Repair of scleral rupture and total retinal detachment in a self-injuring psychotic patient under local anesthesia: a case report

Purpose. Ocular self-injury by psychotic patients is an uncommon cause of o cular morbidity that poses peculiar problems. This report describes a schiz ophrenic self-injuring patient with scleral rupture and retinal detachment (RD), treated under loco-regional anesthesia. Case report. A 65-year-old man presented with scleral rupture, hyphema, tra umatic lens luxation, vitreous prolapse, vitreous hemorrhage and total RD a fter deliberately hitting his head. The fellow eye had been successfully op erated with scleral buckle surgery for the same reason two years earlier. T he patient underwent a two-step surgical procedure under local anesthesia, with repositioning and resection of the uveal prolapse and scleral rupture repair and, separetely, lens removal pars plana vitrectomy (PPV), membrane peeling, retinotomy, laser treatment and SiO tamponade. Results. Twelve months after PPV, the cornea was clear, IOP was 16 mmHg, th e retina was attached and VA was 20/200. The fellow eye maintained 20/30 VA . Conclusions. In psychotic patients the intrinsic difficulty of a traumatic RD is combined with systemic illness, no compliance and the risk of recurre nce. Although ocular traumas usually require general anesthesia, this patie nt undewent both interventions under local anesthesia with sedation, becaus e of his psychotic condition and chronic liver failure. Local anesthesia an d sedation proved effective in controlling pain and intra-operative complia nce even in such a difficult patient. Although it is reasonable to question operating on such patients, we nonetheless believe that every attempt shou ld always be made at gaining useful vision in both eyes since these patient s are at a high risk of recurrent ocular trauma.