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BRIEF COMMUNICATION
Year : 2017  |  Volume : 5  |  Issue : 3  |  Page : 137-139

Attempted autoenucleation: Was not a Greek tragedy!


1 Department of Ophthalmology, Kasturba Medical College, Manipal University, Mangaluru, Karnataka, India
2 Department of Cornea, Aravind Eye Hospitals, Madurai, Tamil Nadu, India

Date of Web Publication11-Oct-2017

Correspondence Address:
Madhurima K Nayak
Department of Ophthalmology, Kasturba Medical College, Manipal University, Mangaluru, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcor.jcor_106_16

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  Abstract 

Autoenucleation, also known as oedipism, is one of the most horrifying forms of self-mutilation frequently reported in literature. This is a case report of a 28-year-old schizophrenic man who autoenucleated his right eye. On examination, globe was luxated, his conjunctiva was lacerated superiorly with Tenon's prolapse, and he had a subconjunctival hemorrhage. Ocular movements were restricted in all positions of gaze. The eye could not be pushed back under general anesthesia. A lateral canthotomy was performed and the lids were sutured along the gray line after forcibly pushing the eye into the orbit. The patient was given intravenous antibiotics and steroids. Antipsychotic medications were restarted. After 1 month, the patient again tried to self-enucleate and was brought to the hospital. The globe was in situ with almost normal ocular movements. This report emphasizes the need to salvage the eye, even in worst of the cases.

Keywords: Enucleation, lateral canthotomy, lateral rectus, medial rectus, oedipism


How to cite this article:
Kamath GM, Nayak RR, Nayak MK, Dudeja L. Attempted autoenucleation: Was not a Greek tragedy!. J Clin Ophthalmol Res 2017;5:137-9

How to cite this URL:
Kamath GM, Nayak RR, Nayak MK, Dudeja L. Attempted autoenucleation: Was not a Greek tragedy!. J Clin Ophthalmol Res [serial online] 2017 [cited 2022 Jul 4];5:137-9. Available from: https://www.jcor.in/text.asp?2017/5/3/137/216427



Self-mutilation is a deliberate nonsuicidal destruction of one's own body tissue, reflecting a borderline mental behavior.[1] The probable reason for such behavior is temporary relief from feelings of depersonalization, guilt, rejection, and boredom as well as hallucinations, sexual preoccupations, and chaotic thoughts.[1] Examples of self-mutilation are eye enucleation, castration, penectomy, head banging, and trichotillomania. Autoenucleation is also called oedipism and is derived from the story of Oedipus who enucleated both his eyes to punish himself for killing his father and marrying his mother. It was first described by Blonel in 1906.[2] It can result from bipolar mania, substance-induced psychosis, obsessive–compulsive neurosis, or posttraumatic stress disorder. We report a case of a 28-year-old man with self-inflicted injury to the right eye who was treated with exploration and globe repositioning.


  Case Report Top


A 28-year-old man, a known case of schizophrenia, had stopped medications for 4 days following which there was worsening of symptoms. Alleged of assaulting an elderly man, our patient was imprisoned. During his imprisonment, he attempted to pull out his right eye and inflicted superficial injures over his body. He was then brought to the hospital. On examination, the right globe was luxated [Figure 1] and [Figure 2]. Visual acuity was counting fingers at 3 meter in the right eye and 20/30 in the left eye. Conjunctiva was congested and showed a laceration with subconjunctival hemorrhage at 7–3 o'clock position. Superior, lateral, and medial recti insertions were severed. Ocular movements were absent in all directions of gaze. Cornea was hazy and pupil was 4 mm round regular and nonreactive. Fundus could not be visualized. Left eye was normal. We attempted a confrontation test and it was normal in the left eye; however, we could not elicit a reliable response in the luxated eye. After consulting a psychiatrist, antipsychotic medications were restarted. The eye was explored under general anesthesia. On exploration, sub-Tenon's necrosis was noted. It was not possible to reposition the globe; hence, reinsertion of muscles was abandoned and lateral canthotomy had to be done [Figure 3]. The necrotic tissue was excised after which the globe was pushed back and lids were forcibly closed over the globe using intermittent 6-0 ethilon sutures through gray line [Figure 3]. Postoperatively, the patient was treated with topical moxifloxacin and intravenous cefotaxime 1 g thrice a day along with intravenous methylprednisolone 1 g in four divided doses in normal saline for 3 days. However, the patient had to be shifted back to prison due to legal issues. During this time, the patient was on irregular medication leading to worsening of symptoms and was brought to us again after 20 days, after the patient had tried to pull out the right eye again. On examination, it was found that the sutures were absent and the lids were open normally. Vision was counting fingers at 1 meter, globe was in situ, and ocular movements had recovered with limitation of elevation and abduction [Figure 4]. Cornea was hazy with a semicircular paracentral leukomatous opacity noted at 5 o'clock position; pupil was 4 mm round regular and sluggishly reactive. The patient remained the same for 2 months and later was lost to follow-up.
Figure 1: Luxated right globe

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Figure 2: Lateral view of luxated right globe

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Figure 3: Lateral canthotomy being performed and lids being sutured

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Figure 4: Postoperative: Globe in situ and almost normal extraocular movements

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  Discussion Top


Most cases of autoenucleation have been reported with psychotic illnesses, most common among them being schizophrenia. Autoenucleation can result from bipolar mania, substance-induced psychosis, obsessive–compulsive neurosis, posttraumatic stress disorder, and major depressive disorder. It can be seen in epileptic patients as well as in postictal confusion state.[3] Autoenucleation has also been reported due to drug-induced psychosis following the use of Lysergic acid diethylamide (LSD)[4] and amphetamine.[5] Patients with frontal lobe encephalomalacia have also been reported with autoenucleation.[6] It is commonly associated with religion and sexual delusions.[7],[8]

Acute medical management by an ophthalmologist should be done to examine the wound for any active bleed. As the ophthalmic artery lies inferior and lateral to the optic nerve, tearing of the optic nerve can shear ophthalmic artery resulting in subarachnoid hemorrhage. A thorough examination of the contralateral eye is needed including field examination to rule out contralateral hemianopia from chiasmal injury.[9],[10] However, automated visual field charting could not be performed in this patient as he was aggressive and not cooperating for further examination. Treatment mainly involves irrigation of the wound with topical antibiotics and surgical repair. A course of intravenous corticosteroids leads to improvement in visual acuity and visual fields.[4],[10] Patients who had enucleated their one eye had increased risk of enucleating the other eye. Hence, aggressive treatment of the underlying illness with close observation of the patient is needed to prevent further damage.

Most of these patients land up with enucleation of eyes.[4] However, our patient had laceration of ocular muscles except for inferior rectus with optic nerve contusion. The fact that the patient recovered with some movements indicate that muscles must have regained insertion following repositioning of the eye and held back by tarsorrhaphy sutures. This is akin to muscle disinsertion and hangback procedure. The hangback procedure is mainly indicated for resurgeries and myopic eyes where the sclera is thin and there is fear of perforation. Here, the tendon and its capsule are disinserted en bloc. The muscle and its capsule recoil according to the limit permitted by the intermuscular septum and the tendon reattaches to the sclera.[11] On the other hand, dissection and manipulation of muscle would have damaged the fascial connections and blood vessels badly and might have led to a different outcome. Although autoenucleation has been more commonly reported in the West,[12] this is a rare case report on how repositioning of eye in the worst of the situations of autoenucleation can salvage the eye to some extent and is worthwhile trying.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Favazza AR. The coming of age of self-mutilation. J Nerv Ment Dis 1998;186:259-68.  Back to cited text no. 1
    
2.
Khan JA, Buescher L, Ide CH, Pettigrove B. Medical management of self-enucleation. Arch Ophthalmol 1985;103:386-9.  Back to cited text no. 2
    
3.
Patil BB, James N. Bilateral self-enucleation of eyes. Eye (Lond) 2004;18:431-2.  Back to cited text no. 3
    
4.
Wolff RS, Wright MM, Walsh AW. Attempted autoenucleation. Am J Ophthalmol 1996;121:726-8.  Back to cited text no. 4
    
5.
Omidvar T, Sharifi V. Amphetamine psychosis and eye autoenucleation. Aust N Z J Psychiatry 2012;46:71.  Back to cited text no. 5
    
6.
Waldfogel S, Field HL, Wu L. Oedipism in a patient with frontal lobe encephalomalacia. Brain Inj 1994;8:377-81.  Back to cited text no. 6
    
7.
Patton N. Self-inflicted eye injuries: A review. Eye (Lond) 2004;18:867-72.  Back to cited text no. 7
    
8.
Witherspoon CD, Feist FW, Morris RE, Feist RM. Ocular self-mutilation. Ann Ophthalmol 1989;21:255-7, 259.  Back to cited text no. 8
    
9.
Tabatabaei SA, Soleimani M, Khodabandeh A. A case of autoenucleation associated with a contralateral field defect. Orbit 2011;30:165-8.  Back to cited text no. 9
    
10.
Parmar B, Edmunds B, Plant G. Traumatic enucleation with chiasmal damage: Magnetic resonance image findings and response to steroids. Br J Ophthalmol 2002;86:1317-8.  Back to cited text no. 10
    
11.
Rosenbaum AL, Santiago AP. Slipped disinserted or severed and lost muscles in clinical strabismus management. Clinical Strabismus Management Principles and Surgical Techniques. Ch. 40. Pennsylvania: W.B. Saunders Company; 1999. p. 529-38.  Back to cited text no. 11
    
12.
Shiwach RS. Autoenucleation – A culture-specific phenomenon: A case series and review. Compr Psychiatry 1998;39:318-22.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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