This case from Virchester is not one to read if you are of a nervous disposition. As always the case is hypothetical to illustrate the learning points (see note below on St.Emlyn’s cases).
A man in his twenties is brought to the ED with a paramedic crew. You review him in the rapid assessment unit and find a calm, chatty, rather happy chap sat on the trolley with a bandage around his head obscuring his eyes. This appears to be home made out of a t-shirt and although there is some blood staining there is no active bleeding.
The paramedics look distressed and hand you a small plastic box of the type that you might normally put sandwiches in.
What’s in the box?
You look inside the box and find two of these.
Well actually they look somewhat more like these. Yup, the box contains two eyeballs with some elements (muscles) attached to the sclera and a strip of optic nerve hanging off the back.
You ask the patient what has happened and he tells you the following. ‘I have taken my eyes out as they have offended god.’
What’s happened here?”
He quotes Matthew 5:29
“And if thy right eye offend thee, pluck it out, and cast it from thee: For it is profitable for thee that one of thy members should perish, and not that thy whole body should be cast into hell.”
I am no expert in religion but this passage does seem to be fairly well known and is the subject of many links and videos on the internet that interpret in rather less dramatic ways than the text appears above. As an example I did find this on youtube, which dismisses the instruction through interpretation. It would seem that for some patients the distinction between the written word and the interpretation is sadly lost.
He appears to be happy and relaxed, joking even with the nurses and paramedics. He is not distressed and appears to be in little or no pain. You examine under the bandage and see that he has indeed removed both eyes. He says that he did this using his fingers and a kitchen knife. He does not want painkillers, is unconcerned by the loss of sight but is happy to cooperate with the assessment. He agrees to talk to the psychiatrists and to be admitted to hospital.
So what’s the diagnosis?
The underlying diagnosis here is most likely to be a major psychiatric illness such as schizophrenia. Whilst patients suffering from other conditions such as structural brain disease or those with a drug related psychosis may also succumb, the majority will have established psychiatric disease. Auto-enucleation of the eyes is a manifestation of that underlying disease rather than being an entity in itself though the term Oedipism is often used to describe it.
The term is thought to derive from Sophocle’s play about Oedipus Rex. In the play Oedipus removes his eyes on discovering that he has unwittingly murdered his father and married his mother.
In terms of management in the ED then this is a clear case where the patient requires co-ordinated care between the psychiatrists and the ophthalmology teams. The clinical role of the ED physician is to ensure that the patient is safe, that they are covered for tetanus, well bandaged and comfortable. The management role is in the co-ordination of the admitting clinical teams and security staff (if needed) to the benefit of the patient, this can be challenging as ophthalmology wards don’t usually have acutely psychotic patients, and psych don’t usually have patients who have been enucleated. Personally I’ve not encountered problems locally, but colleagues at St. Elsewhere have.
Is it always the eyes?
As Oedispism is linked closely to the eyes, then arguably no, for that term to be used it is restricted to autoenucleation. However, patients with similar delusions may remove other body parts such as the genitalia or limbs.
The ‘others'”] These cases are by their nature tragic. From the patient and their relatives perspective the nature of the injury will obviously have severe long term consequences with significant associated disability.
I have also noticed that these cases are ones that tend to stick in the memory longer than many of the other tragedies that we see as emergency physicians. Whilst not the high intensity resus case that usually attracts the formal debrief in the ED, these cases are worth following up with the team involved after a day or two. These cases affect staff in different ways and whilst dramatic any clinician can be affected, and perhaps that’s no bad thing.
There is quite a lot published in this area, but mostly in the Ophthalmology and Psychiatric literature. However, it is highly likely that most patients will come through the emergency department on their way through to the specialists. The article by Fan is a great place to start if you want to know more.
- Fan AH., Autoenucleation. A Case Report and Literature Review. Psychiatry (Edgmont). 2007 October; 4(10): 60–62.
- Schargus M, Schneider E, Klink T. Autoenucleation in a 84-year-old. Int Ophthalmol. 2009 Aug;29(4):281-3. doi: 10.1007/s10792-008-9222-6. Epub 2008 Apr 10.
- Shiwach RS. Autoenucleation–a culture-specific phenomenon: a case series and review. Compr Psychiatry. 1998 Sep-Oct;39(5):318-22.
- Aung T, Yap EY, Fam HB, Law NM. Oedipism. Aust N Z J Ophthalmol. 1996 May;24(2):153-7.
- Schwerkoske JP, Caplan JP, Benford DM. Self-mutilation and biblical delusions: a review. Psychosomatics. 2012 Jul-Aug;53(4):327-33. doi: 10.1016/j.psym.2012.01.007. Epub 2012 May 30.
- Patil BB, James N.Bilateral self-enucleation of eyes.Eye (2004) 18, 431–432. doi:10.1038/sj.eye.6700667
Case studies on St.Emlyn’s
We do present hypothetical cases on St.Emlyn’s. These are based on the experience of our team as educationally active emergency physicians. For centuries doctors and nurses have used stories to teach and learn from each other. However, we are careful not to break any patient confidentiality rules. As a result if we present a case then it will always be fictional and not relating to any specific case or patient. For example if we present an (anonymised) X-ray or ECG we will create a clinical history that is compatible with the radiological/ECG findings but which does not relate to a specific time, location, patient or circumstance.
Whilst it may be argued that this detracts from the clinical learning we believe that patient confidentiality is more important in these matters.
We will create time, date, age, sex, details of the patient and their circumstances etc. Our cases are therefore an amalgam of different cases and experiences. Any resemblance to patients treated by us now, in the past or the future is entirely unintentional and accidental. Our cases are presented to help us all reflect and learn, in that way we might become better clinicians for our patient.
Vive la FOAM! (Free Online Medical Education).