When vision fails, the mind fills in: A case of Charles Bonnet syndrome in an Asian cultural context

ABSTRACT Charles Bonnet Syndrome (CBS) is characterized by vivid visual hallucinations in individuals with significant vision loss who retain cognitive clarity. While often reported in older adults with chronic ophthalmologic disease, it can also occur in younger patients following acute injury to the visual pathway. We report the case of a 33-year-old Indonesian man who developed CBS after neurosurgical resection of a pituitary macroadenoma compressing the optic chiasm. Postoperatively, he experienced agitation and visual hallucinations initially attributed to postoperative delirium. Although delirium resolved, the hallucinations persisted with preserved insight, leading to a diagnosis of CBS. Cultural interpretation played a central role: the patient and his family understood the visions as spiritual phenomena, reinforced by a local shaman, which delayed acceptance of a medical explanation. Management involved psychoeducation delivered in a culturally sensitive manner, low-dose quetiapine, and ongoing follow-up. Hallucinations gradually diminished and resolved within 1 month. This case underscores the diagnostic challenge of CBS in the postoperative setting, especially when cultural beliefs shape symptom interpretation. Clinicians practicing in culturally contextualized environments should integrate respectful engagement with cultural narratives into their diagnostic and therapeutic approach to improve recognition, treatment adherence, and patient outcomes.