Beyond Hyperexcitability: A Review of Neural Mechanisms in Charles Bonnet Syndrome

Charles Bonnet syndrome (CBS) is characterized by complex visual hallucinations in visually impaired individuals who maintain intact cognitive function. Despite significant progress in understanding this condition, the precise neural mechanisms underlying CBS remain incompletely understood. This review synthesizes current evidence regarding the pathophysiology of CBS, with particular emphasis on emerging neurobiological models that extend beyond simple cortical hyperexcitability. Recent neuroimaging, neurophysiological and computational modeling studies suggest that CBS hallucinations may arise from complex interactions between deafferentation-induced neural plasticity, neurotransmitter imbalances and altered functional connectivity within visual processing hierarchies. The evidence increasingly points toward a model involving desynchronization between bottom-up and top-down visual processing pathways, rather than mere hyperexcitability of deafferented visual cortex. This integrated perspective has important implications for both theoretical understanding of visual perception and the development of targeted therapeutic interventions.