago, during exper-
iments that induced forbidden hues, I
Copyright American Academy of Optometry. Unauthorized reproduction of this article is prohibited.
BOOK REVIEW
incidentally created illusory colored tex-
tures, and Sacks helpfully pointed out that
similar pattern formation occurs in other
hallucinatory systems including migraine.
At first I thought Sacks comment odd.
Many hallucinatory systems form simple
illusory patterns like spirals, fan shapes, or
concentric circles, all of which correspond
to oriented stripes of neural activity on
visual cortex or they form illusory lattices
that correspond to a superposition of cor-
tical stripes. These distinctive shapes are
known as Kluver forms, after the scientist
who studied them first with mescaline;
similar effects are inducible by flickering
lights, transcranial electric currents and mag-
netic fields, epileptic seizures, and even by
binocular pressure on the eyeballs. But
migraine is usually different; the arche-
typical migraine hallucination is the
fortification illusion, a moving flickering
serrated arc. The details of the serrations
carry valuable information about the func-
tional neuroanatomy of the visual cortex.
It was Sacks, a migraineur himself, who
noticed that the fortification illusions and
Kluver percepts could coexist in the same
observer and during the same attack.1 In
Sacks hands, migraine is less of a special
case and more a member of the family of
neural pattern-forming systems.
Sacks interweaves his own hallucina-
tory experiences with those of his patients
and others, forming an easy and coherent
narrative that links many conditions. The
sequential discussions of Charles Bonnet
syndrome (CBS), sensory deprivation, and
hemianopia are especially interesting.
Donald Hebb, the Canadian pioneer of
theoretical neuroscience, asked his stu-
dents to study techniques used by Stalin-
ists to force confessions, and they focused
on sensory deprivation. Hebbs students
were aware that nature sometimes pro-
vides sensory deprivation experiments in
subjects who are losing their sight, lead-
ing to hallucinations. Their use of opaque
goggles as an analog to ocular cataracts
was fortuitous because later experiments
showed that subjects hallucinate more
readily to diffuse light than total darkness.
Optometry and Vision Science, Vol. 90, No. 4, April 2013
Sensory deprivation is one of those sub-
jects that attracted wild attention before
slipping back into obscurity, but its clini-
cal equivalent, CBS, has recently under-
gone a serious revival of interest, and Sacks
does a nice job of bringing the subject
back to its roots by telling the story of
Bonnet and his uncle, who shared the
details of his hallucinations with Bonnet,
a budding scholar, while the uncle slowly
lost his sight. Some years later, Bonnet
himself would experience the same con-
dition. Sacks, who lost some vision to a
melanoma, has written off his own CBS
hallucinations.2 Like many vision loss pa-
tients, these three hallucinated a variety of
simple geometric shapes and more com-
plex forms, especially faces. What made
the three of them unusual was that they
were willing to talk about it. The more
usual reticence is sad on two counts: many
CBS sufferers are elderly and worry that
the hallucinations are manifestations of
dementia, whereas many clinicians do not
warn patients with deteriorating vision of
these harmless perceptual side effects, en-
suring that some of their patients suffer
in silence.
Intriguingly, Sacks mentions that some
physicians are now using quetiapine as
an off-label treatment for CBS halluci-
nations. This joins previous reports of
clinicians using carbamazepine to prevent
occipital epileptic hallucinations and di-
phenylhydantoin to treat LSD flashbacks.
What the later two treatments have in
common is that they regulate sodium
channels in nerve membranes, reducing
cortical excitability. This is in keeping
with evidence of excess cortical excitability
in subjects with migraine auras; with
reports of LSD flashbacks induced in
susceptible people using caffeine, nico-
tine, and ocular pressure and flicker; and
with a growing theoretical literature on
pattern formation in neural networks
when excitation is increased in a spatially
uniform fashion.3
Sacks is sometimes gently criticized for
letting the demands of writing for popular
audiences overwhelm scholarly aspects of

his work (Carl Sagan syndrome). At first
glance, it might seem so here; Hallucina-
tions is almost too enjoyably written to
be considered a monograph but has a
remarkable density and variety of infor-
mation. I have been involved in halluci-
nation research for a dozen years, and I
learned something new in every chapter.
Still, there is no effort to be encyclopedic,
and so it is interesting to consider Sacks
choices on what to include and what to
elide. In Sacks early work, there was a
strong emphasis on elementary hallucina-
tions, and Sacks collaborated on some of
the first neural simulations of elementary
hallucinations. Little of this pioneering
work is discussed in the new book; a major
focus instead is on complex hallucina-
tions involving faces, music, illegible text,
unplayable musical scores, and autoscopy
(Doppelganger). The chapters on the hal-
lucinations accompanying narcolepsy,
sleep paralysis, and other sleep disorders
are chilling. The exploration of the relation-
ships between hallucinations, filling-in phe-
nomena, and phantom limb disorders is
fascinating and contains remarkable obser-
vations. Recently, there has been much
work on the neural correlates of elementary
hallucinations (see Billock and Tsou3 for
a review), and a fuller understanding is
starting to emerge. So perhaps it is useful
that Sacks puts most of his emphasis on
the less understood complex hallucinations.
But if I had been as prescient on elemen-
tary hallucinations as Sacks, I dont think
I could have resisted taking a victory lap.
Sacks is made of sterner stuff, and a good
reward for his fortitude would be a serious
revival of scholarly interest in these fasci-
nating phenomena.
For vision researchers, both basic and
clinical, I would nominate Sacks discus-
sions of unreadable text for further
attention. Other researchers have pointed
out how hallucinationsVespecially hallu-
cinations in blind or peripheral fieldsV
seem unusually high in contrast and detail
and can either sharpen unexpectedly with
accommodation and eye movements or
be abolished by them. Sacks agrees that
many hallucinations seem crisp in contrast
and implausibly fine in detail, and yet
hallucinated letters are often unreadable,
and when attention is fixed on them, they
seem rune-like. Elsewhere, Sacks distin-
guishes between realistic-looking halluci-
natory faces and grotesque neurological
Optometry and Vision Science, Vol. 90, No. 4, April 2013
Copyright American Academy of Optometry. Unauthorized reproduction of this article is prohibited.
faces formed by activation of primitive
face-detecting mechanisms. Rune-like let-
ters may be a text analog of neurological
faces, but Im reminded of letter distor-
tions in amblyopia and the prosaic percep-
tion of high-contrast but unreadable text in
peripheral vision. Several lines of research
on deblurring and on the paradoxical
effects of reducing contrast in blur per-
ception suggest a high spatial frequency
extrapolation in spatial vision. Rune-like
shapes are a plausible outcome of extrap-
olating the spatial frequency content of
text, absent a rule for extrapolating the
corresponding phase information. With a
little image processing, transcribed unread-
able hallucinatory text may be decodable.
Whether anyoneVeven the patientsV
would want to read those hallucinatory
ramblings is a separate question.
REFERENCES
1. Sacks O. Migraine, 3rd ed. London, UK:
Picador; 1995.
2. Sacks O. The Minds Eye. New York, NY:
Knopf; 2010.
3. Billock VA, Tsou BH. Elementary visual
hallucinations and their relationships to neu-
ral pattern-forming mechanisms. Psychol Bull
2012;138:744Y74.
Vincent A. Billock
Dayton, Ohio
Surgical Anatomy of the Ocular
Adnexa, David R. Jordan, Louise
Mawn, Richard L. Anderson.
for the orbital surgeon in training, it is the
Oxford: Oxford University Press; 2012.
$175.00.
Book Review e125
This is the second edition of this
monograph, the ninth of 18 thus far in
this series sponsored by the American
Academy of Ophthalmology and edited
by Dr. Richard Parrish. The first edition
of this monograph traces its origins to
a dissection manual for ophthalmology
residents created by Gardner Watson, MD,
from his copious dissection notes compiled
throughout his career at the University
of Ottawa. The lead author, ophthalmic
plastic surgeon David R. Jordan, MD,
also from the University of Ottawa, is the
link to this lineage. This is not immedi-
ately apparent however because none
of the academic affiliations of the three
orbital and oculoplastic surgeons who
authored the monograph are listed.
The amply referenced text of about
200 pages is laid out in logical chapters,
covering scalp and eyelids, orbital bones
and fascial compartments, extraocular
muscles, innervation, vascular and lym-
phatic supplies, and the nasolacrimal
system. This text is illustrated with photo-
graphs of cadaveric dissections completed
by ophthalmology residents at Ottawa
and the intraoperative dissections of the
author(s). The text benefits as well from
the artistic hand of illustrator Tim Hengst
whose work is elegantly on display.
The chapters are well organized, edited
in a single voice, and the text is written
simultaneously at two levels. It is detailed
enough to serve as a source for the oph-
thalmic plastics fellow if read verbatim
but can be an equally valuable introduc-
tion to the anatomy of lids, orbit, and
nasolacrimal system for the ophthalmol-
ogy resident, optometry resident, or fourth
year optometry student when read selec-
tively. The basic text is amplified with
numerous vignettes on clinical application
that offer the reader the answer to the
perennially asked question why do I need
to know this? Some unconventional
nomenclature used for anatomical struc-
tures departs significantly from that used
in standard anatomy texts (e.g., styloid
canal substituted for the facial canal and
stylomastoid foramen), but unlike novice
medical and optometry students, the
intended audience will be able to figure
these out. If there is a significant limitation
to this text as a contemporary companion
surprising absence of even a single com-
puted tomography or magnetic resonance