Self-inflicted enucleations: Clinical features of seven cases

Abstract

We report the clinical presentation, radiography, and management outcomes of autoenucleations (AE). Charts of 7 patients evaluated at 4 institutions with AE were reviewed. Four males and three females had a mean age of 50 years (range 26-72 years). The etiologies were psychosis secondary to underlying mental illness (6, 88%) and substance use (1, 12%), and the mechanism was largely blunt digital injury (6, 88%). Three (43%) AE patients suffered bilateral enucleations. Common concomitant injuries included eyelid lacerations (5, 71%) and optic nerve avulsion (3, 43%). Radiography was utilized for all of the study patients with computed tomography as the most common (5, 71%), followed by ultrasound (1, 14%), and magnetic resonance imaging with CT angiography (1, 14). Orbital exploration was performed in the management of all patients. Orbital implants were placed in 4 (57%) patients. Patients were followed for a mean of 1.9 months (range 1-4 months). Autoenucleation affects both genders and is commonly associated with eyelid lacerations, optic nerve avulsion, and intracranial hemorrhage. The association with intracranial hemorrhage is consistent with prior reports of internal carotid artery injury following shearing of the optic nerve. Autoenucleation cases were seen secondary to mental or substance induced psychosis, and these patients may be at risk for future injuries such as AE of the contralateral globe. The common causes for psychosis reported our patient group include schizophrenia, depression, schizoaffective disorder, and methamphetamine-induced psychosis, which corroborates with similar cases in the literature. Two of three cases of bilateral AE suffered sequential AE where the contralateral globe was enucleated days apart. All patients suffering AE should have full medical, psychiatric, neurologic, and radiologic evaluation and monitoring while under care. When evaluating patients with obvious ocular injury, accompanying intracranial injuries should be ruled out in a timely fashion before pursuing surgical intervention.

Oedipism in West Texas: A case series

“…Self-enucleation more commonly involves the right orbit due to hand dominance and demonstrates an equal male to female distribution. 4 Almost 40% of patients will attempt enucleation of the other eye at some point, as represented by the patient in our first case. 5 Deliberate orbital injuries are more often directed toward the posterior fossa which differentiates from accidental injuries which are directed superiorly towards the frontal lobe.…”

“…All patients should be admitted for intravenous antibiotics for meningitis prophylaxis and fingerless mittens or arm restraints until their psychosis can be adequately treated. 1,4 Antipsychotics are first line medical management; electroconvulsive therapy is a possible adjunctive therapy for refractory cases. 6 ECT requires cautionary use as it may increase intraocular pressure, complicating already serious ocular injuries.…”

Oedipism: An unusual case of auto-enucleation including mechanism of avulsion

“…Use of the fingers is thought to be the commonest mode of injury in AE. 5,6 His cell was described as bare comprising only a bed and toilet. Thus he had no access to objects that could have been utilized.…”

“…In this case the patient received thorough visual field testing and MRI scan which confirmed no neuro-ophthalmological sequelae. 6 Management of AE cases is challenging and often the first port of call is the ophthalmologist for obvious reasons. 6 Central to this case was the early involvement of the mental health team and at the time of the enucleation, the patient was reportedly suffering from persecutory delusions triggered by the influence of illicit drug use.…”

Drugs of abuse and ocular effects

“…26 There are also occasional documented cases of self-inflicted enucleations following consumption of drugs. 27…”