Schizophrenia is a chronic and severe mental disorder that affects how a person thinks, feels, and behaves. Self-harm is a common complication of schizophrenia, and it can take many forms ranging from minor trauma to grievous injuries. This case report highlights the concerning form of self-harm leading to ocular injury, which led to serious complications of retinal detachment. This case report describes a 45-year-old male with paranoid schizophrenia who lost his eyesight due to self-harm leading to retinal detachment. The patient believed in having powers of the sun God Surya which were received by sun rays entering his eyes but later started hearing voices accusing him of being an imposter and cautioning him of punishment by the Gods. The felt that his eyes were the conduit for this connection and started punching himself regularly in both the eyes to break the connection. Gradually, he lost his eyesight due to blunt trauma to his eyes. The psychiatric evaluation revealed delusions of grandiosity, persecution, and reference, along with third- and second-person auditory hallucination, and delusional perception. The patient was initiated on the oral formulation of olanzapine at a dose of 20 mg hiked gradually in 4 weeks and received psychosocial interventions as well. This case report highlights the complexity of self-harm in schizophrenia and the need for a multifaceted approach to address it effectively. Individuals with schizophrenia who engage in self-harm should receive prompt medical attention to address any physical injuries and prevent long-term complications such as permanent vision loss.

Retinal detachment, Schizophrenia, Treatment

Mudgal V, Savita V, Shah K (2023) The Curse of Surya: A Rare Case Report on Retinal Detachment in a Patient of Schizophrenia. Ann Psychiatry Ment Health 11(1): 1182.

Paranoid schizophrenia is a chronic mental illness characterized by the presence of delusions, hallucinations, and disordered thinking. Delusions are often persecutory or grandiose in nature and are often accompanied by auditory hallucinations. Schizophrenia is a severe mental disorder that affects 1% of the population worldwide [1]. Surya is a deity in Hindu mythology who is associated with the sun and is worshipped as the god of light and illumination. In Hinduism, Surya is an important deity and is often worshipped in the morning as a part of daily rituals and prayers. He is also associated with knowledge, as he is believed to illuminate the world with his rays of light and dispel darkness and ignorance. In Hindu mythology, Surya is often depicted as a benevolent deity who bestows blessings on his worshippers, but he is also believed to be capable of great power and wrath. Self-harm is a serious concern for individuals with mental health conditions, particularly those with schizophrenia. Schizophrenia is a chronic and severe mental disorder that affects how a person thinks, feels, and behaves. People with schizophrenia often experience symptoms such as hallucinations, delusions, and disordered thinking. Unfortunately, self-harm is a common complication of schizophrenia, and it can take many forms, including cutting, burning, or hitting oneself. One particularly concerning form of self-harm in schizophrenia is self-harm leading to ocular injury, which can lead to serious complications such as retinal detachment. Retinal detachment is a condition in which the retina separates from the back of the eye, which can cause vision loss if not treated promptly. This type of self-harm can be particularly challenging to manage as it not only affects the patient’s mental health but also their physical health and well-being. It is important to understand the underlying causes of self-harm in schizophrenia and work with healthcare professionals to develop appropriate treatment plans. In addition, individuals with schizophrenia who engage in self-harm should receive prompt medical attention to address any physical injuries and prevent long-term complications such as permanent vision loss. As per research done by Large et al., the Reported clinical diagnosis in serious self-inflicted ocular injury was found to be schizophrenia in around 85% of cases [2]. Overall, self-harm in schizophrenia is a complex issue that requires a multifaceted approach to address effectively. In this report, we present a case of a 45-year-old male with paranoid schizophrenia, who developed grandiose delusions and auditory hallucinations after staring at the sun for a prolonged duration and subsequently lost his eyesight due to retinal detachment along with a focus on the phenomenology of schizophrenia and management in the context of self-inflicted injuries.

A 45-year-old male, who is a devout Hindu, labor by occupation was referred from the department of ophthalmology with complaints of odd behavior, talking to himself, and suspiciousness. He had visited the department of ophthalmology due to complaints of diminution of vision in both eyes. After evaluation and fundal examination, he was found to have rhegmatogenous retinal detachment the reason for which was deemed to be blunt trauma [Figure 1].

Figure 1: Fundal examnination demonstrating retinal detachment seondary to self inflicted trauma.

On further inquiry, it was revealed that the patient had caused the ocular injury by punching himself regularly in both eye sockets. The patient was admitted to the department of psychiatry for detailed evaluation. During the clinical assessment, the patient reported that he is a devout Hindu and has been praying to the sun God daily for many years and offered water early in the morning while looking at the sun as a ritual. Around two years back like every day after he had performed his worship to the sun God and was pouring water by looking at the sun, he felt something strange and kept on staring at the sun for two to three minutes continuously. He reported developing a headache and discomfort in his eyes after staring at the sun, so he came back to his house and went to rest for a while. After waking up suddenly around two hours later, he felt a connection between himself and the sun god which was established by his staring at the sun through the sun rays, and his eyes were the conduit for this connection.

He started to believe that he had obtained the powers of the sun god and could lighten up the darkest of places, can control when the day dawns and the night sets, he felt the responsibility to remove darkness and punish the evil [Figure 2].

Figure 2: Patients representation of him acquiring power of Sun God

This sense of power and grandiosity continued, during which he stopped going to work as he believed to be meant for great things. He stopped performing his daily rituals as well as he felt he himself has a part of the sun God and often behaved like a person of importance and demanded his family members worship him. Around two to three months later, he started feeling that his powers were decreasing, as he is not able to control things around him. He started hallucinating which talked of how he had offended God by believing that he had the powers of the Sun God and that God would take revenge. The hallucinations were second and third-person in nature and constantly repeated to the patient – “you are an imposter; you have stolen God’s power and will be punished.” As he had a strong belief that it was through his rituals, he had obtained these powers he restarted his worship but his hallucinations continued. Then he developed the notion that it was through his eyes he obtained his powers and thus through his eyes, only he would be able to be rid of this punishment. Due to this notion, he started banging his head frequently and punched himself over the eyes to break the connection of his eyes to the sun. He did not choose any other mode of injuring his eyesight like stabbing or corrosive use so that his eye structure can remain intact as he wanted to offer his whole eyes as part of his penance to the sun God. Gradually he lost his eyesight due to retinal detachment due to recurrent blunt trauma to his eyes.

Upon psychiatric evaluation, he was found to have delusions of grandiosity, persecution, and reference, along with third- and second-person auditory hallucination, and delusional perception, with poor insight. A diagnosis of Paranoid schizophrenia was made, on clinical assessment using Brief Psychiatric Rating Scale he had a score of 72 out of 126. The patient was initiated on the oral formulation of olanzapine at a dose of 10 mg hiked gradually in four weeks to 20 mg. The patient showed partial response to medication, the BPRS score reduced from 72 to 56. Liaison with the department of ophthalmology was maintained, and the poor prognosis of the retinal detachment was explained. Initially, the patient was apprehensive about seeking ophthalmic care because if his eyesight improves the sun God might torture him again which proved to be a barrier to his treatment. After six months of continuous treatment along with psychoeducation and supportive psychotherapy, the patient had significant improvement in symptoms and had developed insight as well. He started to do his activities of daily living but remained anxious about his symptoms returning. His eyesight remained compromised with complete vision loss in the left eye and partial loss in the right eye, for which he was under review by the department of ophthalmology. Owing to the chronic nature and poor prognosis of the retinal detachment his surgery was deferred.

Self-inflicted eye injury in schizophrenia is a rare but severe form of self-harm that can lead to significant physical and psychological harm. Schizophrenia is a chronic and severe mental disorder that affects how a person thinks, feels, and behaves. Patients with schizophrenia are at an increased risk of self-harm and suicide, and eye injuries are one of the potential forms of selfinjury that can occur in these patients. Various authors in the past have reported self-harm in the context of schizophrenia, however, cases of retinal detachment secondary to self-inflicted traumatic injury have been rarely discussed [3-5]. This case highlights the need for a culturally sensitive approach to the evaluation and management of psychiatric symptoms. This case also emphasizes the importance of exploring cultural and religious beliefs in the evaluation and management of psychiatric symptoms.

The case presented above is a unique case of paranoid schizophrenia, where the patient’s religious beliefs played a significant role in the development of his delusions. The patient’s belief in the sun god and his perception of the sun’s rays being the conduit for his connection with the god is a fascinating initiation to his psychosis by the process of delusional perception. The patient also had a grandiose delusion, where one believes they have a special power or relationship with a deity or supernatural entity. Delusional perception designates a sudden, idiosyncratic, and often self-referential delusion triggered by neutral perceptual content [6].The patient believed that staring at the sun imbibed him with the powers of the sun God. This explains the phenomenon of “two-membered ness” seen in delusional perception, which means that the patient assigns a new delusional meaning to normal perception, and links both of them internally.

The case described above highlights the complexity of the presentation of self-inflicted eye injury in schizophrenia. The patient’s belief that his eyes were the conduit for his connection to the sun god led him to repeatedly punch himself in the eye sockets, causing retinal detachment and vision loss. The patient’s actions were driven by his delusions and hallucinations and were not motivated by suicidal intent. The patient’s case highlights the need for early identification and management of schizophrenia to prevent the development of delusions and hallucinations that can lead to self-injury.

Schizophrenia can lead to self-harm in various ways, including cutting, burning, mutilating, and hitting oneself. In addition to acting out on the psychosis patients with schizophrenia may experience emotional dysregulation, which can lead to impulsive behavior and increased risk of self-harm [7]. Self-inflicted eye injury is a rare but severe form of self-harm that can lead to permanent vision loss and other ocular complications. Patients with schizophrenia who engage in self-inflicted eye injury may use various methods, including punching or hitting oneself, poking oneself in the eye, or using foreign objects to damage the eye. The resulting ocular complications can include retinal detachment, corneal abrasion, globe rupture, and orbital fractures, among others [8].

Previous literature has established that early identification and management of schizophrenia is crucial in preventing self-harm and promoting patient safety [9,10]. Antipsychotic medications are the mainstay of treatment for schizophrenia, and they can effectively reduce the severity of positive symptoms such as hallucinations and delusions. Psychosocial interventions such as cognitive-behavioral therapy, psychoeducation, and supportive psychotherapy can also help patients manage their symptoms and prevent the development of self-harm behaviors. Family therapy can also be beneficial in improving communication and reducing stress within the family unit. Patients who engage in self-inflicted harm present a unique challenge for both psychiatrists and nursing staff, necessitating a customized management plan. To meet the diverse needs of such patients, a combination of behavioral, pharmacological, and psychotherapeutic interventions is necessary. It is important to consider schizophrenia as a potential differential diagnosis in cases of self-inflicted injuries.

In conclusion, self-inflicted eye injury is a severe and rare form of self-harm that can occur in patients with schizophrenia. Patients with schizophrenia who engage in self-harm may use various methods to inflict injury upon themselves, and the resulting ocular complications can lead to permanent vision loss and other ocular complications. Timely recognition and effective management of schizophrenia, particularly in cases involving grandiose or persecutory hallucinations, is imperative in mitigating the risk of self-harm and ensuring patient well-being. This involves the judicious use of antipsychotic medications and psychosocial interventions. Collaborative care between psychiatry and ophthalmology departments can also help ensure comprehensive care for patients with self-inflicted eye injuries. Further research is needed to understand the complex relationship between culture, religion and psychopathology of mental illness to develop more effective treatment strategies.

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