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Show 'I', II.JHh Rdven rrl'~~, New Ynrk Blindness from Self-Inflicted Gunshot Wounds James R. K~an~, M.D. h)ur p.ltients Whll .1ttl'l11ptl'd suicide by using h'lIldguns sun'i"ed bit.lll'f.ll llplic nl'r\'t' dl'stfuclil1l1 wilh limill'd .ldditilln.ll nellrll!tlgic,ll d,lm,lge. From the Department of Neurology, Los Angell's CountyUniversity of Southern California Ml'dical Center, Los Angl'll's, California. Address correspondence and rt'print requests til j.ln1l'S R. Keane, M.D., 1200 N. State St., Los Angl'!t-s, CA '10(0). 247 Firearms are the most common means of suicide in the United States. The head is the target for nearly 90'7<, of men and 50'7c of women (80 lk overall) when handguns are the weapon (18'k of wounds are in the chest and 2l7c are in the abdomen). Rifle wounds involve the head about as commonly as do those from handguns, but shotgun suicides target the head only about onehalf of the time (1-3). Temple wounds (90'7< right-sided) are most common, regardless of the type of firearm used. With handguns, the open mouth is a distant second choice, followed by entry wounds under the chin and in the center of the forehead. The mouth is also the second choice with shotguns, whereas rifles are aimed more frequentlv at the forehead (1-3). When a gun is held to the anterior temple, the bullet may travel immediately behind the orbits, transecting both optic nerves, with relatively minor damage to frontal or temporal lobes. Suicide victims who "swallow the barrel" usually destroy the brainstem with instantlv fatal results, but gunshots aimed directly up'Nard behind the upper It'eth or beneath the chin may destwy lme optic nerve with little accompanying s~'mptomatic frontal lobe damage. The following four patients were blinded by gunshot suicide attempts with surprisingly little associated neuwlogical impairment. CASE HISTORIES Case 1 A 33-year-old man, with a past history of suicide attempts by hanging, automobile exhaust, and wrist slJshing, shot himself in the right temple. The bullet exilt'd the left temple, and the patient was immedialt'ly blind but never unconscious. On f. [( KEANE ,1dmissilll1 tll the hllSpit,ll, Ill' W,lS cllmb,ltive and cllntused, but \\',lS ,lble tll giVl' ,1 dl'l,liled history, I k sllllull'd rl'pl',lll'div lor Sllml'lllll' to "turn the light lin," Light pnceptilln WdS ,lbsl'nt in both l'\'l'S, till' tundi were 110rm,11, his pupils wen' fixed tll light, ,1Ild till' globl's Wl'rl' immobile, A CllmpUll'd tllmllg'''l ph V (CT) SCd n showed plll'U moCl'ph, llus ,lnd ,1 sm,lll right subdurdl hl'm,ltllm,l, His right llptic c,lIl,ll was sh,ltll'red ,1Ild the posll'rillr kft urbil W,lS disrupll'd (Fig, I), CHlltid ,1Ilgillg''' lphv showed no vascul'lr injuries, During his J-week hospital stay, he had no rl'turn of vision, but movements of his left lid and glolw improved considerably, One wel,k 'lfter discharge home in the carl' of his family, he succeedl'd in killing himself. Case 2 An I8-year-old woman shot herself underneath the right side of her chin and the build exill'd through the left side of her forehead without producing unconsciousness, On admission she was awake and walking about, but blind in the right eye, Vision in the left eye appeared normal and her eye movements were intact bilaterally, A CT scan showed bullet fragments superiorly between the frontal lobes. Angiograms were considered normal. Bullet and bone fragments were removed surgically from the tip of the left frontal lobe. On the fifth hospital day, without warning, she awoke completely blind, She had no light perception or pupillary light reactions in either eye in the presence of normal fundi. Repeat angiography now showed irregularity of the left supraclinoid carotid artery and a traumatic aneurysm of the anll'rior cerebral artery (Fig. 2). The left ophthalmic arll'ry was in severe spasm (Fig. 3), probably accounting for her delayed visual loss. On the seventh hospital day, she experienced a sudden cardiac arrest, presumably related to aneurysm rupture, and could not be resuscitated. Case 3 An 18-year-old man shot himself in the right temple, On admission he was blind and lethargic, but able to follow some commands. His pupils were fixed to light, but varied spontaneously in size; the optic fundi were normaL His angiogram showed impaired right middle cerebral artery perfusion. He remained blind and subsequently developed bilateral complete optic atrophy. Case 4 A 48-year-old man shot himself in the right temple with a 38-caliber handgun. On admission he was blind, stuporous, and showed severe restriction of all movements of the right eye. He slowIv regained alertness and recovered full eye movements, His discs became severely atrophic, but he regained bare finger-counting vision in a temporal island of the left eye. Irregularly-pigmented chorioretinal scars were evident inferior to both optic discs. Five months later, he was readmitted following an intentional drug overdose. I I I FIG. 1. Case 1: CT views, following bullet entry at right temple and exiting left temple, show hemorrhagiccontusion of right temporal lobe tip, swollen right optic nerve and all' inSide right orbit. and bullet path directly through left optic nerve within canal. :;WC/lJ!: FIG. 2. Case 2 Frontal (left) and lateral (right) views of right carotid angiogram show traumatic aneurysm of anterior cerebral artery (arrows). 249 DISCUSSION The three patients who shot themselves in the right temple were blinded instantly. Minor fundus concussive effects were seen in one patient, but were insufficient to explain the absence of light perception. All three subsequently developed se- FIG. 3. Case 2: Subtraction lateral view of left carotid angiogram shows irregularly narrowed ophthalmic artery (arrow). vere optic atrophy; two remained blind, while one showed minimal visual recoverv- in one ev- e. Clinical findings and radiographic evidence in-dicate that blindness resulted from damage to the intracranial and canalicular optic nerves. Injury to optic tracts would be accompanied by upper brainstem and hypothalamus damage, whereas disruption of the chiasm certainly would be accompanied by injury to the carotid arteries. The patient who shot herself under the right side of the chin destroyed the ipsilateral optic nerve and damaged the opposite carotid artery as the bullet ascended diagonally. Dela~'ed left ophthalmic artery spasm was the likel\' mechanism for blindness in the second eve. Suicide attempts using handguns have anterior intracranial trajectories that may produce blindness as their principal residual effect. Loss of vision, unfortunately, neither discourages nor impedes further suicide attempts. Acknowledgment: J,1mshid Ahmadi, M.D., assisted with radiographic intl'rprl'tation. REFERENCES I. EiSl'Il' JW. Rl'av DT, C""k A. Sitl'S l1i suicidal gunshot wounds. f 1"'I"!";S;e Sei J9R1;20:-tRO-5. , Cohll' S. /l'lIldgun slIicidl's. ["rms;e Sei Ga: 1977;8:2. J. Di Maill VJM. CllllsII,,' il',III"'!>: I'l"lleliCllI aSI'lyls llf firearms, Ilallis/ies alld li,rms;e l<'ellll;'1"<'S. Nl'W York: Elsevier, 1985. I elill Nt'I/nJ-opl,thalllIl11. Vol. 6, No. .1, 19Sti |
