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Self-induced, Bilateral Retinal Detachment in Tourette Syndrome
Arch Ophthalmol. 2004;122:930-931.
In 1885, the French neurologist Georges Gilles de la Tourette described 9 patients with childhood-onset tics accompanied in some by uncontrollable noises and utterances, as well as hyperactivity and obsessive-compulsive behavior.1 The current diagnosis of Tourette syndrome, according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), involves multiple motor tics and at least 1 vocal tic, which occur many times a day, nearly every day, or intermittently for more than 1 year. Tics must begin before age 18 years.2 The average age of onset is 7 years, and boys are more commonly affected than girls. Motor tics are characterized by involuntary movements such as facial grimacing, frequent eye blinking, blepharospasm, spitting, and arm jerking. Vocal tics often have an aggressive or sexual component, such as grunting, barking, echolalia, and coprolalia (uncontrolled swearing). The condition often results in deleterious social consequences. We report a case of self-induced bilateral retinal detachment in a young man with Tourette syndrome who was initially referred for monocular hyphema.
Report of a Case
A 25-year-old white man was initially seen with a 1-week history of floaters and decreased vision in his left eye. The patient had been diagnosed with Tourette syndrome at age 7 years, obsessive-compulsive disorder at age 11 years, and depression at age 24 years. His motor tics involved excessive blinking, blepharospasm, clapping, jabbing his fingers into his eyes, and punching himself in the periorbital area. The patient was taking buspirone hydrochloride (10 mg twice a day) and clomipramine hydrochloride (25 mg twice a day). On examination, the patient was alert and oriented, and he had no evidence of cognitive impairment. Visual acuity was 20/200 OD and hand motion OS. There was no afferent pupillary defect. Intraocular pressures were 18 OD and 16 OS. Slitlamp examination findings of the right eye demonstrated pigment deposits on the corneal endothelium, moderate (2+) aqueous pigmented cells, and posterior subcapsular cataract. The left eye had a less than 1-mm hyphema and many (4+) circulating red blood cells in the anterior chamber, as well as a dense posterior subcapsular cataract. Funduscopy results revealed a retinal dialysis from the 1:30 to the 4:30 clock position with a macula-on-retinal detachment in the right eye. Vitreous hemorrhage was present centrally in the left eye, and there were nasal and temporal giant retinal tears. The right eye was repaired with a scleral buckling procedure. The left eye underwent anterior segment washout, pars plana lensectomy, pars plana vitrectomy, endolaser, and silicone oil injection. Intraoperatively, the giant retinal tears were found to extend from the 12:30 to the 4:30 clock position with 4 long radial extensions to the temporal macula and from the 6-o'clock to the 11-o'clock position with 1 long radial extension to the optic disc. There was an additional radially oriented posterior retinal break. Postoperatively, the retinas were attached in both eyes. One month later, the left eye developed proliferative vitreoretinopathy with retinal detachment and underwent reoperation. At 6 months, the retinas remained attached and the visual acuity was 20/100 OU.
Comment
Ophthalmic manifestations of Tourette syndrome include frequent blinking and blepharospasm, gaze deviations and abnormal saccades, and accidental and self-inflicted ocular injuries.3-5 The retinal detachments in our patient were most likely the result of repeated, self-induced finger jabbing to the eyes since the patient had no other risk factors for retinal detachment. In patients with retinal detachment, factors suggesting a traumatic etiology typically include unilateral vitreoretinal findings, retinal dialysis or giant retinal tear, and age younger than 40 years.6-7 However, in patients with self-induced or repeated trauma, the vitreoretinal pathologic features may be bilateral, as demonstrated by our patient. To prevent further self-injury, patients should wear protective polycarbonate goggles, and they should be monitored closely in conjunction with the psychiatry service. Treatment of the underlying disorder with behavior modification and pharmacotherapy is essential, and pharmacological agents that antagonize dopamine are most effective in reducing the severity of motor and vocal tics.
The authors have no relevant financial interest in this article.
AUTHOR INFORMATION
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Sue Lim, MD;
Kourous A. Rezai, MD;
Gary W. Abrams, MD;
Dean Eliott, MD
Detroit, Mich
Corresponding author: Dean Eliott, MD, Kresge Eye Institute, Wayne State University School of Medicine, 4717 St Antoine, Detroit, MI (e-mail: deliott{at}med.wayne.edu).
REFERENCES
1. Jankovic J. Tourette's syndrome. N Engl J Med. 2001;345:1184-1192.
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2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, DC: American Psychiatric Association; 1994:100-105.
3. Tatlipinar S, Sener EC, Ilhan B, Semerci B. Ophthalmic manifestations of Gilles de la Tourette syndrome. Eur J Ophthalmol. 2001;11:223-226.
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4. Margo CE. Tourette syndrome and iatrogenic eye injury. Am J Ophthalmol. 2002;134:784-785.
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5. Robertson MM, Trimble MR, Lees AJ. Self-injurious behaviour and the Gilles de la Tourette syndrome: a clinical study and review of literature. Psychol Med. 1989;19:611-615.
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6. Goffstein R, Burton TC. Differentiating traumatic from nontraumatic retinal detachment. Ophthalmology. 1982;89:361-368.
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7. Eliott D, Avery RL. Nonpenetrating posterior segment trauma. Ophthalmol Clin North Am. 1995;8:647-666.
SECTION EDITOR: W. RICHARD GREEN, MD
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