Autoenucleation

from Wikipedia, the free encyclopedia

Autoenucleation ( Greek αὐτό ~ 'self', Latin ex 'from', nucleus 'the nucleus'; loosely translated self-ginning ) is an ophthalmological or psychiatric term for the self-injurious or self-mutilating removal ( enucleation ) of one's own eye .

Research and cultural history

Autoenucleation was first described as a psychiatric phenomenon in 1846 by Gottlob Heinrich Bergmann . The less common term Oedipism ( French oedipisme ), alluding to the Oedipus myth, goes back to Charles Blondel (1906). The literature also mentions three patron saints of ophthalmology who, according to legends, tore their own eyes out of noble motifs ( Lucia of Syracuse , Triduana and Medana).

Most of the literature on individual cases comes from the Anglo-American region (United Kingdom, United States, Canada, Australia). An exclusive occurrence in the ( Christian ) West was suspected, but is de facto (known cases of Muslims, Asians and Africans) not available.

Prevalence and risk

Studies assume that autoenucleation occurs with a prevalence of 2.8 to 4.3 per 100,000 people. An examination of 50 cases found that 39% of the cases had both eyes removed; Men and women were affected equally often. Autoenucleation in children is rare; mostly a mental handicap is the cause.

Causes, Correlations, and Associations

A psychosis , mostly schizophrenia , is often assumed to be the underlying cause. Other causes that have been reported include substance-induced psychoses (e.g. from drugs , alcohol or poisoning with chemical solvent fumes), bipolar manias , obsessive-compulsive " neuroses ", post-traumatic stress disorders and severe depression . In one case there was an autoenucleation after an epileptic seizure, which in retrospect was classified as postictal psychosis. Other possible causes are neurolues , Lesch-Nyhan syndrome , Down syndrome and structural injuries to the brain , although organic diseases are a rare cause.

There is often an association with religious and sexual delusions , with those affected citing the concepts of sin , evil , guilt and atonement as the motive for their actions. Many cite Bible passages for this (especially Mt 5.29  EU ). Sometimes the eye itself is perceived as evil, and sometimes the eye is held responsible for having to experience threatening situations. Immediately after auto-enucleation, this is generally not regretted; There is temporarily a reduction in feelings of guilt or a feeling of relief. Explanations for the connection between reducing guilt and injuring one's own eyes are speculative and controversial in research; Among other things, the eye is discussed as a symbol of the self (because of the role of the development of visual perception in building up consciousness ), with which the self can be punished or killed, but the whole can continue to live.

Often those affected have already had auto-aggressive behavior or suicide attempts . The specialist literature suggests that after auto-enucleation has taken place, there is an increased risk of renewed self-harm (which can also affect the remaining eye), even if the affected person is monitored by medical staff.

Course and complications

The specific autoenucleation is often limited to just one eye. In order to cut through or even tear out the optic nerve , it takes a sudden and considerable effort.

Autoenucleation is accompanied by a rupture of the ophthalmic artery , which leads to profuse bleeding. If the artery is divided intra-orbitally before the opening to the optic canal , the bleeding will occur within the eye socket. If the vessel is torn off in or behind the opening, subarachnoid hemorrhage can occur.

There may also be leakage of cerebrospinal fluid .

Another complication can be purulent meningitis . In one case of autoenucleation, an aneurysm subsequently formed at the junction between the internal carotid artery and the ophthalmic artery. Cases of panophthalmitis are also known. The latter can also be caused by unsuccessful autoenucleations, in which the insufficient expenditure of force resulted in a sclera rupture . Unsuccessful autoenucleations can also lead to loss of vision due to injuries, bleeding, edema and bruises of the retina .

treatment

Autoenucleation requires immediate medical intervention. This is primarily an emergency medical care and consists of a combination of ophthalmic-surgical and psychiatric measures.

In the case of active bleeding, adequate hemostasis must be achieved by direct compression of the ophthalmic artery . If there is no heavy bleeding in the orbital area, a subarachnoid hemorrhage is suspected. The eye socket should be used for cell culture and flushing, and a topical antibiotic installed . Tetanus vaccination is indicated for all adults .

A complete medical history of the individual should be obtained, as well as careful questioning about drug use or the presence of neurological symptoms. A thorough neurological exam involves examining the patient's state of mind and looking for signs of meningism or focal neurological deficits. Using finger perimetry , indications of the injury to the optic nerve junction can be determined. If neurological failure or subarachnoid hemorrhage is suspected, computed tomography or neurosurgical examination may be indicated.

Attempted autoenucleation can lead to massive tissue swelling within the orbit and thus damage the optic nerve. A functional test can be carried out using computed tomography or VEP tests, and intraocular pressure can be measured using suitable tonometry methods . A systemic treatment with steroids builds, if necessary, the pressure, but can strengthen the affected psychotic behavior. If the eye has been irreparably damaged by the auto-enucleation attempt, regular enucleation may be indicated to reduce the risk of sympathetic ophthalmia . Neuroimaging or electrodiagnostic methods can be used to determine whether the injuries actually lead to irreversible blindness for the person concerned .

In order to rule out a hemorrhagic diathesis , PT , PTT and platelet count should also be determined in the laboratory . In the enucleated eye, the cornea can be examined to determine whether it is suitable for tissue donation . A drug test of the urine can be helpful in determining substance-induced psychosis . If relevant substances are present, detoxification may be necessary.

After admission to the hospital, the person concerned should be carefully observed to identify signs of local infections, meningitis, active subarachnoid hemorrhage, and renewed self-mutilating or suicide attempts. If the autoenucleation only took place in one eye, the remaining eye should have a complete organ diagnosis, as well as visual acuity and visual field examination, and observed for possible sympathetic ophthalmia.

The use of psychiatric professionals and the introduction of precautionary measures against suicide or parasuicide are advisable. For immediate prophylaxis against suicide or self-mutilating behavior, rapid, parenteral treatment with tranquillants ( neuroleptics , antidepressants ) was recommended . Occasionally, electroconvulsive therapy has also had good results. Successes with eye prostheses in recovery have been reported.

See also

literature

  • Jemshed A. Khan, Lucinda Buescher, Carl H. Ide, Ben Pettigrove: Medical Management of Self-Enucleation. In: Archives of Ophthalmology. Vol. 103, No. 3, 1985, ISSN  0003-9950 , pp. 386-389, doi : 10.1001 / archopht . 1985.01050030082027 .
  • Maria-A. Gamulescu, Stefan Serguhn, Josef-M. Aigner, Chris P. Lohmann, Johann Roider: Enucleation as a form of autoaggression - two case reports and an overview of the literature. In: Clinical monthly sheets for ophthalmology. Vol. 218, No. 6, 2001, ISSN  0023-2165 , pp. 451-454, doi : 10.1055 / s-2001-16261 .
  • Niall Patton: Self-inflicted eye injuries: a review. In: Eye. Vol. 18, No. 9, 2004, ISSN  0950-222X , pp. 867-872, doi : 10.1038 / sj.eye.6701365 .
  • Alexander H. Fan: Autoenucleation. A Case Report and Literature Review. In: Psychiatry. Vol. 4, No. 10, October 2007, ISSN  1550-5952 , pp. 60-62, PMC 2860527 (free full text).

Individual evidence

  1. ↑ A case of religious monomania that caused outrageous self-harm. In: General journal for psychiatry . Vol. 3, 1846, pp. 365-380 ( full text in the Google book search); see also Gamulescu et al .: Enucleation as a form of autoaggression. In: Clinical monthly sheets for ophthalmology. Vol. 218, No. 6, 2001, pp. 451-454, here p. 451.
  2. ↑ In his dissertation: Charles Blondel : Les Auto-Mutilateurs. Éétude psycho-pathologique et médico-légale. Jules Rousset, Paris 1906. See also Khan et al .: Medical Management of Self-Enucleation. In: Archives of Ophthalmology. Vol. 103, No. 3, 1985, pp. 386-389, here p. 387.
  3. ^ Patton: Self-inflicted eye injuries: a review. In: Eye. Vol. 18, No. 9, 2004, pp. 867-872, here p. 868; see. Khan et al .: Medical Management of Self-Enucleation. In: Archives of Ophthalmology. Vol. 103, No. 3, 1985, pp. 386-389, here p. 388; on Triduana, see John Foster: The Legend and Shrine of Saint Triduana. In: British Journal of Ophthalmology Vol. 37, No. 12, December 1953, ISSN  0007-1161 , pp. 763-765, PMC 1324296 (free full text); on Medana, see James A. Ross: A Patron Saint for British Ophthalmologists. In: British Journal of Ophthalmology. Vol. 38, No. 10, October 1954, pp. 634-635, PMC 1324411 (free full text).
  4. ↑ Gamulescu et al .: Enucleation as a form of autoaggression. In: Clinical monthly sheets for ophthalmology. Vol. 218, No. 6, 2001, pp. 451-454, here pp. 451 f.
  5. ↑ See Raj S. Shiwach: Autoenucleation - A culture-specific phenomenon: a case series and review. In: Comprehensive Psychiatry. Vol. 39, No. 5, September / October 1998, pp. 318-322, doi : 10.1016 / S0010-440X (98) 90042-6 .
  6. ↑ Gamulescu et al .: Enucleation as a form of autoaggression. In: Clinical monthly sheets for ophthalmology. Vol. 218, No. 6, 2001, pp. 451-454, here p. 452; Fan: Autoenucleation. In: Psychiatry. Vol. 4, No. 10, 2007, pp. 60-62, here p. 62.
  7. ↑ a b Fan: Autoenucleation. In: Psychiatry. Vol. 4, No. 10, 2007, pp. 60-62, here p. 61.
  8. ↑ Fan: Autoenucleation. In: Psychiatry. Vol. 4, No. 10, 2007, pp. 60-62, here pp. 61-62.
  9. ↑ Gamulescu et al .: Enucleation as a form of autoaggression. In: Clinical monthly sheets for ophthalmology. Vol. 218, No. 6, 2001, pp. 451-454, here p. 452; see. Patton: Self-inflicted eye injuries: a review. In: Eye. Vol. 18, No. 9, 2004, pp. 867-872, here p. 869, where a correlation of pediatric cases of self-harm to the eye with Tourette's syndrome and Lesch-Nyhan syndrome is established; however, the inclusion of these syndromes is described by Khan et al .: Medical Management of Self-Enucleation. In: Archives of Ophthalmology. Vol. 103, No. 3, 1985, pp. 386-389, here p. 388, characterized as incorrect. See also Fan: Autoenucleation. In: Psychiatry. Vol. 4, No. 10, 2007, pp. 60-62, here p. 61.
  10. ↑ a b Gamulescu et al .: Enucleation as a form of autoaggression. In: Clinical monthly sheets for ophthalmology. Vol. 218, No. 6, 2001, pp. 451-454, here p. 451.
  11. ↑ a b c Fan: Autoenucleation. In: Psychiatry. Vol. 4, No. 10, 2007, pp. 60-62, here p. 62.
  12. ↑ a b c Gamulescu et al .: Enucleation as a form of autoaggression. In: Clinical monthly sheets for ophthalmology. Vol. 218, No. 6, 2001, pp. 451-454, here p. 453.
  13. ↑ a b c d e f g h Khan et al .: Medical Management of Self-Enucleation. In: Archives of Ophthalmology. Vol. 103, No. 3, 1985, pp. 386-389, here p. 388.
  14. ^ Patton: Self-inflicted eye injuries: a review. In: Eye. Vol. 18, No. 9, 2004, pp. 867-872, here p. 868.
  15. ↑ a b c d Patton: Self-inflicted eye injuries: a review. In: Eye. Vol. 18, No. 9, 2004, pp. 867-872, here p. 869.
  16. ↑ I. Tuwir, E. Chako, D. Brosnahan, L, Cassidy: Drug induced autoenucleation with Resultant chiasmal damage. In: British Journal of Ophthalmology. Vol. 89, No. 1, January 2005, p. 121, doi : 10.1136 / bjo.2004.049676 , PMC 1772460 (free full text).
  17. ↑ a b c d e Patton: Self-inflicted eye injuries: a review. In: Eye. Vol. 18, No. 9, 2004, pp. 867-872, here p. 870.
  18. ^ Khan et al .: Medical Management of Self-Enucleation. In: Archives of Ophthalmology. Vol. 103, No. 3, 1985, pp. 386-389, here pp. 388 f.