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Self-enucleation is an uncommon event, most often occurring in patients with a functional or toxic psychosis. Reports of self-enucleation most frequently describe schizophrenic patients and those abusing hallucinogenic drugs. Self-enucleating patients use fingers or instruments to remove the globe. As with external traumatic enucleation, attempted or successful self-enucleation may result in significant damage to ocular structures, including the globe, conjunctiva, extraocular muscles, blood vessels, optic nerve and chiasm.
Treatment modalities following traumatic enucleation or attempted self-enucleation are aimed at preserving vision and the globe and minimizing injury to the ocular structures. Although visual prognosis may be poor, globe repositioning provides both improved cosmesis and decreased psychological stress to the patient and should be undertaken if at all possible. The literature deals mainly with case reports of globes subluxated from external trauma, which often involve significant facial injury, and spontaneous subluxation in patients with shallow orbits or Graves ophthalmopathy.
In cases of spontaneous subluxation, there is significantly less edema and external injury than with traumatic subluxation. Repositioning the globe in these cases is therefore technically less challenging, with patients even learning to perform these maneuvers on themselves.
The patient was a 52-year-old psychotic Hispanic prisoner who was brought to the emergency department after attempted self-enucleation of his left globe. He said that he had felt his eyeball was “no good” and had tried to remove it from the eye socket with his fingers. He said that he had immediate vision loss and severe pain.
History. The patient reported no other ocular or medical history. However, his medication list included several antipsychotic medications.
Examination. On external examination, the upper and lower eyelids were markedly edematous, and the left globe was markedly proptotic, with the upper eyelid partially tucked behind the equator of the globe (Fig. 1). The extraocular movements of his right eye were normal; the left eye showed limited movement superiorly, medially and laterally, with essentially no downward duction. The visual acuity of the right, uninvolved eye was J1+ at near; the left eye had no light perception (NLP). The IOP was 22 mmHg in the right eye and 18 mmHg in the left eye. His left pupil was nonreactive, with a 3+ relative afferent pupillary defect. The left conjunctiva was diffusely injected and mildly chemotic, but the cornea remained clear (Fig. 1). There was a 2 mm hyphema. A dilated examination was deferred.
A CT scan showed an intact, proptotic left globe, with a taut, thin optic nerve, an avulsed inferior rectus muscle and moderate retrobulbar stranding with edema(Figs. 2A and 2B).
Management. The management options for this situation were either to bring the patient into the operating room to explore and reposition the globe or to more rapidly reposition the globe in the emergency department. The case was discussed with the attending ophthalmologist, and the decision was made to reposition the globe immediately in the emergency department to avoid additional damage to the globe and orbital structures by any delay involved in getting to the OR.
The patient was placed under conscious sedation with propofol, using appropriate cardiopulmonary, pulse oximetry and end-tidal CO2 monitoring. After an appropriate level of anesthesia was achieved, topical proparacaine was liberally applied to the left eye. The upper and lower eyelids were retracted using a mini–Desmarres retractor and a large paper clip bent into a retractor. Direct anteroposterior thumb pressure was applied to the center of the cornea. The globe was reduced into the orbit with continued firm pressure. The necrotic, exposed portion of the inferior rectus muscle was excised. Following the repositioning procedure, the eyelids returned to normal anatomic position (Figs. 3A and 3B).
Follow-up. The patient was seen in the eye clinic on postoperative day two. He reported a significant decrease in pain. Visual acuity in the affected eye remained NLP, and the IOP was 25 mmHg. His globe was appropriately positioned within the orbit (Fig. 4A). He had 3+ conjunctival injection and chemosis, as well as a central corneal epithelial defect and mild corneal edema. He had 2+ anterior chamber flare and vitreous hemorrhage. A dilated eye examination revealed extensive subretinal and intraretinal hemorrhage overlying the disc, the macula and portions of the peripheral retina (Fig. 4B). He was discharged on prednisolone acetate 1 percent four times daily, scopolamine 0.25 percent twice daily and bacitracin eye ointment four times daily in the left eye. He was told to get bed rest (with the head of his bed at 30 degrees), to avoid heavy lifting or straining and to wear spectacles with polycarbonate safety lenses at all times to protect his remaining functional eye.
The patient was seen weekly for one month, and then again for a three-month follow-up. At his three-month follow-up, the patient reported no pain in the eye and no psychosocial stress because of his appearance. In the affected eye, extraocular movements were normal superiorly, medially and laterally, but severely limited inferiorly. Vision remained NLP in the left eye, and IOP was normal at 17 mmHg. The examination revealed mild lagophthalmos with 2 mm of inferior scleral show. He had mild diffuse (1+) conjunctival injection, and the cornea was clear. The anterior chamber was clear, the pupil was minimally reactive and the lens and vitreous were clear. The patient declined a dilated eye examination and photos at this visit.
Although the prognosis for vision after traumatic globe subluxation is poor, rapid reduction of the globe to restore normal anatomic position of the globe and eyelids can prevent loss of the eye and can permit retention of reasonably normal cosmesis. Various case reports have described good cosmetic and psychosocial outcomes following repositioning of a subluxated globe from external trauma, and our case shows that similar outcomes can be achieved with the repositioning of a subluxated globe after attempted self-enucleation.
Drs. Rizzo and Krispel are ophthalmology residents at the University of California, Davis, Eye Center. Dr. Caspar is professor of ophthalmology at UC Davis.
MORE ONLINE: Go to www.eyenetmagazine.org to view a video of the procedure.