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Autoenucleation of a Blind Eye

2001; Lippincott Williams & Wilkins; Volume: 21; Issue: 1 Linguagem: Inglês

10.1097/00041327-200103000-00008

1536-5166

Jason S. Dilly, Richard K. Imes,

Child Abuse and Related Trauma

Autoenucleation has been reported sporadically in ophthalmic and psychiatric literature. Individuals who attempt to blind themselves are usually psychotic and often have a history of substance abuse. Sexual and religious delusions are common. All previous reports of autoenucleation have, to our knowledge, involved sighted eyes. We report the case of a man who digitally removed his blind OS, resulting in complete temporal hemianopia in his remaining eye from chiasmal injury. CASE REPORT A 54-year-old man with a medical history of paranoid schizophrenia was found sitting in a chair with an intact globe lying on the floor next to him. His hands were blood soaked, his OS lids were swollen, and he was bleeding from a left lower eyelid laceration. In the emergency room, the orbit was lavaged with antibiotic solution, the lower eyelid laceration was repaired, and a pressure dressing was applied. Examination of the patient's OD revealed a complete temporal hemianopia. He was admitted to the hospital and started on intravenous antibiotics and haloperidol. The patient said his eye was "evil and had to come out." He had stopped taking his psychiatric medications several weeks before removing the eye. Nine years before this episode, he had attempted to remove this eye with his fingers, causing a scleral rupture, retinal detachment, and dislocated lens. The eye was blind thereafter. Gross examination of the globe showed attached, but torn, extraocular muscles and an attached segment of optic nerve measuring 59 mm in length (Fig. 1). Histopathologic examination of the globe and nerve showed retinal detachment, dislocated lens, and complete atrophy of the optic nerve. There was no evidence of chronic intraocular inflammation, glaucomatous cupping of the disc, or rubeosis of the iris. Magnetic resonance imaging showed absence of the left globe, left optic nerve, and left half of the optic chiasm (Fig. 2).FIG. 1.: Enucleated left globe with attached optic nerve segment measuring 59 mm.FIG. 2.: T1-weighted coronal MRI revealing complete absence of the left half of the chiasm after autoenucleation.DISCUSSION In 1984, Krauss et al. (1) reported a case of autoenucleation and reviewed the medical literature. They found previous reports of 19 cases of bilateral autoenucleation and 31 cases of unilateral autoenucleation. The point at which the optic nerve was severed was reported in 18 eyes. In two cases, the nerve was severed at or near the globe. In 10 cases, the nerve was severed between 15 mm and 30 mm posterior to the globe. In six cases, the nerve was severed at or near the chiasm. In 7 of 31 cases of unilateral autoenucleation, a temporal hemianopia was found in the remaining eye. In 1996, Arkin et al. (2) reported the case of a 25-year-old man who enucleated his OS with his fingers, removing the globe and 46 mm of attached optic nerve. An incomplete temporal hemianopia was recorded OD. Magnetic resonance imaging showed absence of the left optic nerve and asymmetry of the anterior chiasm. Our case showed absence of the left half of the chiasm and a complete temporal hemianopia OD. Sin, guilt, and atonement are common themes in cases of autoenucleation. Many patients are religiously preoccupied and refer to the bible verse St. Matthew 5:29, which says: "And if thy right eye offend thee, pluck it out, and cast it from thee: for it is profitable for thee that one of thy members should perish, and not that thy whole body should be cast into hell." Ferenczi (3) interprets autoenucleation as self-castration. One of two patients reported by MacLean and Robertson (4) in 1976 removed his OS with his fingers after finding no suitable instrument to remove his genitalia. In 1976, Wolff, Wright, and Walsh (5) described a 24-year-old man who attempted to remove his OS after attempting to sever his penis. Menninger (6) suggests that autoenucleation is focal suicide; however, we would not characterize our patient's removal of his already blind or "dead" eye as focal suicide. Our case demonstrates that vision is not essential to provoke a psychotic patient to remove an eye.