Pathological Changes to the Subcortical Visual System and its Relationship to Visual Hallucinations in Dementia with Lewy Bodies

  • Daniel ErskineEmail author
  • John-Paul Taylor
  • Alan Thomas
  • Daniel Collerton
  • Ian McKeith
  • Ahmad Khundakar
  • Johannes Attems
  • Christopher Morris


Recurrent complex visual hallucinations are a core clinical feature of dementia with Lewy bodies (DLB) and are typically well-formed, often consisting of figures, such as people or animals [1]. Despite the profound impact upon patients and caregivers in DLB, the aetiopathology of visual hallucinations remains largely unknown. In this article we discuss the anatomy of the human visual system, hypotheses of the genesis of visual hallucinations in DLB, and imaging and neuropathological studies that have attempted to understand visual hallucinations on a functional and anatomical basis.

The Human Visual System

Human visual input comes from the eye, where light is transduced by the photoreceptors of the retina and transmitted along the optic nerve. Retinal ganglion cells, whose axons comprise the optic nerve, transmit a neural representation of the observed visual field to the lateral geniculate nucleus (LGN) of the thalamus, the primary subcortical relay centre between the...



DE is funded by Alzheimer’s Research UK. The funder had no role in production of the manuscript or the choice of when or where to publish.


  1. 1.
    McKeith IG, Boeve BF, Dickson DW, Halliday G, Taylor JP, Weintraub D, et al. Diagnosis and management of dementia with Lewy bodies: Fourth consensus report of the DLB Consortium. Neurology 2017, 89: 88–100.CrossRefGoogle Scholar
  2. 2.
    Ungerleider LG. Two cortical visual streams. Anal Vis Behav 1982: 549–586.Google Scholar
  3. 3.
    Diederich NJ, Stebbins G, Schiltz C, Goetz CG. Are patients with Parkinson’s disease blind to blindsight? Brain 2014, 137: 1838–1849.CrossRefGoogle Scholar
  4. 4.
    Collerton D, Mosimann UP, Perry E (Eds). The Neuroscience of Visual Hallucinations. Wiley, 2015.Google Scholar
  5. 5.
    Hanoglu L, Yildiz S, Cakir T, Hanoglu T, Yulug B. FDG-PET scanning shows distributed changes in cortical activity associated with visual hallucinations in eye disease. Endocr Metab Immune Disord Drug Targets 2018.
  6. 6.
    Shine JM, Muller AJ, O’Callaghan C, Hornberger M, Halliday GM, Lewis SJ. Abnormal connectivity between the default mode and the visual system underlies the manifestation of visual hallucinations in Parkinson’s disease: a task-based fMRI study. NPJ Parkinsons Dis 2015, 1: 15003.CrossRefGoogle Scholar
  7. 7.
    Makin SM, Redman J, Mosimann UP, Dudley R, Clarke MP, Colbourn C, et al. Complex visual hallucinations and attentional performance in eye disease and dementia: a test of the Perception and Attention Deficit model. Int J Geriatr Psychiatry 2013, 28: 1232–1238.CrossRefGoogle Scholar
  8. 8.
    Erskine D, Taylor JP, Firbank MJ, Patterson L, Onofrj M, O’Brien JT, et al. Changes to the lateral geniculate nucleus in Alzheimer’s disease but not dementia with Lewy bodies. Neuropathol Appl Neurobiol 2016, 42: 366–376.CrossRefGoogle Scholar
  9. 9.
    Taylor JP, Firbank M, Barnett N, Pearce S, Livingstone A, Mosimann U, et al. Visual hallucinations in dementia with Lewy bodies: transcranial magnetic stimulation study. Br J Psychiatry 2011, 199: 492–500.CrossRefGoogle Scholar
  10. 10.
    Taylor JP, Firbank M, O’Brien JT. Visual cortical excitability in dementia with Lewy bodies. Br J Psychiatry 2016, 208: 497–498.CrossRefGoogle Scholar
  11. 11.
    Delli Pizzi S, Maruotti V, Taylor JP, Franciotti R, Caulo M, Tartaro A, et al. Relevance of subcortical visual pathways disruption to visual symptoms in dementia with Lewy bodies. Cortex 2014, 59: 12–21.CrossRefGoogle Scholar
  12. 12.
    Khundakar AA, Hanson PS, Erskine D, Lax NZ, Roscamp J, Karyka E, et al. Analysis of primary visual cortex in dementia with Lewy bodies indicates GABAergic involvement associated with recurrent complex visual hallucinations. Acta Neuropathol Commun 2016, 4: 66.CrossRefGoogle Scholar
  13. 13.
    Erskine D, Thomas AJ, Taylor JP, Savage MA, Attems J, McKeith IG, et al. Neuronal loss and α-synuclein pathology in the superior colliculus and its relationship to visual hallucinations in dementia with lewy bodies. Am J Geriatr Psychiatry 2017, 25: 595–604.CrossRefGoogle Scholar
  14. 14.
    Erskine D, Thomas AJ, Attems J, Taylor JP, McKeith IG, Morris CM, et al. Specific patterns of neuronal loss in the pulvinar nucleus in dementia with lewy bodies. Mov Disord 2017, 32: 414–422.CrossRefGoogle Scholar
  15. 15.
    Zhou H, Schafer RJ, Desimone R. Pulvinar-cortex interactions in vision and attention. Neuron 2016, 89: 209–220.CrossRefGoogle Scholar
  16. 16.
    Erskine D, Khundakar AA. Stereological approaches to dementia research using human brain tissue. J Chem Neuroanat 2016, 76(Pt B): 73–81.CrossRefGoogle Scholar
  17. 17.
    Erskine D, Ding J, Thomas AJ, Kaganovich A, Khundakar AA, Hanson PS, et al. Molecular changes in the absence of severe pathology in the pulvinar in dementia with Lewy bodies. Mov Disord 2018, 33: 982–991.CrossRefGoogle Scholar
  18. 18.
    Roodveldt C, Christodoulou J, Dobson CM. Immunological features of alpha-synuclein in Parkinson’s disease. J Cell Mol Med 2008, 12: 1820–1829.CrossRefGoogle Scholar
  19. 19.
    Surmeier DJ, Sulzer D. The pathology roadmap in Parkinson disease. Prion 2013, 7: 85–91.CrossRefGoogle Scholar
  20. 20.
    Erskine D, Patterson L, Alexandris A, Hanson PS, McKeith IG, Attems J, et al. Regional levels of physiological alpha-synuclein are directly associated with Lewy body pathology. Acta Neuropathol 2018, 135: 153–154.CrossRefGoogle Scholar

Copyright information

© Shanghai Institutes for Biological Sciences, CAS 2019

Authors and Affiliations

  • Daniel Erskine
    • 1
    Email author
  • John-Paul Taylor
    • 1
  • Alan Thomas
    • 1
  • Daniel Collerton
    • 1
    • 2
  • Ian McKeith
    • 1
  • Ahmad Khundakar
    • 3
  • Johannes Attems
    • 1
  • Christopher Morris
    • 1
  1. 1.Institute of NeuroscienceNewcastle UniversityNewcastle upon TyneUK
  2. 2.Northumberland, Tyne and Wear NHS TrustNewcastleUK
  3. 3.School of Science, Engineering and DesignTeesside UniversityMiddlesbroughUK

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