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Sir,

Self-inflicted injury to the eyes is a rare but devastating phenomenon. There are several cases of self-inflicted ocular injuries reported especially among psychotic patients but similar injuries have also been reported in patients with obsessive/compulsive neuroses, drug-induced psychosis, organic mental states including epilepsy, encephalitis, diabetes with renal vascular and infective complications.1

Self-mutilation is rarely encountered by ophthalmologists but one must be very suspicious to avoid misdiagnosis when dealing with psychotic patients, especially schizophrenics. Here we report a schizophrenic patient who was misdiagnosed as bilateral panuveitis initially, but in fact had bilateral endophthalmitis due to self-mutilation.

Case report

A 32-year-old schizophrenic woman suffering from visual loss and pain in both eyes was referred to our clinic with diagnosis of bilateral panuveitis, and topical corticosteroid and cyloplegic drops had been initiated by the referring ophthalmologist. The left eye has perception of light vision and the right eye has no perception of light. There were no pupil reactions in either eye. Mild anterior chamber reaction, fibrinoid membrane formation, cataract, and posterior synechias were present bilaterally, and there were dense vitreous membranes and opacities in both eyes. Careful biomicro-scopic evaluation revealed conjunctival laceration and scleral perforation 10–12 mm posterior to the limbus at the six o’clock position bilaterally. There was no visible uveal tissue prolapsus in both eyes (Figure 1).

Figure 1
figure 1

Bilateral posterior synechias, keratic precipitates, vitreous membranes, and inferiorly located scar tissues secondary to scleral perforations: (a) right eye; (b) left eye of the patient.

Full size image

Although she had denied initially, after psychiatric consultation she accepted that she had perforated her eyes with a sewing (crochet) needle: right eye 5 weeks and left eye 3 weeks ago. She attributed this self-violation act to the shame of her sexual hallucinations. Ultrasonography disclosed total retinal detachmet in her right eye, while there were dense vitreous membranes and opacities bilaterally. Neurologic evaluation revealed normal findings and psychiatric consultation confirmed the diagnosis of schizophrenia and antipsychotic medical therapy initiated.

Considering the fact that there was no light perception in the left eye, we decided to operate the right eye first. Under general anaesthesia, pars plana vitrectomy and membrane pealing was performed but we could not achieve to reattach the retina because of severe retinal atrophy and dense subretinal fibrosis. The patient and her family refused operation of the second eye.

Comment

Schizophrenia seems to be the most common feature in reported cases of self-inflicted ocular mutilation.1,2 The most severe form of self-mutilation can be self-enucleation, and several factors are stressed in these cases: castration fears; failure to resolve oedipal conflicts; repressed homosexual impulses; severe guilt; self-punishment.2 Since ego and eye are related, violence directed to the eye can also be a part of suicidal gesture.

Self-inflicted ocular mutilaton may be presented to the ophthalmologists in many different clinical pictures including corneal laceration, scleral/corneal perforations, blunt orbital trauma, or even enucleation of the globe.1,2,3,4,5,6 One may interpret the trauma and its cause more readily when the presentation is manifest, but sometimes, it can be quite difficult as in our case. Hardly visible perforations, patient's denial of the condition, and a long time interval between the perforation and admission to the doctor easily lead to misdiagnosis. Ophthalmologists must always keep the self-inflicted ocular mutilation in their mind when dealing with mentally disordered patients.