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schizophrenia and other different types of psychosis are the most frequent disorders , which may be accompanied by visual hallucinations ( 1 ) .
visual hallucinations have been reported in 16% to 72% of patients with schizophrenia or schizoaffective disorders and it is one of the diagnostic criteria of schizophrenia ( 2 - 4 ) and its presence is related to the severity of illness ( 5 ) . nowadays
ant dopaminergic antipsychotics and serotonin - dopamine antagonists are the only therapeutic choices and recently anti - acetyl cholinesterase agents have been suggested ( 6 ) . despite all these treatments , patients may have refractory hallucinations .
transcranial magnetic stimulation ( rtms ) is a technique using magnetic field for stimulation of brain . in july 2011 , the fda introduced rtms system as class ii ( special controls ) in the federal register by the phrase of :  in order to provide a reasonable assurance of safety and effectiveness of these devices  ( 7 )
. rtms could be a promising therapeutic method for visual hallucinations , due to the theories which suggest cortical hyperactivity as a probable mechanism for unreal visual sensations ( 8 - 10 ) .
firstly , a 52-year - old patient who lost his vision partially follows a myocardial infarction .
( 11 ) at harvard medical school reported immediate remission lasting for a week following stimulating the visual cortex ( 2 cm above the patient s inion , 1 hz , 10 minutes ) , which had not been induced by sham stimuli given previously .
the researchers suggested that probably the reduction of increased cortical excitability is the mechanism of responsiveness .
the second case was a 32-year - old patient with refractory paranoid schizophrenia affected by complex hallucinations involving auditory , visual and olfactory systems .
( 8) in france conducted a functional neuroimaging with electrical source reconstruction and considered occipito - temporal sulcus as the target of stimulation . in 2009 , the team reported that 10 sessions of low frequency ( 1 hz ) , suppressed hallucinations significantly leaving minimum residues including tinnitus and phosphine . the third case was a 50-year - old woman experiencing visual sensations including changing colors and lights since loss of her vision bilaterally , suggestive of the charles bonnet syndrome .
functional mri showed hyperactivity in extra - striate visual area v5/mt and the fusiform gyrus ( v4 ) related to visual sensations , where meppelink et al .
the premier sham stimulation on v5 could not make any change , but later session of real rtms by frequency of 1 hz at v5/mt and v1 led to almost complete suppression of a part of hallucinations for two days .
the patient was a 29-year - old woman who had received psychiatric treatments since the age of 19 , following talking to herself , grandiosity and persecutory delusions , irritability and aggressiveness .
the diagnosis of schizophrenia confirmed by scid - i interview based of dsm - iv - tr , when the visual hallucinations commenced without symptoms of any mood disorder .
electroencephalography and brain magnetic resonance imaging did not reveal any abnormality , as well as laboratory results .
the content of hallucinations was strange persons with threatening facial expressions . at the time of introduction to neurotherapy unit of rasoul - akram hospital in december 2013
, she took 400 milligram of clozapine per day , but she still had refractory visual hallucinations .
she had insight that these persons are not real , but they still made her anxious .
she had experienced a wide variety of classical and atypical agents with full therapeutic dosage and for enough duration that just resulted in few periods of transient partial remission .
the team decided to perform inhibitory stimulation on her brain hoping to diminish hallucinations .  
the patient received 12 sessions of rtms , 5 times per week ( 1 hz frequency , for 20 minutes , 100% of the motor threshold , magventure ; mag machine pro 100 ) on o2 , continuing the medications as before . before the fifth session , she reported decrease in the frequency of hallucinations as low as 5 , considering 10 for description of the pretreatment situation using analog visual scale . at the end of therapeutic course , she reported that the frequency and severity limited to 2.5 .
her mother and her psychiatrist also confirmed improvement in her symptoms , mood and irritability .
she did not report any immediate or delayed adverse effect . at follow - up interview after three months
, she was still satisfied with the outcomes and hallucinations were limited to rare appearances of humanoid features .
this result supports our hypothesis about effectiveness of rtms in treatment of visual hallucinations and is compatible with the cortical hyperexcitability theory about its pathogenesis . as it can be concluded of the dr jardri s case report
, functional neuroimaging may be beneficial in localizing a specific target for stimulation and may prevent wasting time and cost on targets , which are less possible to be involved in the pathogenesis ( 8) . although this combination seems to be efficacious , it may not be possible everywhere .
existing evidence suggests in the absence of functional imaging that occipital area is a promising target , because of probable role of the occipital cortex in the chain of pathogenesis of visual hallucination ( 13 ) .
rtms can be investigated as a method for the treatment of visual hallucinations , especially for refractory types .
we suggest basic studies by functional imaging on visual hallucination ( both in refractory and responsive cases ) .
priority of basic localizing studies may prevent bias in the results of studies to ineffectiveness due to targeting irrelevant points , and leads to acceleration in achievement of a consensus on efficiency of rtms on visual hallucinations .
a 29-year - old woman with schizophrenia introduced for application of repetitive transcranial magnetic stimulation for refractory visual hallucinations . following inhibitory rtms on visual cortex 
 she reported significant reduction in severity and simplification of complexity of hallucinations , which lasted for three months . 
 rtms can be considered as a possibly potent treatment for visual hallucinations .