A 23 year old man was referred from the emergency department with sudden bilateral eye pain and visual loss. On further history, he had been made redundant at work that day, and had proceeded to 'try and blind' himself as a result. He had first poured alcohol over eyes, which was unsuccessful. He had then super-glued his eyelids open, cut both eyes with a razor blade, and pressed on his eyes. He denied consuming any alcohol or illicit drugs prior to the event. He also denied hallucinations and suicidal ideation. Past medical history included asthma, failure to thrive, and a number of behavioural problems including depression, nocturnal enuresis, and being bullied at school. There was no past history of self harm. He had previously taken Amitriptyline as a teenager, which had since been ceased.

On examination, he was a disheveled young man with blood stains on his face. He had a blunted affect but was otherwise coherent and appropriate. Visual acuity (VA) was hand movements (HM) in the right eye (OD) and count fingers (CF) in the left eye (OS). On slit-lamp biomicroscopy, both eyes were soft, with inferiorly peaked pupils. There was an inferior sub-conjunctival haemorrhage OD, with an underlying scleral laceration. There was an inferior conjunctival bleb OS, filled with visible uvea. Corneal folds, superficial punctate keratopathy and shallow anterior chambers were noted in both eyes. A superior cataract was noted in the OD. The retinas could not be assessed. The patient was given oral levofloxacin 500 mg, and arrangements were made for urgent surgical repair. Preliminary psychiatric assessment of the patient elicited a sense of regret at having attempted to blind himself, as well as chronic indicators of low mood, self esteem and confidence.

Operative repair was carried out 4 hours later by a consultant ophthalmologist, under general anaesthesia. Horizontal perforating scleral lacerations, measuring approximately 1.1 mm OD and 1.3 mm OS in length, were found approximately 3 mm inferior to the limbus in both eyes. The prolapsed uvea OS was repositioned into an intraocular position, after which the scleral lacerations and conjunctiva were repaired with 8.0 nylon and vicryl sutures, respectively. Subconjunctival cefuroxime and gentamicin were given. Indirect ophthalmoscopy revealed a flat retina OS, and poor view OD due to the cataract. The patient was awakened from general anaesthesia without difficulty.

The following day the VA was CF OD, and 6/36 OS, and B-scan ultrasonography showed flat retinas in both eyes, with localized inferior vitreous haze/blood. Over the remainder of the five day admission, VA progressively improved to 6/12 OS, but remained worse OD due to the cataract. Further psychiatric assessment elicited no psychosis or suicidal thoughts, poor mood and insight, and a tendency towards social anxiety and avoidance. The psychiatric plan was for discharge when medically fit, and follow up was arranged. The patient was subsequently commenced on Fluoxetine 20 mg daily, which was ceased after 12 months by the psychiatric care team.

Over the two months after discharge the patient attended regular ophthalmic outpatient follow up. VA OS continued to improve to 6/5+4, but remained stable OD at HM. The right cataract progressed to the point where no view of the right retina was possible. Uncomplicated cataract surgery was carried out OD, 81 days after the initial injury. A month later VA OD was 6/6+3 with pin-hole correction, and the patient was reading well. Nine months after the injury, VA with both eyes was 6/5 after refraction. Early posterior capsular opacification was noted OD, and an early nuclear sclerotic cataract noted OS, presumably a late developing complication of the initial trauma. Treatment of these findings, as well as refraction for the lack of accommodation in the pseudophakic eye, was discussed and further follow up arranged. However the patient failed to attend and was lost to follow up. There has been no reported repetition of deliberate self-harm since this episode.