Throughout the evaluation, the patient and her
mother exchanged hostile and antagonistic remarks,
which often interfered with her interview and exami-
nation. Once the mother was asked to exit the room, the
patient admitted to cheating on previous ophthalmic
examinations. Furthermore, she stated that her visual
loss was long-standing and that she knew why: “Because
I touched my eye too much.” When asked to demon-
strate what she meant, she placed her right index ﬁnger
under her right supraorbital rim and subluxated her right
ocular globe until it protruded under her inferior eyelid
(Figure 2). This was a voluntary maneuver that she
secretly performed in response to frustration or anger
induced by her mother, since age ﬁve to six years. She
also mentioned that during this maneuver, she would
sometimes feel a “cable” under her ﬁnger. Subsequent
communication with her psychiatrist conﬁrmed that
there was no history of self-mutilation or violence, but
the patient had been diagnosed two years earlier with a
nonspeciﬁc psychosis for which she remained under
In our patient, no external signs of ocular injury were
present, but a severe right optic neuropathy resulted
from stretching and direct digital massaging of the optic
nerve. Progressive blindness induced by optic nerve
stretching was recently reported in a 46-year-old obses-
sive-compulsive man in reaction to episodes of anxiety,
stress, and irritation.
The digital maneuver used by our
patient (Figure 2) also caused right ptosis by partial
disinsertion of the levator palpebrae muscle and right
cheek hypoesthesia by direct trauma to the maxillary
nerve before entering the infraorbital canal.
Her examination suggested an orbital apex lesion, but
the true nature of the visual loss was disclosed only
when real communication with the child was estab-
lished. Self-inﬂicted visual loss should remain a diag-
nostic consideration in patients with unexplained visual
loss, even in the absence of obvious psychotic or
self-mutilating behavior. Correct diagnosis is important
for appropriate psychiatric treatment, because of the risk
of fellow eye involvement.
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2. Yang HK, Brown GC, Magargal LE. Self-inﬂicted ocular
mutilation. Am J Ophthalmol 1981;91:658 – 663.
3. Brown R, Al-Bachari MAH, Kambhampati KK. Self-inﬂicted
eye injuries. Br J Ophthalmol 1991;75:496 – 498.
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Gaze-dependent and Time-restricted
Visual Acuity Measures in Patients
With Infantile Nystagmus
Dongsheng Yang, PhD, Richard W. Hertle, MD,
Vanessa M. Hill, BS, and Deana J. Stevens, MD
We report a new method of measuring visual
function in patients with INS by demonstrating the
effects of eccentric gaze and forced time restriction on
Cross-sectional, comparative case-series.
No-time-restricted acuity (NTRA) and time-
restricted acuity (TRA) for 19 patients and 18 controls
were measured at multiple horizontal gaze angles.
INS patients showed a signiﬁcant lower visual
acuity than controls (P < 0.0001). The TRA were
signiﬁcantly decreased in most gaze positions relative to
NTRA in INS patients (P ؍ 0.03) while there were no
difference among controls. About half of the INS pa-
tients showed that their best visual acuity was gaze
dependent, matching the preferred head posture in both
NRTA and TRA paradigms.
Gaze-dependent visual acuity tested with
and without time restriction may be a useful measure of
visual function in INS patients and could be used in
interventional clinical trials. (Am J Ophthalmol 2005;
139:716-718. © 2005 by Elsevier Inc. All rights re-
HE QUALITY OF VISUAL FUNCTIONS IN PATIENTS WITH
disorders of the ocular motor system, such as, infantile
nystagmus syndrome (INS), is often not represented by
routine measures of visual acuity.
We measured gaze-
dependent visual acuity (GDVA) with and without time
restriction and showed it can be a useful reference for
clinical application and may better reﬂect real-world visual
function in patient with INS.
Eleven male and eight female INS patients (average age,
24 years) with binocular visual acuity better than 20/200
diagnosed clinically and with eye movement recordings
showing typical waveforms; 9 male and 9 female (average
age 34 years) control subjects were asked to identify
single-surrounded optotypes on the center of a computer
screen under binocular conditions. The heads of subjects
Accepted for publication Sep 24, 2004.
From the Department of Ophthalmology (D.Y., R.W.H.), Children’s
Hospital of Pittsburgh, and The Eye and Ear Institute (D.Y., R.W.H.),
The University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania;
Department of Ophthalmology (V.M.H.), The Ohio State University,
and Department of Ophthalmology (D.J.S.), Columbus Children’s Hos-
pital, Columbus, Ohio.
Inquiries to Dongsheng Yang, PhD, Departments of Ophthalmology
Children’s Hospital of Pittsburgh and The Eye and Ear Institute, The
University of Pittsburgh Medical Center, Pittsburgh, PA; fax: (412)
692-7220; e-mail: email@example.com