Psychological distress and coping following eye removal surgery.

Purpose: Psychological distress is reasonably well documented in people with facial disfigurement; however, in patients following eye removal surgery this has not been studied adequately. We hypothesised that lower distress levels would be associated with age and more adaptive coping strategies and that women would be more likely to report higher levels of distress and, therefore, use maladaptive coping strategies.Methods: This exploratory, cross-sectional study measured distress and coping in a sample of 56 post enucleation or evisceration patients. The Hospital Anxiety and Depression Scale and the Brief COPE measured distress and coping strategies.Results: In all, 25.5% and 10.9% of the sample had high levels of anxiety and depression, respectively. Significant associations were found between levels of distress, coping strategies and demographic variables (p < .05). There were significant differences in coping strategies between those with higher and lower levels of distress (p < .05). Females reported higher levels of anxiety (U = 202.5, p < .01) and depression (U = 229, p < .05) than males. Those who experienced enucleation or evisceration aged between 20 and 39 years reported significantly higher levels of depression compared with other age groups (U = 68.5, p < .01).Conclusions: There was a relatively low level of distress across the whole sample, but we found high levels of distress in a considerable proportion (18.18%) of participants. Participants' coping strategies and levels of distress were correlated. Females and participants aged between 20 and 39 years at time of eye removal were particularly vulnerable to distress.

A Case of Self-Enucleation in an Incarcerated Patient: Case Report and Review of Literature.

Self-enucleation is a severe form of self-injurious behavior which presents as an ophthalmologic and psychiatric emergency. It is usually known to occur with untreated psychosis, however, there have been reports of self-enucleation across various psychopathologies. We review a case documenting self-enucleation in the forensic setting in a patient with an unusual presentation and cluster of psychotic symptoms. Literature was reviewed using PubMed/Medline databases with key terms: "forensic science," "forensic psychiatry," "auto-enucleation," "self-enucleation," "Oedipism," "self-harm." This case is unique as it offers an alternative presentation to those most commonly depicted in current literature, helps highlight the sparsity of literature depicting self-enucleation in the forensic setting, and stimulates discussion around various potential differential diagnoses, management strategies and complications of self-enucleation within the forensic setting. It is prudent to emphasize need for aggressive and collaborative treatment for the forensic population regardless of psychopathology, presentation, or propensity for secondary gain.

Gender and Racial Disparities in Cases of Autoenucleation.

OBJECTIVE: This review demonstrates the gender and racial disparities among patients who have committed ocular autoenucleation. DESIGN: Peer-reviewed articles were identified and reviewed on the basis of a literature search in PubMed/MEDLINE and Ovid/EMBASE databases from all available literature to date. RESULTS: We identified 60 cases of autoenucleation published in contemporary literature with nine attempted cases. The ratio of men to women who have committed autoenucleation is 8:1. Only 28 cases of autoenucleation included confirmed reports of racial makeup. 17 out of 28 cases were White, eight out of 28 cases were Hispanic or Asian, and only three cases were Black. White patients account for 61% of the cases, while Black patients make up 11% and other races constitute 28%. The common underlying psychiatric motivations among autoenucleation patients include biblical interpretations, religious delusions, and paranoia of the eye. The most common associated psychiatric disorders among patients with autoenucleation include schizophrenia, major depressive disorder, and bipolar disorder. CONCLUSION: Autoenucleation largely occurs amongst male patients with active psychiatric disorders. Our findings challenge previously published reviews where the incidence of autoenucleation is reported as equal for the two sexes. A higher incidence among the White population is also suggested. This is the first time gender and racial disparity have been demonstrated with respect to autoenucleation.

[Ocular prosthetics. Fitting, daily use and complications]. / Augenprothetische Versorgung. Anpassung, Handhabung und Komplikationen.

BACKGROUND: Ocular prosthetics make a decisive contribution to the functional, esthetic and psychosomatic rehabilitation of patients after ocular extirpation. OBJECTIVES: This article provides an overview of the fitting, daily care and complications of ocular prosthetics. METHODS: The study comprised a PubMed literature review and own clinical results. RESULTS: Ocular prosthetics made from cryolite glass or perspex can be manufactured and fitted 5-8 weeks after removal of the eye. During this period a conformer is placed within the conjunctival sac in order to prevent scar formation and shrinking of the socket. Artificial eyes can be worn continuously, only interrupted by a short but regular cleaning procedure. Artificial tears and lid hygiene improve the comfort of wearing. Glass prostheses have to be renewed every 1-2 years, while perspex prostheses need to be polished once a year. Complications, such as giant papillary conjunctivitis or blepharoconjunctivitis sicca are facilitated by poor fit, increased age and inappropriate care of the prosthetic device. In the case of socket shrinkage or anophthalmic socket syndrome, surgical interventions are needed to re-enable the use of an artificial eye. CONCLUSION: Adequate fitting, daily care of ocular prosthetics and therapeutic management of associated complications are mandatory for a durable functional, esthetic and psychosomatic rehabilitation after ocular extirpation.

Psychosocial Outcomes in Adult Survivors of Retinoblastoma.

PURPOSE: Survival rates for individuals diagnosed with retinoblastoma (RB) exceed 95% in the United States; however, little is known about the long-term psychosocial outcomes of these survivors. PATIENTS AND METHODS: Adult RB survivors, diagnosed from 1932 to 1994 and treated in New York, completed a comprehensive questionnaire adapted from the Childhood Cancer Survivor Study (CCSS), by mail or telephone. Psychosocial outcomes included psychological distress, anxiety, depression, somatization, fear of cancer recurrence, satisfaction with facial appearance, post-traumatic growth, and post-traumatic stress symptoms; noncancer CCSS siblings served as a comparison group. RESULTS: A total of 470 RB survivors (53.6% with bilateral RB; 52.1% female) and 2,820 CCSS siblings were 43.3 (standard deviation [SD], 11) years and 33.2 (SD, 8.4) years old at the time of study, respectively. After adjusting for sociodemographic factors, RB survivors did not have significantly higher rates of depression, somatization, distress, or anxiety compared with CCSS siblings. Although RB survivors were more likely to report post-traumatic stress symptoms of avoidance and/or hyperarousal (both P < .01), only five (1.1%) of 470 met criteria for post-traumatic stress disorder. Among survivors, having a chronic medical condition did not increase the likelihood of psychological problems. Bilateral RB survivors were more likely than unilateral RB survivors to experience fears of cancer recurrence (P < .01) and worry about their children being diagnosed with RB (P < .01). However, bilateral RB survivors were no more likely to report depression, anxiety, or somatic complaints than unilateral survivors. CONCLUSION: Most RB survivors do not have poorer psychosocial functioning compared with a noncancer sample. In addition, bilateral and unilateral RB survivors seem similar with respect to their psychological symptoms.

Vision-Related Quality of Life and Appearance Concerns Are Associated with Anxiety and Depression after Eye Enucleation: A Cross-Sectional Study.

AIMS: To investigate the association of demographic, clinical and psychosocial variables with levels of anxiety and depression in participants wearing an ocular prosthesis after eye enucleation. METHODS: This cross-sectional study included 195 participants with an enucleated eye who were attending an ophthalmic clinic for prosthetic rehabilitation between July and November 2014. Demographic and clinical data, and self-reported feelings of shame, sadness and anger were collected. Participants also completed the National Eye Institute Visual Function Questionnaire, the Facial Appearance subscale of the Negative Physical Self Scale, and the Hospital Anxiety and Depression Scale. Regression models were used to identify the factors associated with anxiety and depression. RESULTS: The proportion of participants with clinical anxiety was 11.8% and clinical depression 13.8%. More anxiety and depression were associated with poorer vision-related quality of life and greater levels of appearance concerns. Younger age was related to greater levels of anxiety. Less educated participants and those feeling more angry about losing an eye are more prone to experience depression. Clinical variables were unrelated to anxiety or depression. CONCLUSIONS: Anxiety and depression are more prevalent in eye-enucleated patients than the general population, which brings up the issues of psychiatric support in these patients. Psychosocial rather than clinical characteristics were associated with anxiety and depression. Longitudinal studies need to be conducted to further elucidate the direction of causality before interventions to improve mood states are developed.

Socioeconomic and psychological impact of treatment for unilateral intraocular retinoblastoma.

PURPOSE: To identify the socioeconomic and psychosocial impacts of clinical treatment decisions for advanced unilateral intraocular retinoblastoma. DESIGN: Retrospective observational case series. SETTING: institutional study at Alexandria Main University Hospital. STUDY POPULATION: records of 66 unilateral retinoblastoma cases treated from May 2005 to May 2013 were retrospectively reviewed. Sixty cases were eligible (International Intraocular Retinoblastoma Classification [IIRC] group C, D or E). PROCEDURES: two treatment groups were compared: enucleation vs. salvage treatment. Salvage treatment eyes were further subdivided based on IIRC group. Six socioeconomic parameters (financial burden, financial impact, psychological, social, medical and tumor impacts) were scored. Parameter scores ranged from 0 to 3, for overall score range 0 (no adverse impact) to 18 (severe adverse impact). MAIN OUTCOME MEASURES: derived Socioeconomic scores were correlated with treatment and outcomes. RESULTS: The enucleation group (28 eyes) had a median overall Socioeconomic score of 4/18, significantly lower than the salvage treatment group (32 eyes), median score 11/18 (P<0.01). Socioeconomic score varied with IIRC group. Attempted eye salvage failed in 25 children, due to uncontrolled tumor (44%) and socioeconomic impact of cumulative therapies (56%). Treatment duration and Socioeconomic score were higher for the 5 children in the salvage treatment group who developed metastatic disease compared to those without metastasis (P<0.01). CONCLUSIONS: The socioeconomic and psychosocial impacts of attempted ocular salvage for unilateral intraocular retinoblastoma are severe, in comparison to primary enucleation. Primary enucleation is a good treatment for unilateral retinoblastoma.

Evaluación y manejo de los insulinomas. Presentación de 4 casos y revisión de la literatura / Evaluation and management of the insulinomas. Report of four cases and review of the literature

Introducción: Los insulinomas son tumores neuroendocrinos poco frecuentes que habitualmente tienen buen pronóstico. El objetivo es la presentación y revisión de la literatura médica a propósito de 4 casos. Material y Métodos: Estudio descriptivo, observacional y retrospectivo de los pacientes diagnosticados e intervenidos en el Hospital Universitario de San Juan de Alicante de insulinomas, en un periodo de 18 años (1995-2013). Resultados: Nuestro grupo de estudio incluyó 4 pacientes, 1 caso en hombres (25%) y 3 en mujeres (75%), con una mediana de edad de años (rango 3; 72). La distribución de las lesiones fue : cuerpo (1 caso), proceso uncinado (1 caso), cabeza (1 caso), cola (1 caso). El diagnóstico preoperatorio se realizó mediante test del ayuno y Tac abdominal. La ecografía intraoperatoria se realizó en todos los casos. El procedimiento quirúrgico de elección fue la enucleación. Actualmente se encuentran libres de enfermedad en un seguimiento a 10 años. Conclusiones: Los insulinomas son tumores infrecuentes que presentan buen pronóstico a largo plazo. Su diagnóstico topográfico en ocasiones es complejo. El tratamiento de elección es la cirugía y el procedimiento quirúrgico empleado con mayor frecuencia es la enucleación

Background: Insulinomas are infrecuent neuroendocrine tumors that usually have a good prognosis. The goal is the presentation and review of the literature about 4 cases. Methods: A retrospective study of all patients diagnosed with insulinomas surgically managed at San Juan de Alicante Hospital during the period between 1995 and 2013 was performed. Results: We analyzed 4 patients, three females (75%) and one male (25%) with a range age (39 to 72 years). Distribution of the lesions were: body (1 case), uncinate process (1 case), head (1 case), tail (1 case). Preoperative diagnosis was made by fasting test and abdominal CT. In all cases, intraoperative ultraound was made. Surgical management of choice was enucleation. Currently, they are free of disease at 10 years of follow up. Conclusions: Insulinomas are infrecuent tumors with good long-term prognosis. Its topographic diagnosis is sometimes complex. The treatment of choice is surgery and the surgical procedure most often used is enucleation

Health-related quality of life after surgical removal of an eye.

PURPOSE: This study compared the general health-related quality of life (HRQOL) and the vision-specific HRQOL in patients following the surgical removal of 1 eye who had good vision in the remaining eye to a group of binocular patients with good vision in OU. METHODS: The Medical Outcomes Study Short Form 12 and the National Eye Institute Visual Function Questionnaire HRQOL surveys were administered to 29 patients who had surgical removal of an eye who attended an ocular prosthetics clinic and to 25 binocular persons who accompanied a patient. All subjects in each group had best-corrected visual acuity of 20/40 or better. Overall statistical significance was tested using Cramer's V followed by individual t tests for independent groups for each of the scales on the 2 questionnaires to determine whether the means between the 2 groups differed statistically. RESULTS: The patient group had a mean age of 50.98 years (range, 19-76 years). The control group had a mean age of 49.46 years (range, 18-76 years). The mean time after loss of vision was 28.03 years (range, 1-71 years), and the mean time from surgical removal of the eye was 23.6 years (range, 0.5-59.5 years). There was an overall significant difference between the 2 groups on the 15 derived subscales of the 2 forms (Cramer's V, p = 0.0025). Three general HRQOL subscales (Short Form 12-mental component summary, Short Form 12 physical component summary, and National Eye Institute Visual Function Questionnaire-General Health) showed no differences between the 2 groups (p = 0.48, p = 0.81, and p = 0.78, respectively). Three of the 12 vision-specific National Eye Institute Visual Function Questionnaire subscales demonstrated statistically significant differences between the patient and control groups: peripheral vision (p = 0.0006), role difficulties (p = 0.015), and the composite score (p = 0.014). In addition, 2 monocular patients had given up driving compared with no binocular subjects (p = 0.056). CONCLUSIONS: This population of monocular patients had general physical and mental HRQOL equivalent to the normal binocular group despite the surgical removal of 1 eye. However, the reduced vision-specific HRQOL of monocular patients on the National Eye Institute Visual Function Questionnaire indicates that there are substantial residual visual deficits even after prolonged monocular status.

[Traumatic enucleation. Accident or self-mutilation?]. / Traumatische Enukleation. Unfall oder Selbstverletzung?

A 52-year-old woman was admitted for emergency treatment after traumatic enucleation. Because of the position of the avulsed eye and the acute mental condition of the patient a trauma caused by self-mutilation could not be excluded. There was even the suspicion of self-enucleation in a second case and in both cases a psychiatrist was consulted but ultimately a disastrous accident was clearly verified for both patients. Nevertheless, an interdisciplinary evaluation should be initiated in cases of patients with a suspicious traumatic injury as in cases of self-mutilation the danger of relapse is high in the first hours and weeks after the primary event.

Prosthetic rehabilitation of a patient with enucleated eye - a case report.

BACKGROUND: The loss of an eye has a crippling effect on the psychology of the patient, making rehabilitation process challenging for both doctor and patient. OBJECTIVE: To report a case of anophthalmic socket with prosthetic rehabilitation in a cost effective manner. CASE: A 32-year-old female presented with anophthalmic socket for prosthetic rehabilitation. A custom made ocular prosthesis was implanted successfully. CONCLUSION: The custom made ocular prosthesis is simple, affordable and can be carried out in a small clinical set-up and provides a superior natural appearance.

Self-mutilation and biblical delusions: a review.

OBJECTIVE: To review the literature for cases of deliberate self-harm that directly reference Bible verses as a motivation for action and discuss predictive factors of such behaviors and post-injury management strategies. METHODS: Sixteen cases of self-mutilation prompted by Biblical verses were found in the existing literature. The authors also describe a novel case of penile amputation prompted by a verse from the Gospel of Matthew. RESULTS: Four biblical verses associated with self-mutilation were found, all from the Gospel of Matthew. All patients presented with a diagnosis of psychosis at the time of the event. Other common themes include substance abuse, guilt over sexual acts, absence of pain or regret, and destruction of the severed body part. CONCLUSIONS: Patients with symptoms of psychosis may misinterpret various verses from the Gospel of Matthew as instructions to engage in self-injurious behavior. Psychiatrists should be aware of these four verses to understand their significance and potentially forestall these behaviors.

Self-enucleation: forget Freud and Oedipus, it's all about untreated psychosis.

Self-enucleation is a rare but serious ophthalmological and psychiatric emergency. It has traditionally been considered to be the result of psycho-sexual conflicts, including those arising from Freud's Oedipal complex and Christian religious teaching. However, an analysis of published case reports suggests that self-enucleation is a result of psychotic illnesses such as schizophrenia. Early treatment with antipsychotic medication in the case of unilateral or threatened self-enucleation might prevent some cases of blindness.