A Case of Attempted Bilateral Self-Enucleation in a Patient with Bipolar Disorder

Abstract

Attempted and completed self-enucleation, or removal of one's own eyes, is a rare but devastating form of self-mutilation behavior. It is often associated with psychiatric disorders, particularly schizophrenia, substance induced psychosis, and bipolar disorder. We report a case of a patient with a history of bipolar disorder who gouged his eyes bilaterally as an attempt to self-enucleate himself. On presentation, the patient was manic with both psychotic features of hyperreligous delusions and command auditory hallucinations of God telling him to take his eyes out. On presentation, the patient had no light perception vision in both eyes and his exam displayed severe proptosis, extensive conjunctival lacerations, and visibly avulsed extraocular muscles on the right side. An emergency computed tomography scan of the orbits revealed small and irregular globes, air within the orbits, and intraocular hemorrhage. He was taken to the operating room for surgical repair of his injuries. Attempted and completed self-enucleation is most commonly associated with schizophrenia and substance induced psychosis, but can also present in patients with bipolar disorder. Other less commonly associated disorders include obsessive-compulsive disorder, depression, mental retardation, neurosyphilis, Lesch-Nyhan syndrome, and structural brain lesions.

Keywords: bipolar disorder; hyperreligiosity; self-enucleation.

Figure 1.

Appearance on presentation after attempted bilateral self-enucleation. The globes have been pulled anteriorly and display significant conjunctival lacerations and hemorrhage. Due to the anterior displacement there is severe exposure keratopathy with poor eyelid coverage of the corneas bilaterally. The superior rectus muscle is exposed and dehisced from its attachment in the right eye.

Figure 2.

Axial computed tomography scan of the orbits without contrast showring small, irregular globes anteriorly displaced. There is bilateral intraocular hemorrhage and disorganization of the intraocular contents.

Figure 3.

Coronal computed tomography scan of the orbits without contrast showing multiple foci of air and trace fat stranding within the extraconal and intraconal orbits bilaterally.

Figure 4.

Appearance during intraoperative wound exploration and repair. There is severe bilateral proptosis and conjunctival lacerations. The right eye shows a dehisced superior rectus muscle from the injury.