Abstract
Purpose of Review
Visual snow (VS) involves visualization of innumerable dots throughout the visual field, sometimes resembling “TV static.” Patients who experience this symptom may also have additional visual symptoms (e.g., photophobia, palinopsia, floaters, and nyctalopia) with a pattern now defined as visual snow syndrome (VSS). This manuscript describes both VS and VSS in detail and provides an updated review on the clinical features, pathophysiology, and optimal management strategies for these symptoms.
Recent Findings
VS/VSS may be primary or secondary to a variety of etiologies, including ophthalmologic or brain disorders, systemic disease, and medication/hallucinogen exposure. Evaluation involves ruling out secondary causes and mimics of VS. Increasing evidence suggests that VSS is a widespread process extending beyond the visual system. Pathophysiology may involve cortical hyperexcitability or dysfunctional connectivity of thalamocortical or attention/salience networks.
Summary
VSS is typically a benign, non-progressive syndrome and can be managed with non-medicine strategies. Though no medication provides complete relief, some may provide partial improvement in severity of VS.
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Puledda F, Schankin C, Digre K, Goadsby PJ. Visual snow syndrome: what we know so far. Curr Opin Neurol. 2018;31:52–8.
Metzler AI, Robertson CE. Visual snow syndrome: proposed criteria, clinical implications, and pathophysiology. Curr Neurol Neurosci Rep. 2018;18:52.
Schankin CJ, Puledda F, Goadsby PJ. Visual snow syndrome: is it normal or a disorder - and what to do with patients? Eur J Neurol. 2020;27:2393–5.
•• Puledda F, Schankin C, Goadsby PJ. Visual snow syndrome: a clinical and phenotypical description of 1,100 cases. Neurology. 2020;94:e564-e574. Large survey of VS and VSS cases, reviewing clinical characteristics and some secondary causes.
Liu GT, Schatz NJ, Galetta SL, Volpe NJ, Skobieranda F, Kosmorsky GS. Persistent positive visual phenomena in migraine. Neurology. 1995;45:664–8.
Evans RW, Aurora SK. Migraine with persistent visual aura. Headache. 2012;52:494–501.
•• Schankin CJ, Maniyar FH, Digre KB, Goadsby PJ. ‘Visual snow’ - a disorder distinct from persistent migraine aura. Brain. 2014;137:1419–1428. Original paper outlining many of the positive visual symptoms associated with VSS, and the original proposed criteria for VSS.
Headache Classification Committee of the International Headache Society (IHS) The International Classification of Headache Disorders, 3rd edition. Cephalalgia. 2018;38:1–211.
•• Mehta DG, Garza I, Robertson CE. Two hundred and forty-eight cases of visual snow: a review of potential inciting events and contributing comorbidities. Cephalalgia. 2021;41:1015–1026. Extensive review of secondary causes of VS in a large cohort.
Scutelnic A, Slavova N, Klein A, et al. Symptomatic visual snow in acute ischemic stroke: a case series. Headache. 2023;63:173–6.
Hodak J, Fischer U, Bassetti CLA, Schankin CJ. Episodic visual snow associated with migraine attacks. JAMA Neurol. 2019.
Samaha J, Gosseries O, Postle BR. Distinct oscillatory frequencies underlie excitability of human occipital and parietal cortex. J Neurosci. 2017;37:2824–33.
Kolmel HW. Complex visual hallucinations in the hemianopic field. J Neurol Neurosurg Psychiatry. 1985;48:29–38.
Marshall CR. Entoptic phenomena associated with the retina. Br J Ophthalmol. 1935;19:177–201.
Bowen SF Jr. Retinal entoptic phenomena. Some diagnostic use Arch Ophthalmol. 1963;69:551–5.
Kondziella D, Olsen MH, Dreier JP. Prevalence of visual snow syndrome in the UK. Eur J Neurol. 2020.
Graber M, Scutelnic A, Klein A, Puledda F, Goadsby PJ, Schankin CJ. Natural course of visual snow syndrome: a long-term follow-up study. Brain Commun. 2022;4:fcac230.
Schankin CJ, Maniyar FH, Sprenger T, Chou DE, Eller M, Goadsby PJ. The relation between migraine, typical migraine aura and “visual snow.” Headache. 2014;54:957–66.
van Dongen RM, Waaijer LC, Onderwater GLJ, Ferrari MD, Terwindt GM. Treatment effects and comorbid diseases in 58 patients with visual snow. Neurology. 2019;93:e398–403.
Solly EJ, Clough M, Foletta P, White OB, Fielding J. The psychiatric symptomology of visual snow syndrome. Front Neurol. 2021;12: 703006.
Yoo YJ, Yang HK, Choi JY, Kim JS, Hwang JM. Neuro-ophthalmologic findings in visual snow syndrome. J Clin Neurol. 2020;16:646–52.
Puledda F, Ffytche D, O’Daly O, Goadsby PJ. Imaging the visual network in the migraine spectrum. Front Neurol. 2019;10:1325.
Bittner AK, Diener-West M, Dagnelie G. Characteristics and possible visual consequences of photopsias as vision measures are reduced in retinitis pigmentosa. Invest Ophthalmol Vis Sci. 2011;52:6370–6.
Patel RC, Vitale AT, Creel DJ, Digre KB. Not all that flickers is snow. J Neuroophthalmol. 2020.
Hang C, Yan Y. Case report: Visual snow as the presenting symptom in multiple evanescent white dot syndrome. Two case reports and literature review. Front Neurol 2022;13:972943.
Brown GC, Brown MM, Fischer DH. Photopsias: a key to diagnosis. Ophthalmology. 2015;122:2084–94.
Braithwaite T, Holder GE, Lee RW, Plant GT, Tufail A. Diagnostic features of the autoimmune retinopathies. Autoimmun Rev. 2014;13:534–8.
Bessero AC, Plant GT. Should ‘visual snow’ and persistence of after-images be recognised as a new visual syndrome? J Neurol Neurosurg Psychiatry. 2014;85:1057–8.
Werner RN, Gustafson JA. Case report: visual snow syndrome after repetitive mild traumatic brain injury. Optom Vis Sci. 2022;99:413–6.
Catarci T. Occipital ischaemic stroke after visual snow phenomenon - a case report. Cephalalgia. 2021;41:871–4.
Puledda F, Villar-Martinez MD, Goadsby PJ. Case report: transformation of visual snow syndrome from episodic to chronic associated with acute cerebellar infarct. Front Neurol. 2022;13: 811490.
Braceros KK, Asahi MG, Gallemore RP. Visual snow-like symptoms and posterior uveitis following COVID-19 infection. Case Rep Ophthalmol Med. 2021;2021:6668552.
Berkowitz E, River Y, Digre K, Tiosano B, Kesler A. Visual snow: a case series from Israel. Case Rep Ophthalmol. 2020;11:205–11.
Panayiotopoulos CP. Visual phenomena and headache in occipital epilepsy: a review, a systematic study and differentiation from migraine. Epileptic Disord. 1999;1:205–16.
Chen BS, Lance S, Lallu B, Anderson NE. Visual snow: not so benign. J Clin Neurosci. 2019;64:37–9.
Abraham HD. Visual phenomenology of the LSD flashback. Arch Gen Psychiatry. 1983;40:884–9.
Martinotti G, Santacroce R, Pettorruso M, et al. Hallucinogen persisting perception disorder: etiology, clinical features, and therapeutic perspectives. Brain Sci. 2018;8.
Ellison-Wright ZS, Ben. A persisting perception disorder after cannabis use. Progress Neurol Psychiatry. 2015.
A GL, Goodman C, Bor O, Lev-Ran S. Synthetic cannabis substances (SPS) use and hallucinogen persisting perception disorder (HPPD): two case reports. Isr J Psychiatry Relat Sci. 2014;51:277–280.
Eren OE, Schoberl F, Schankin CJ, Straube A. Visual snow syndrome after start of citalopram-novel insights into underlying pathophysiology. Eur J Clin Pharmacol. 2021;77:271–2.
Naguy A, Naguy C, Singh A. Probable methylphenidate-related reversible “visual snow” in a child with ADHD. Clin Neuropharmacol. 2022;45:105–6.
Choi SY, Jeong SH, Kim JS. Clomiphene citrate associated with palinopsia. J Neuroophthalmol. 2017;37:220–1.
Venkatesh R, Gujral GS, Gurav P, Tibrewal S, Mathur U. Clomiphene citrate-induced visual hallucinations: a case report. J Med Case Rep. 2017;11:60.
Yun SH, Lavin PJ, Schatz MP, Lesser RL. Topiramate-induced palinopsia: a case series and review of the literature. J Neuroophthalmol. 2015;35:148–51.
Ihde-Scholl T, Jefferson JW. Mitrazapine-associated palinopsia. J Clin Psychiatry. 2001;62:373.
Hughes MS, Lessell S. Trazodone-induced palinopsia. Arch Ophthalmol. 1990;108:399–400.
Faber RA, Benzick JM. Nafazodone-induced palinopsia. J Clin Psychopharmacol. 2000;20:275–6.
• Puledda F, Vandenbussche N, Moreno-Ajona D, Eren O, Schankin C, Goadsby PJ. Evaluation of treatment response and symptom progression in 400 patients with visual snow syndrome. Br J Ophthalmol. 2022;106:1318–1324. Survey of 400 patients with VSS, reviewing their subjective response to a variety of treatments.
Raviskanthan S, Ray JC, Mortensen PW, Lee AG. Neuroimaging in visual snow - a review of the literature. Front Ophthalmol. 2022;2.
Kondziella D. Visual snow syndrome and the emperor’s new clothes. Brain Commun. 2022;4:fcac178.
Sinclair SH, Azar-Cavanagh M, Soper KA, Tuma RF, Mayrovitz HN. Investigation of the source of the blue field entoptic phenomenon. Invest Ophthalmol Vis Sci. 1989;30:668–73.
Zaroban NJ, Kedar S, Anderson D, Vuppala AD. Analysis of retinal structure and electrophysiological function in visual snow syndrome: an exploratory case series. J Neuroophthalmol. 2023;43:227–31.
Luna S, Lai D, Harris A. Antagonistic relationship between VEP potentiation and gamma power in visual snow syndrome. Headache. 2018;58:138–44.
Yildiz FG, Turkyilmaz U, Unal-Cevik I. The clinical characteristics and neurophysiological assessments of the occipital cortex in visual snow syndrome with or without migraine. Headache. 2019;59:484–94.
McKendrick AM, Chan YM, Tien M, et al. Behavioral measures of cortical hyperexcitability assessed in people who experience visual snow. Neurology. 2017;88:1243–9.
Unal-Cevik I, Yildiz FG. Visual snow in migraine with aura: further characterization by brain imaging, electrophysiology, and treatment–case report. Headache. 2015;55:1436–41.
Bou Ghannam A, Pelak VS. Visual snow: a potential cortical hyperexcitability syndrome. Curr Treat Options Neurol. 2017;19:9.
Eren O, Rauschel V, Ruscheweyh R, Straube A, Schankin CJ. Evidence of dysfunction in the visual association cortex in visual snow syndrome. Ann Neurol. 2018;84:946–9.
Schankin CJ, Maniyar FH, Chou DE, Eller M, Sprenger T, Goadsby PJ. Structural and functional footprint of visual snow syndrome. Brain. 2020;143:1106–13.
Puledda F, Ffytche D, Lythgoe DJ, et al. Insular and occipital changes in visual snow syndrome: a BOLD fMRI and MRS study. Ann Clin Transl Neurol. 2020;7:296–306.
Aldusary N, Traber GL, Freund P, et al. Abnormal connectivity and brain structure in patients with visual snow. Front Hum Neurosci. 2020;14: 582031.
Boulloche N, Denuelle M, Payoux P, Fabre N, Trotter Y, Geraud G. Photophobia in migraine: an interictal PET study of cortical hyperexcitability and its modulation by pain. J Neurol Neurosurg Psychiatry. 2010;81:978–84.
Denuelle M, Boulloche N, Payoux P, Fabre N, Trotter Y, Geraud G. A PET study of photophobia during spontaneous migraine attacks. Neurology. 2011;76:213–8.
Puledda F, O’Daly O, Schankin C, Ffytche D, Williams SC, Goadsby PJ. Disrupted connectivity within visual, attentional and salience networks in the visual snow syndrome. Hum Brain Mapp. 2021;42:2032–44.
Seeley WW. The salience network: a neural system for perceiving and responding to homeostatic demands. J Neurosci. 2019;39:9878–82.
Klein A, Schankin CJ. Visual snow syndrome as a network disorder: a systematic review. Front Neurol. 2021;12: 724072.
Llinas R, Urbano FJ, Leznik E, Ramirez RR, van Marle HJ. Rhythmic and dysrhythmic thalamocortical dynamics: GABA systems and the edge effect. Trends Neurosci. 2005;28:325–33.
Perves D AG, Fitzpatrick D, et al. Neuroscience. 2nd Edition.: Sunderland (MA): Sinauer Associates. 2001.
Hepschke JL, Seymour RA, He W, Etchell A, Sowman PF, Fraser CL. Cortical oscillatory dysrhythmias in visual snow syndrome: a magnetoencephalography study. Brain Commun. 2022;4:fcab296.
Lauschke JL, Plant GT, Fraser CL. Visual snow: a thalamocortical dysrhythmia of the visual pathway? J Clin Neurosci. 2016;28:123–7.
Coppola G, Bracaglia M, Di Lenola D, et al. Lateral inhibition in the somatosensory cortex during and between migraine without aura attacks: correlations with thalamocortical activity and clinical features. Cephalalgia. 2016;36:568–78.
Coppola G, Parisi V, Di Lorenzo C, et al. Lateral inhibition in visual cortex of migraine patients between attacks. J Headache Pain. 2013;14:20.
Llinas RR, Ribary U, Jeanmonod D, Kronberg E, Mitra PP. Thalamocortical dysrhythmia: a neurological and neuropsychiatric syndrome characterized by magnetoencephalography. Proc Natl Acad Sci USA. 1999;96:15222–27.
Shibata M, Tsutsumi K, Iwabuchi Y, et al. [(123)I]-IMP single-photon emission computed tomography imaging in visual snow syndrome: a case series. Cephalalgia. 2020;40:1671–5.
Hepschke JL, Martin PR, Fraser CL. Short-wave sensitive (“blue”) cone activation is an aggravating factor for visual snow symptoms. Front Neurol. 2021;12: 697923.
Han MHE, Ciuffreda KJ, Rutner D. Historical, diagnostic, and chromatic treatment in visual snow syndrome: a retrospective analysis. Optom Vis Sci. 2023;100:328–33.
Ciuffreda KJ, Han ME, Tannen B, Rutner D. Visual snow syndrome: evolving neuro-optometric considerations in concussion/mild traumatic brain injury. Concussion. 2021;6:CNC89.
Tsang T, Shidlofsky C, Mora V. The efficacy of neuro-optometric visual rehabilitation therapy in patients with visual snow syndrome. Front Neurol. 2022;13: 999336.
Eren O, Schankin CJ. Insights into pathophysiology and treatment of visual snow syndrome: a systematic review. Prog Brain Res. 2020;255:311–26.
Coleman W, Sengupta S, Boisvert CJ. A case of visual snow treated with phenylephrine. Headache. 2021;61:792–3.
Gersztenkorn D, Lee AG. Palinopsia revamped: a systematic review of the literature. Surv Ophthalmol. 2015;60:1–35.
Vieira JR LR. Visual snow induced by triptans (poster presentation). 58th annual meeting of the American Headache Society. Seeing Diego, California. 2016.
Piquet AL, Khan M, Warner JEA, et al. Novel clinical features of glycine receptor antibody syndrome: a series of 17 cases. Neurol Neuroimmunol Neuroinflamm. 2019;6: e592.
Vaphiades MS, Celesia GG, Brigell MG. Positive spontaneous visual phenomena limited to the hemianopic field in lesions of central visual pathways. Neurology. 1996;47:408–17.
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Both authors prepared the main manuscript text and the table. Both authors made substantial contributions to the manuscript and revised it for intellectual content. Both authors approve the current submitted version.
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Jennifer I. Stern, MD, is a shareholder in Emmyon, a biotechnology company that has no relevance to any topic in this manuscript. Carrie E. Robertson, MD, has previously served on advisory boards for Lundbeck, Biohaven, Impel, Linpharma, and Satsuma. She has received research support from Teva, Pfizer, and Lundbeck, with funds paid to her institution. She also receives royalties as author and section editor for UpToDate.
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Stern, J.I., Robertson, C.E. Visual Snow: Updates and Narrative Review. Curr Pain Headache Rep 28, 55–63 (2024). https://doi.org/10.1007/s11916-023-01186-3
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DOI: https://doi.org/10.1007/s11916-023-01186-3