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Year : 2022  |  Volume : 2  |  Issue : 4  |  Page : 969-970

Out of the box - Traumatic autoenucleation: A case report

Department of Orbit, Oculoplasty, Ocular Oncology and Ocular Prosthetics, Aravind Eye Hospital and PG Institute of Ophthalmology, Madurai, Tamil Nadu, India

Date of Submission12-Apr-2022
Date of Acceptance12-Jul-2022
Date of Web Publication11-Oct-2022

Correspondence Address:
Dr. Meghana Tanwar
Medical Consultant, Aravind Eye Hospital, 1, Anna Nagar, Madurai - 625 009, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijo.IJO_948_22

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A 53-year-old gentleman, presented with an alleged history of seizures at home during which he suffered trauma to his left eye leading to prolapse of the globe. This globe luxation was associated with lid lacerations and active bleeding from the orbit. The lacerations were repaired, the globe was enucleated, and eventually, a prosthesis was fit for cosmesis. Autoenucleation usually occurs in patients with psychiatric illness or drug abuse and rarely in cases of accidental trauma. We present this case report to highlight the clinical presentation of such a trauma with complications, which might be overlooked while treating such patients.

Keywords: Autoenucleation, orbital trauma, traumatic enucleation

How to cite this article:
Tanwar M, Kumar S. Out of the box - Traumatic autoenucleation: A case report. Indian J Ophthalmol Case Rep 2022;2:969-70

How to cite this URL:
Tanwar M, Kumar S. Out of the box - Traumatic autoenucleation: A case report. Indian J Ophthalmol Case Rep [serial online] 2022 [cited 2022 Nov 27];2:969-70. Available from: https://www.ijoreports.in/text.asp?2022/2/4/969/358198

Autoenucleation has previously been reported in patients with psychiatric illness or drug abuse.[1] In the setting of a dramatic presentation and a need to expedite management of these actively bleeding patients, there might be clinical signs which might be overlooked. We present a case of autoenucleation following an unwitnessed episode of seizures and discuss the possible associated complications, which should be kept in mind for optimal treatment.

  Case Report Top

A 53-year-old gentleman, presented with pain and bleeding from his left eye for 5 h following an alleged history of unwitnessed seizures early that morning during which he hit a window ledge. He was a known epileptic, on regular medications with the last witnessed episode five years ago.

After the incident, he was taken to a general hospital where an anticonvulsant (injection fosphenytoin) was administered. His vitals were stable and the left eye was noted to be dangling outside the socket for which he was referred to an ophthalmic facility.

On examination, he was well oriented to time, place, and person and was responding coherently to the examiner's questions. His right eye examination was within the normal limits. There were lacerations in the middle third of the upper lid involving the lid margin and in the lower lid extending onto the cheek (30 mm × 5 mm). The globe was luxated and was hanging along with the avulsed optic nerve (measuring 31 mm) by the medial rectus muscle [Figure 1]a.
Figure 1: (a) Enucleated left eye hanging via the medial rectus muscle (b) Computed tomography scan (axial section) showing prolapsed left globe (c) Photograph immediately post-enucleation with conformer in place and repaired lid tears(d) Fifteen days post-surgery with ocular prosthesis in-situ

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A computed tomography scan showed avulsion of the globe from the left optic nerve with an anteromedial displacement of the eyeball, a retrobulbar hematoma (2.48 × 1.7 cm), and a large blow-out fracture of the medial wall of the left orbit with orbital fat and medial rectus herniation without entrapment [Figure 1]b. An un-displaced blow-out fracture of the floor of the left orbit without muscle entrapment was also noted. The lateral and the superior recti with the levator palpebrae superioris were edematous. There was pre- and post-septal surgical emphysema. There was neither evidence of a foreign body nor any evidence of focal parenchymal injury or hematoma in the brain.

His blood investigations, chest skiagram, and echocardiograms were normal. The left eye was enucleated and the upper and lower lid tears were repaired in layers under general anesthesia [Figure 1]c. A conformer was placed in the anophthalmic socket. Post-operatively he was started on intravenous cefotaxime (1 g q12 h) and metronidazole (0.5 g q8 h) for five days along with oral anti-inflammatory agents and topical gatifloxacin (0.3%) eye ointment (q8 h). On the fifteenth post-operative day, he was fitted with an ocular prosthesis [Figure 1]d. At this point, the patient was comfortable and visual fields in the other eye were plotted on the Bjerrum's screen, which revealed no defect.

  Discussion Top

Autoenucleation is the self-inflicted extraction of the globe in which the globe is entirely removed from the orbit and all connections are severed.[2] The Greeks recognized this phenomenon, known as oedipism, in reference to Oedipus Rex, who after realizing he had unwittingly murdered his father and married his mother, gouged out both his eyes with his mother's brooches.[3] Another is the story of Saint Lucia of Syracuse, a devout Christian, who took a vow of chastity. However, a male admirer was so taken with the beauty of her eyes that she feared that she might break her vow of chastity. So, she tore out her eyes and delivered them to the admirer on a plate saying: “Here thou hast what thou have so much desired leave me now in peace.”[1],[4]

Most cases of autoenucleation result in injury solely confined to the orbit. Occasionally, however, more severe and even life-threatening complications have been reported:

  1. Neurovascular complications: Neurovascular sequelae after autoenucleation represent serious and life-threatening injuries.[5] As the globe is removed, blood vessels might be sheared and the subarachnoid space may fill with blood, leading to subarachnoid hemorrhage. Hence, it is imperative we image the orbit and brain at presentation to identify such an intracranial bleed, which might be life-threatening.
  2. Cerebrospinal fluid (CSF) leak: It has been reported that CSF leaks can occur in patients who undergo planned enucleation.[6] This has also been reported as a rare complication after autoenucleation. Thus, a thorough pre-operative examination is necessary to rule out a CSF leak, which would require a multi-specialty referral with modification of management.
  3. Chiasmal damage and visual field defects: The chiasma is anatomically prone to injury by autoenucleation. Chiasmal damage after autoenucleation has been described in the literature, which can occur from traumatic optic nerve avulsion near the chiasma.[7] Thus evaluation for visual field defects in the other eye is required in these patients.
  4. Infection: Following autoenucleation, suppurative meningitis has been reported to be the cause of mortality.[8] Thus, administration of intravenous antibiotics and careful monitoring of the patient's neurological status is essential in these patients.
  5. Internal carotid artery dissection has also been reported in the literature.[9]

  Conclusion Top

Autoenucleation is, therefore, an ocular as well as a neurological emergency. The treating physician should always consider neuroimaging to rule out neurovascular complications and start parenteral antimicrobials promptly because of the high risk of intracranial spread of infection. From an ophthalmic point of view, it is mandatory to check for visual fields in the other eye when the patient is stable and to place a primary orbital implant for a good post-operative cosmesis.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Khan JA, Buescher L, Ide CH, Pettigrove B. Medical management of self-enucleation. Arch Ophthalmol 1985;103:386-9.  Back to cited text no. 1
Moshfeghi DM, Moshfeghi AA, Finger PT. Enucleation. Surv Ophthalmol 2000;44:277-301.  Back to cited text no. 2
Leibovitch I, Pietris G, Casson R, Selva D. Oedipism: Bilateral self-enucleation. Am J Emerg Med 2006;24:127-8.  Back to cited text no. 3
Koch FL. Patron saints of the eyes. Trans Am Ophthalmol Soc 1943;41:490-535.  Back to cited text no. 4
Kotlus BS, Lo MW. Subarachnoid hemorrhage and vasospastic stroke after self-enucleation. Ophthalmic Plast Reconstruct Surg 2007;23:425-7.  Back to cited text no. 5
Massoud VA, Fay A, Yoon MK. Cerebrospinal fluid leak as a complication of oculoplastic surgery. Semin Ophthalmol 2014;29:440-9.  Back to cited text no. 6
Krauss HR, Yee RD, Foos RY. Autoenucleation. Surv Ophthalmol 1984;29:179-87.  Back to cited text no. 7
Nettleship E. Intracranial affections: On a case of meningitis after excision of the eye ball. Trans Ophthalmol Soc UK 1886;6:445–80.  Back to cited text no. 8
Joud H, Noureldine MHA, Peto I, Kumar JI, Bajric J, Agazzi S. Subarachnoid hemorrhage and internal carotid artery dissection and occlusion following self-enucleation. Asian J Neurosurg 2020;15:1050-4.  Back to cited text no. 9
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