We describe an interesting case of illusory palinopsia following IVF treatment in a woman diagnosed as having unexplained infertility.
Estrogen plays a vital role in follicular development, ovulation, and pregnancy if conception occurs. Treatment with ART includes the use of ovulation- induction drugs like clomiphene citrate or treatment with FSH analogs or gonadotropin-releasing hormone antagonists and human chorionic gonadotropin. Palinopsias are visual disturbances characterized by persistent recurrence of a visual image after the stimulus has been withdrawn. Palinopsias are grouped into two categories: illusory palinopsias and hallucinatory palinopsias [
6]. Illusory palinopsias are caused by migraines, head trauma, prescription drugs, or hallucinogen-persisting perception disorder. The afterimages in illusory palinopsias are affected by ambient light and motion and are unformed, indistinct, or low resolution similar to that described by our patient. Hallucinatory palinopsias are due to posterior cortical lesions. An MRI of her brain did not show any neurological lesions. Migraine was considered one of the differential diagnoses in this case. However, our patient had no family or past history of migraine and her symptoms were not followed by migraine-like headache. A physician’s and a neurologist’s opinion were also sought to rule out migraine which was absent. Pre-eclampsia or eclampsia-induced visual symptoms were ruled out as our patient did not have high blood pressure or pedal edema during her pregnancy. Hence, her symptoms could be secondary to the IVF treatment. Illusory palinopsias are caused by diffuse neuronal pathology such as global alterations in neurotransmitter receptors. Yilmaz
et al. [
7] have shown different patterns of visually evoked potential latencies during different phases of the menstrual cycle. The latencies are reduced during the follicular and ovulatory phases while they are increased during the ovulatory phase of the menstrual cycle. Estrogen inhibits ɤ-aminobutyric acid synthesis, an important inhibitory neurotransmitter in the cerebral and visual cortexes and is involved in the genesis of visually evoked potentials. The inhibition of ɤ-aminobutyric acid reportedly increases the excitatory effect on the striate cortex [
8]. Thus, estrogen can directly or indirectly stimulate the visual cortex, thus triggering the development of visual hallucinations. A functional MRI (fMRI) to check for the cortical activation areas during the symptoms could have been useful. However, in our case the symptoms lasted for < 10 minutes and therefore it was practically not possible for her to undergo fMRI. Visual hallucinations following treatment with ovulation induction drugs like clomiphene citrate due to a similar pathomechanism has also been reported [
9,
10]. Keratoconus progression due to increase in estrogen levels following IVF treatment has been reported by Yuksel
et al. [
5]. Ratson
et al. [
4] reported a higher risk of developing retinal detachment following IVF treatment. In our case, we believe that the visual symptoms described were secondary to increased estrogen levels due to IVF treatment.