Abstract
Background and aims
This report aims to illustrate a case of self-inflicted ocular and orbital injury, resulting in severe tissue loss and ophthalmoplegia in a patient with no known history of mental illness.
Methods and results
A 71-year-old male initially presented to the emergency department with significant tissue loss from his left upper and lower lids, orbital tissue loss and complete ophthalmoplegia, after reportedly tripping and falling onto his desk. He subsequently attended the emergency department on two further occasions with similar injuries, affecting the same and contralateral eye, whilst maintaining a traumatic cause for his injuries. He was eventually admitted to a psychiatric ward for mental health assessment. This report covers his progress as well as illustrating his injuries with images.
Conclusion
Self-harm is an important differential diagnosis in cases where the mechanism of injury does not correspond to the extent of injury or tissue loss. It can, however, be difficult to differentiate from accidental injury and even with repeated assessments, a formal psychiatric diagnosis may not be possible.
A 71-year-old male presented to the emergency department, alone, via ambulance, with significant loss from his left upper and lower eyelids and orbital tissue loss (Figure 1). At presentation, he had external ophthalmoplegia on the left side, due to damage to the third, fourth and sixth cranial nerves (shearing of nerves at the superior orbital fissure) and a severed medial rectus was noted on computed tomography scan (Figure 2). He reported that his injuries were caused by tripping on his dog and falling onto the corner of a desk. He had no previous ocular problems and had Type 1 diabetes, with stable blood glucose control (with insulin) over 20 years. He had no history of drug abuse or alcohol excess and lived alone independently with his dog. Further examination revealed an intact eyeball, normal pupil reactions and normal fundus examination. Vision was normal in the unaffected right eye, with reduced Snellen visual acuity of 6/18 in the affected left eye. During this admission, there was no cause for concern regarding his behaviour, albeit that he was noticeably calm given the significant injuries he had sustained. He underwent upper and lower eyelid laceration repair and medial rectus repair under general anaesthesia. He was allowed home with chloramphenicol eye ointment and viscotears eye ointment. He continued to attend follow-up as planned, showed good compliance with his medication and made a good recovery, as shown (Figure 3).
Injuries at first presentation – Full thickness eyelid laceration of upper eyelid, full thickness laceration and loss of medial two-thirds of lower eyelid tissue. CT showing the left medial rectus severed from the globe at the first presentation. Follow-up – three weeks after reconstructive lid repair to left eye: Healing wounds, with reduced palpebral aperture due to tissue loss. Ophthalmoplegia of left eye, with the image showing attempted upgaze.
Eight weeks after his initial presentation, he presented to the emergency department with right-sided upper and lower eyelid lacerations, allegedly having tripped on a box at home. This time he was brought in by his sister, but she was unable to shed any light on the mechanism of injury. The eyelid and orbital injuries on the right side appeared similar to the injuries he had sustained on the left side, including the loss of orbital tissue and severed medial rectus muscle (Figure 4). The eyeball was intact, and he now had ophthalmoplegia on the right side, similar to his previous presentation. He underwent eyelid laceration repair on the right side. Repair of the severed medial rectus muscle was not possible as there was extensive loss of muscle and orbital tissue. He was prescribed chloramphenicol eye ointment and lacrilube eye ointment to prevent exposure keratopathy.
Injuries at second presentation – Significant full thickness loss of upper eyelid medially, with total loss of the lower eyelid. Significant loss of orbital tissue, medially inferiorly and temporally down to the orbital rim.
On this occasion, he was referred to the mental health team in view of the strikingly similar pattern of injuries, inconsistencies in his account of the mechanism of injury, and his apparent lack of concern. At formal psychiatric assessment, no mental health issues were identified, with no evidence of suicidal or self-harm ideation, dementia or psychosis. Subsequent follow-ups indicated worsening ocular surface disease, due to the limited protection offered by deficient and immobile eyelids. One month after the second injury, he was noted to be developing exposure keratopathy as there was significant loss of eyelid tissue and conjunctival tissue leading to lagophthalmos (inability to close one’s eyelids) and symblepharon (adhesion of the palpebral to bulbar conjunctiva resulting in a loss of fornices), respectively. Exposure keratopathy was managed with frequent use of lubricants (lacrilube eye ointment). He was also offered tarsorrhaphy and an opportunity to correct the symblepharon; however, he declined further surgery at this stage. At the time, his visual acuity was hand movements in his right eye and 6/18 in his left eye.
Eighteen weeks after the initial presentation, he again appeared at the emergency department, this time brought in by a friend, reporting that he had suffered a further fall at home. Again his friend had not been a witness and could offer no further understanding to the situation. The resulting left-sided injury involved more extensive loss of the eyelid and peri-ocular tissue (Figure 5). As there was no eyelid tissue left, a full thickness skin graft was used to cover the wound and eyeball. Conjunctiva from the fornix was used to cover and protect the cornea. He was later assessed by the mental health team, who then transferred and admitted him to a mental health unit for further assessment and observation under section 2 of the Mental Health Act. Interestingly, this gentleman had previously never been diagnosed as having or exhibiting any symptoms or signs of mental illness, and he had no medical history or disability to explain his frequent falls. His diabetes remained well controlled throughout. What prompted a further psychiatric assessment was his inconsistent description of the mechanism of injury and the significant injuries he had sustained which did not correlate. Furthermore, throughout his clinical assessments he seemed indifferent and ambivalent to the situation, given the fact that at this stage he had lost significant vision in both eyes. Further reconstructive procedures were performed to improve eyelid closure including use of amniotic membrane grafts to reform the fornices and protect the ocular surface on both sides as well as a skin graft to repair injuries from his third admission (Figure 6).
Injuries at third presentation – Complete loss of upper and lower eyelid tissue. Loss of peri-ocular tissue exposing the orbital rim bone. One year following the initial injury – Skin graft over the left globe and tight and immobile eyelids of the right eye.
On his most recent assessment one year on from the initial injury, his visual acuity was 6/24 in the right eye and perception of light in the left eye. He had been registered partially sighted, and was managing fairly well with the remaining vision in his right eye. He never regained extra-ocular movements in either eye. It appears that this patient may have attempted a self-enucleation, which caused shearing injury to third, fourth and sixth nerves at the superior orbital fissure and partial or complete avulsion injury to extra-ocular muscles. 1 His insulin regimen was amended to allow district nurses to administer the injections at his home. In total, he spent just over a month in the mental health unit, where they did not observe any psychotic or self-harm behaviour. He, however, declined a trial of antipsychotic treatment and was eventually discharged with a nonpsychotic chaotic and challenging behaviours care cluster. These care clusters ensure patients are discharged with a personalised care plan to prevent further occurrences, with close monitoring of their mental health in the community and access to help. 2 However, no formal psychiatric diagnosis was made.
Discussion
In the literature, self-inflicted eye injuries are unusual, and are associated with various disorders, most commonly schizophrenia and drug induced psychosis. 3 Other psychiatric associations include depression, borderline personality disorder, post-traumatic stress disorder and obsessive compulsive disorder.3,4They can also be associated with some organic disorders such as neurosyphilis, epilepsy, Lesch–Nyhan Syndrome, dementia, structural brain lesions and even diabetes.3–5Drugs have been implicated in some cases, including cannabis, stimulants such as amphetamine and cocaine, and hallucinogens. 4 One study which reviewed 41 cases found that the majority of cases involved young, male schizophrenics, psychotics or those suffering from alcohol or drug abuse. 6
Self-inflicted ocular injuries can range from mild anterior segment trauma such as trichotillomania to penetrating orbital injuries, lid lacerations and even enucleation. Self-enucleation is the most severe form, also known as oedipism, in reference to the Greek legend of Oedipus, who gouged his eyes out.3,4Modes of injury include blunt trauma, digital injuries and use of common household objects. 4 The true incidence of self-inflicted ocular injuries may be difficult to quote, as the literature is sparse and predominantly limited to case reports/series. A recent literature review suggested a higher predilection in men, with a ratio of 8:1, and in Caucasians. 7 In the Western world, over half of the cases of ocular self-injury result from patients with active psychotic symptoms, often with religious delusions or hallucinations referencing the bible, viewing self-injury as necessary to purge sin.3,8Altered body image is commonly present among self-mutilators, and there is an almost universal association with either religious or sexual ideation. 3 These religious and sexual ideations may coexist and the eyes act as a symbol onto which conflicts and guilt are displaced, resulting in relief on elimination or mutilation of the eye. 3
Our case highlights that mental health is an important consideration when the mechanism of an injury does not correlate with the damage sustained, even in a patient with no prior history of mental illness. Our patient does not fit the criteria most commonly reported in the literature, being older in age, with no previous history of mental illness, alcohol or drug abuse. He was tested for syphilis which was reported to be negative, and he had no history of seizures.
His one risk factor of note is his chronic history of diabetes, which rarely has been documented as an association with self-inflicted eye injury. Diabetes is known to increase pain threshold, which may allow patients to tolerate the pain during self-infliction. 9 It is also associated with mental health issues, owing to its chronic nature. 9 Our patient, even during his stay at the mental health hospital, did not show any signs of psychotic or depressive behaviour, however he unusually remained apathetic despite his severe injuries.
Although self-mutilation in other aspects of medicine are more commonly seen – such as biting ones lips, pulling hair, burning or cutting skin – it is extremely rare to involve injuries to the eye. 3 Reports of self-harm to eyes are scanty, with very few literature reviews, and studies mainly reliant on published case reports. 3 Self-harm as a psychiatric diagnosis can be difficult to establish and studies have suggested that a formal diagnosis may not be possible in over 50% of cases. 10 However, self-harm should remain a differential diagnosis in cases where the alleged mechanism of injury does not correspond to the extent of injury or tissue loss, particularly in repeated cases, and we believe this could apply to injuries in any part of the body. Although the injuries were suggestive of self-harm in this gentleman, a formal diagnosis of self-harm was not made during his admission because he denied it and there was no history of mental illness. A diagnosis of self-harm may not be spotted at the first presentation. In rare cases, a definite diagnosis of self-harm may not be possible, even after a repeated psychiatric assessment, as seen in this case, and we may be required to establish self-harm as a diagnosis of exclusion.
Footnotes
Authors’ contributions
ES-A: Involved in patient care, obtaining clinical information and images, case write up and submission. JH: Involved in patient care, involved in taking images contained in document and editing write up. SS: Involved in patient care as the lead Consultant, editing write up and support with submission.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.