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Introduction Some persons with Charles Bonnet syndrome (CBS) suffer significant anxiety because of their visual hallucinations, while others do not. The aim of the study presented here was to compare levels of anxiety in persons with low vision with and without CBS. Methods This retrospective study compared the level of anxiety in 31 persons with CBS and 26 persons without CBS. These participants were recruited voluntarily from senior centers, a low vision support group, and an ophthalmology practice in October and November 2010. All were administered surveys to measure cognitive function (TICS: Telephone Interview for Cognitive Status), anxiety (STAI: State and Trait Anxiety Inventory), and general health (GHQ: General Health Questionnaire). The responses of the two groups were compared. Results The participants with CBS exhibited higher levels of anxiety than did those without CBS on both the STAI and GHQ surveys, but this difference did not reach statistical significance. The proportion of participants who were pharmacologically treated for anxiety was four times higher in the CBS cohort than in the cohort without CBS: CBS: 36% (11 of 31), those without CBS: 9% (2 of 22), p value = .03. The participants with CBS who took medication for anxiety scored higher on the STAI and GHQ than did those without CBS, but these differences did not reach statistical significance. Discussion The findings indicate that persons with CBS have higher levels of anxiety than do those without CBS. The highest levels of anxiety occurred in the participants with CBS who were being treated for anxiety with medications. Although the findings did not reach statistical significance, they suggest that anxiety is an important consideration when treating individuals with CBS. Implications for practitioners Persons with CBS who have difficulty tolerating visual hallucinations may benefit from interventions that are directed at managing anxiety, such as counseling, visual rehabilitation, and pharmacological treatment.

Central scotomas--areas of the nonseeing retina within the central 20 degrees of the visual field--are present in approximately 90% of vision rehabilitation patients (Fletcher & Schuchard, 1997). They vary in size and shape and can be small or large, symmetrical or asymmetrical, round or irregularly shaped. Most central scotomas border fixation on one side and can be overcome with magnification and sometimes eccentric viewing. However, these strategies seldom suffice in the case of ring scotomas (see Figure 1), which border three or four sides of fixation and have been present in 20%-47.5% of patients with eye conditions that affect central vision (Fletcher & Schuchard, 1997; Messias et al., 2007; Mogk, 2009). Patients with ring scotomas generally have near-normal acuity (Maguire & Vine, 1986; Moil et al., 2001; Rotenstreich, Fishman, & Anderson, 2003), which does not reflect their functional impairment in reading and activities of daily living (Fletcher & Schuchard, 1997; Sarks, Sarks, & Killingsworth, 1988; Sunness et al., 1999; Sunness, Rubin, Zuckerbrod, & Applegate, 2008). They display a characteristic slow-fast-slow reading pattern when performing tests such as the MNREAD acuity chart (Legge, Ross, Luebker, & LaMay, 1989; Sunness, 2008). They read the largest print slowly, speed up with the middle print sizes as more letters fit within the central island of vision, and then slow again when the print drops below the size they can discern (Fletcher & Schuchard, 2006; Fletcher, Schuchard, Walker, & Raskauskas, 2008). Most patients with ring scotomas fixate centrally even for targets that are larger than the central island (Messias et al., 2007; Mori et al, 2001), possibly because reorganization of cortical visual processing only occurs in the absence of foveal vision (Baker, Dilks, Peli, & Kanwisher, 2008). Three principles characterize the approach to intervention for patients with fovealsparing scotomas: education about the scotoma, supporting the use of the limited central vision, and maximizing the potential to use the peripheral retina. AWARENESS OF THE SCOTOMA The most essential issue for successful intervention for ring scotomas is that both the clinician and the patient are aware of the visual pattern and its clinical significance. Ring scotomas can be confusing and nonsensical to patients. Training may include increasing awareness of the difficulty of reading large print and of the negative impact of substantial magnification that causes the target to fall on the scotomatous area. Education about the nature of the ring scotoma can prepare patients to learn effective reading strategies and engage in vision rehabilitation. Families and caregivers may think that the patient's description of his or her vision seems illogical, leading to distrust and doubt about the patient's visual function and performance of activities. Education can avoid such misunderstandings (Cimarolli & Boerner, 2005) and thus support optimal functioning by improving the patient's social environment. One of the most concrete methods for successful education is providing a visual image of the ring scotoma with either a Scanning Laser Ophthalmoscope (SLO; SLO-101, Rodenstock, Dusseldorf, Germany) or California Central Visual Field Test (CCVFT; Mattingly, California), defining the scotoma in lay terms (for example, a doughnut-shaped blind spot), and then discussing precisely how the patient's scores on reading acuity tests changed with the print size. [FIGURE 1 OMITTED] USING THE CENTRAL ISLAND OF VISION The second step is to evaluate and support the use of the central island when it is functional. Practitioners need to determine the size, visual acuity, and contrast sensitivity of the seeing central area, the extent of the surrounding scotoma, and the nature of the patient's habitual fixation. Does the patient consistently fixate centrally or shift to eccentric fixation when viewing larger images? …

Vision rehabilitation is a clinical discipline in which there is a great deal of discussion with patients--reviewing patients' goals; educating patients about their ocular condition; outlining rehabilitation options; and often conveying "bad news," such as the assessment that a patient can no longer drive or that it is anticipated that a patient's vision will never improve. This article reviews two published models of physician-patient communication and addresses how each may apply to health care professionals in vision rehabilitation who communicate with patients, such as discussing the need to stop driving with patients who have age-related macular degeneration (AMD). Communication with patients is a core clinical skill for all health care professionals that can be evaluated, taught, and improved. Medical schools historically taught this skill informally and referred to physicians as having or not having a "good bedside manner." Today, more emphasis is placed on communication as a teachable skill in the health care setting, with a shift toward communication skills being more explicitly taught and evaluated. In the United States, the Accreditation Council for Graduate Medical Education requires that "residents must be able to demonstrate interpersonal and communication skills that result in effective information exchange and teaming with patients, their patients' families, and professional associates" (Hutul, Carpenter, Tarpley, & Lomis, 2006, p. 401). One can consider how clinicians communicate with patients who have AMD by considering how one would approach a discussion in the following hypothetical scenario: Mr. B is a spry 80 year old who lives alone. He was diagnosed with AMD three years ago and has had photodynamic treatment in one eye and antivascular endothelial growth factor intravitreal treatment to his left eye. Mr. B's acuity is now 20/100 OD and 20/200 OS. His contrast sensitivity is markedly reduced, and he has large scotomas in the left eye and scotomas encircling the central retina in the right eye. His wife recently died, and he moved to a neighboring city to be closer to his two daughters. Mr. B drives only during the day. He reported that he is depressed, having fallen recently and experiencing the symptom of seeing "people and faces" that he knows are not there. He set his car keys on the desk beside him when the interview started and cried twice during the interview. How does a clinician approach a patient who needs to be told that he cannot continue to drive? How does a clinician approach a patient who begins to cry during the interview? This scenario presents many issues for a vision rehabilitation clinician to discuss with Mr. B. THE SPIKES STRATEGY Robert Buchman is an oncologist who wrote both a text, How to Break Bad News: A Guide for Health Care Professionals (Buchman, 1992), and an article entitled, "Breaking Bad News: The SPIKES Strategy" (Buchman, 2005). He defined bad news as any news that is contrary to a patient's expectations. It is the patient's perception of the situation that determines how bad the news is, not the clinician's perception of the significance of the discussion. The SPIKES protocol is a strategy, not a scripted language, for approaching discussions with a patient. It recommends that health care professionals consider the sequential steps outlined by Buchman: setting, perception, invitation, knowledge, empathy, and strategy and summary. The SPIKES protocol first recommends that clinicians attend to the setting, so that significant news is discussed at a time when privacy is assured, the appropriate individuals are present, the clinician can be comfortably seated at the same level as the patient, and the clinician can be attentive and not rushed. In the second step, perception, the clinician asks before he or she tells. As Buchman (1992, p. 140) noted, "Before you break bad news to your patients, you should glean a fairly accurate picture of their perception of the medical situation--in particular, how they view the seriousness of the condition. …