by Alexander H. Fan, MD; and Stephen Fink, MD

Dr. Fan is a staff psychiatrist, Cedars-Sinai Medical Center, Los Angeles, California; Dr. Fink is with the Department of Anesthesiology, Stanford University.

Abstract

Objective: To inform readers of the psychopathology underlying ocular autoenucleation. Design: Case report and literature review. Setting: Surgical and psychiatric units of tertiary care medical center. Participants: One male adult patient with schizophrenia. Results: Clinical results of this patient were resolution of psychotic symptoms with anti-psychotic medication and blindness in patient’s left eye. Conclusion: This case report is consistent with many cases in the medical and psychiatric literature which demonstrate a psychotic illness underlying acts of autoenucleation. A review of the literature emphasizes the need for aggressive multidisciplinary treatment of the medical emergency and underlying psychiatric condition.

Key Words: autoenucleation, psychosis, schizophrenia, self-injury, eye

Introduction

Considered the most devastating of self-inflicted eye injuries, autoenucleation was first described in the medical literature in 1846 and subsequently termed “Oedipism” by Blonel in 1906.[1] This term refers to the character Oedipus in Sophocles’s play Oedipus Rex, who autoenucleated both eyes upon discovering that he had unwittingly murdered his father and married his mother. Although the prevalence of Oedipism is unknown, studies have estimated a prevalence rate of 2.8 to 4.3 per 100,000 in the population.[2,3] A review of fifty cases of autoenucleation found an equal incidence in men and women [4]. Although autoenucleation is an uncommon manifestation of psychiatric and medical illness, the severity of its consequences argues strongly for clinicians to understand its psychiatric presentations and proper medical management. We present a case of unilateral autoenucleation by a young schizophrenic man followed by a brief literature review on Oedipism.

CASE REPORT

The patient is a 21-year-old man who autoenucleated his left eye with a steak knife in a foreign country reportedly by stabbing his left eye 10 or 11 times. He was immediately taken to a local hospital where his wound was cleaned and dressed. He received antibiotics and a tetanus vaccine. His family arranged for his prompt return to the United States and admission to our tertiary care hospital for further evaluation and treatment. Olanzapine (5mg/day) was started by the psychiatry consultation service after he was admitted to the surgery service. A computed tomography (CT) scan of the orbits and sinuses was done. The urine toxicology screen revealed no illicit drugs. The remnants of the ruptured globe were then removed, and the lacerations to his left upper and lower eyelids and lateral canthus were repaired.

After the patient was medically stabilized, he was transferred to our hospital’s psychiatric unit on an involuntary basis for being a danger to himself. In the initial psychiatric evaluation after transfer, he described frequent auditory hallucinations “from demons and the devil” and feeling “locked into a hotel by security” prior to his autoenucleation. The patient provided no other significant history concerning the autoenucleation or any past psychiatric history. When asked to explain the incident, the patient responded nonchalantly, “It was due to temporary insanity.” He denied any current or recent substance abuse. The patient denied any acute stressors or significant losses prior to his autoenucleation. He also denied having any significant mood symptoms prior to the incident. He denied having any significant medical conditions.

Past psychiatric history provided by the patient’s family revealed that the patient had been diagnosed with schizophrenia, paranoid type, within one year prior to his autoenucleation. Several months prior to his travel abroad, he had his first psychiatric hospitalization, which was prompted by onset of argumentative and destructive behavior as well as worsening of his paranoid, grandiose, and tangential thinking. Olanzapine was initiated and titrated to a dose of 25mg/day to treat the psychosis. After his hospitalization, he started outpatient psychiatric care and was generally adherent with medication. He was noted to have had a marked decrease in psychotic symptoms during this period, and he was able to regain much of his premorbid level of function, including his career as a professional musician. The patient then decided to stop taking the olanzapine in anticipation of his travel abroad. The patient enucleated his eye two weeks subsequent to his discontinuation of medication.

On mental status examination, the patient appeared well groomed with clean and dry gauze over his left orbit. His speech was within normal limits for rate, rhythm, and volume. His psychomotor behavior was normal. His attitude toward his examiners was guarded, and he related to his treatment team in a superficial manner. His mood was slightly irritable, and his affective range was constricted. His affect seemed inappropriate given the severity of his self-injury. His thought process was linear and goal-directed. His thought content had no overt paranoid ideations or delusions. He denied having current suicidal or homicidal ideations. He denied having current auditory or visual hallucinations. He had no overt impairment in impulse control. His insight and judgment seemed impaired but was difficult to determine due to his guarded attitude.

The patient had an uneventful hospital course. The patient was fully adherent with his medications. His dose of olanzapine was rapidly titrated to 20mg/day. He remained socially isolative within the inpatient milieu, and he continued to interact with his treatment team in a guarded and superficial manner. However, he never displayed any bizarre behavior; nor did he report any current psychotic symptoms during his psychiatric hospitalization. He never showed any remorse for enucleating his left eye. His attitude toward his self-injury could even be described as la belle indifference. He displayed good impulse control and generally cooperative behavior throughout his hospitalization. The patient was discharged from the psychiatric unit after only five days because his psychotic symptoms seem well controlled.

DISCUSSION AND LITERATURE REVIEW

The presented case is similar to other reported cases of autoenucleation. Most reported cases have described patients diagnosed with a psychotic illness, most commonly schizophrenia. Autoenucleation resulting from substance-induced psychosis, bipolar mania, obsessive-compulsive “neuroses,” posttraumatic stress disorder, and major depressive disorder have also been reported. One case report described an epileptic male who autoenucleated both eyes during what was later diagnosed as a postictal psychosis.[5] Cases of autoenucleation have also been reported with medical conditions, such as neurosyphilis,[6] Lesch-Nyhan syndrome,[7] Down syndrome,[8] and structural brain lesions.[9] A review of the medical and psychiatric literature emphasizes the need for a multidiscliplinary approach to the treatment of autoenucleation patients to address the medical emergency and the psychiatric illness.

Because autoenucleation has grave implications for patients, it is important to understand its potential medical complications and appropriate medical management. Khan, et al., suggested that the acute medical management by an ophthalmologist begins with visualization of the wound to examine for active bleeding. The absence of orbital bleeding may indicate a subarachnoid hemorrhage (SAH). Because the ophthalmic artery is inferior and lateral to the optic nerve, tearing of the optic nerve can shear the ophthalmic artery and result in a SAH. Khan described an autoenucleation patient with a SAH that was overlooked because the patient was floridly psychotic. This patient complained of weakness and numbness in his left lower extremity; a CT scan revealed a SAH. A thorough neurological exam including a visual field exam of the undamaged eye is needed to rule out contralateral heminanopsia from chiasmal injury.10 Parmar, et al., reported a patient who enucleated his right eye causing swelling of the left chiasm resulting in a contralateral hemianopsia. A course of intravenous methylprednisolone led to greatly improved visual fields in the inferotemporal quadrant.[11] Culturing and irrigating the wound and applying topical antibiotics should be done before evaluation for surgical repair. A CT scan of the orbits can clarify the full extent of injury. A tetanus vaccine should be administered to all adult patients.

The psychiatric literature on autoenucleation indicates that it is commonly associated with religious and sexual delusions.[12,13,14,15] These patients often refer to concepts of sin, evil, guilt and atonement as their motives for self-harm. Many of these psychotic patients cite biblical teachings as their motives. Matthew 5:29 states, “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.” Schiwach suggested that Oedipism may be “unique to the psychotic patients in the Christian West.”[14] However, Aksaray, et al., later presented the case of a 39-year-old Muslim man who blinded himself during the Muslim celebration of sacrifices. This patient with schizophrenia had delusions that he ruined the religious holiday for his community.[15] Patton speculated that “the eyes may act as a symbol of the self onto which conflicts, fears, and guilt are displaced; and, thus, by elimination or mutilation of the eye, relief from these feelings is obtained.”[13]

The medical and psychiatric literature strongly suggests that autoenucleation patients are at greater risk for further self-harm. Dilly, et al., presented a case in which a man enucleated an eye that had been already blind from a previous attempt at enucleation. This case demonstrates that vision is not required for a psychotic patient to injure an eye.[16] A review of 50 cases found a surprisingly high (39%) incidence of bilateral autoenucleation.[4] Similarly, Witherspoon, et al., reported that patients who had enucleated one eye are at an increased risk of enucleating the other eye, even under the care of hospital staff.[12] Another study also concluded that autoenucleation may occur more frequently within institutions.[17] These reports emphasize the need for aggressive treatment of the underlying illness and close observation of autoenucleation patients to prevent further self-harm.

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