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An elderly woman with schizophrenia presented with a pair of scissors penetrating her left orbit and an enucleated right globe. Computed tomography (CT) revealed a pair of scissors penetrating the superior orbital fissure, with the blades traveling lateral to the left cavernous sinus and midbrain and ending just superior to the left cerebellar hemisphere.

She underwent left pterional craniotomy and removal of the scissors, with insertion of an external ventricular drain. Exploration under anesthesia revealed no left globe rupture, but the globe had been severed from the ophthalmic artery and nerve.

Fig.1 The patient at presentation in the emergency department, with scissors penetrating the left orbit.

Further patient psychiatric history revealed poor compliance with medication, leading to intense hallucinations of her deceased son’s voice telling her that her eyes were “evil” and required removal. She died 5 months later after developing an intracranial abscess.

Autoenucleation is predominantly a manifestation of psychosis, especially if there are concurrent delusions that a patient’s eyes pose a threat to themselves or their loved ones. Initial emergency management includes CT to rule out subarachnoid hemorrhage. Antipsychotics should be considered, perhaps even in the absence of psychotic symptoms because of the near certainty of an underlying psychosis.

Fig.2 CT showing the scissors traveling to the superior aspect of the left cerebellar hemisphere. And a 3D CT reconstruction image.

Subsequent inpatient management includes one-to-one nursing, fingerless mittens, and arm restraints; these may be the only way to prevent deluded and determined patients from causing more damage as antipsychotic medications take effect. Prevention is key; mental health practitioners should be alert to delusions about eyes and consider regularly assessing a patient’s risk of self-mutilation.

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