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Sir,

Self-enucleation of eyes in an extreme but fortunately rare form of self-harm. We present a case and review the literature.

Case report

A 48-year-old Caucasian male was brought to the Accident and Emergency Department with a history of self-gouging of both his eyes. Both his orbits were bandaged and there was very little ooze down over cheeks. His enucleated eyeballs, along with a long stump of optic nerve, were stored in a pot filled with normal saline (Figure 1—both enucleated eyes). He was calm and apparently in no pain. The history was patchy and his relatives said that he indeed had a very troubled family life. There was no significant past ocular history. He was a known epileptic and had a recent epileptic attack, prior to the self-enucleation. His medication included topiramate and lamotrigine.

Figure 1
figure 1

Both enucleated eyeballs.

Full size image

He was admitted to the ward for observation and possible repair of the sockets. In the ward, he was quiet and refused any medication. He refused a closer examination of his orbits. A psychiatric consult concluded that he was suffering from a postictal psychosis, which had led him to do such an act. He was under constant nursing supervision through out the night. The next morning the sockets were examined closely and it was decided to leave them to heal spontaneously. Chloramphenicol eye ointment was prescribed for the sockets. He was registered fully blind and referred to artificial eye centre for prosthesis. He remains under psychiatric care.

Legendary background

In the Greek play Oedipus Rex1 by Sophocles, the Theban King Oedipus unwittingly married his mother and killed his father. He then cleansed himself of the mortal sin by gouging his eyes out with his mother's golden brooches.

In the Bible:2 Matthew 5.29 quotes Jesus as saying ‘And if thy right eye offend thee pluck it out, and cast it from thee: for it is profitable for thee that one of the thy members should perish, and not that thy whole body should be cast into hell’.

Marco Polo,3 in the 13th century, described a pious Baghdad carpenter who, after yielding to sinful thoughts about a young female customer, enucleated his right eye with his cobbler's awl.

Saint Triduan of Scotland,4 who on hearing that a prince was chiefly attracted by transcendent beauty of her eyes, enucleated her eyes to give to the prince.

Saint Lucia of Syracuse,5 who when fearing her vow for chastity, enucleated her own eyes and sent them to an admirer to stave off his advances.

In Norse mythology,6 Odin exchanged his eyes for the right to drink a single draught from the spring of Mimir, which offered wisdom and understanding.

Comment

The various forms of ocular self-mutilation include blunt trauma, penetrating injuries, and attempted and successful enculeation. Self-enucleation, also called Oedipism, is fortunately a rare form of extreme self-harm. There is no specific cause for people to enucleate their own eyes. The majority of the reported cases occur in those with psychotic illness,7 most commonly due to schizophrenia, drug-induced psychosis, manic phases of bipolar disorder, obsessive-compulsive neuroses, post-traumatic stress disorder, and depression. The psychotic patients frequently have delusions with religious and sexual content.8 Pain sensation has been noted to be considerably diminished in such patients, as shown in this case too. Organic illness7 that have been reported to stimulate self-mutilation of the eyes included delirium tremens, encephalitis, Lasche–Nyhan syndrome, Gilles de la Tourette's syndrome, Cornelia de Lange's syndrome, diabetes mellitus and epilepsy.

Completed digital self-enucleation is remarkable in that it tends to cause little haemorrhage, conserves ample conjunctiva for the lower fornix, and is followed by uneventful healing, whether the conjunctiva is sutured or not. The fitting of prostheses does not pose a serious problem in these cases. Management of patients following self-enucleation must involve a close cooperation between the ophthalmologist and the psychiatrist. Patients may not understand the implications of or may refuse treatment. Constant nursing supervision is necessary during in patient ophthalmic care, and lengthy in-patient psychiatric care may subsequently be needed. These patients are at high risk for further self-mutilation and precautions must be taken to prevent these.