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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 19  |  Issue : 2  |  Page : 169-171

Solar retinopathy on sun-gazing in mania


1 Junior Resident in Department of Psychiatry, SRM Medical College and Research Centre, SRM IST, Kancheepuram, Tamil Nadu, India
2 Associate Professor, Department of Psychiatry, SRM Medical College and Research Centre, SRM IST, Kancheepuram, Tamil Nadu, India
3 Professor and HOD, Department of Psychiatry, SRM Medical College and Research Centre, SRM IST, Kancheepuram, Tamil Nadu, India

Date of Web Publication31-Dec-2018

Correspondence Address:
Dr. Arul Saravanan Ramachandran
Department of Psychiatry, SRM Medical College and Research Centre, SRM IST, Kattankulathur, Kancheepuram - 603 203, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/AMH.AMH_24_18

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  Abstract 


Solar retinopathy is a rare complication of damage to the retina due to unnatural exposure to bright light. Few cases have been reported in international literature in special groups like in children, psychiatric patients, direct gazing of solar eclipse and in certain occupations like arc welding. Of the few that are reported in mental institutions, majority had a diagnoses of schizophrenia. Along with the review of the reported cases, we report the first case of solar retinopathy in a patient who indulged in sun gazing during acute manic phase in our country.

Keywords: Bipolar disorder, mania, mood disorder, photoretinitis, solar retinopathy


How to cite this article:
Reddy M, Abhilasha P, Ramachandran AS, Thirunavukarasu M. Solar retinopathy on sun-gazing in mania. Arch Ment Health 2018;19:169-71

How to cite this URL:
Reddy M, Abhilasha P, Ramachandran AS, Thirunavukarasu M. Solar retinopathy on sun-gazing in mania. Arch Ment Health [serial online] 2018 [cited 2019 Jan 22];19:169-71. Available from: http://www.amhonline.org/text.asp?2018/19/2/169/248881




  Introduction Top


Photoretinitis is damage to the retina of the eye due to excessive exposure to bright light. Solar retinopathy (also known as photic retinopathy, foveomacular retinitis, solar retinitis, and eclipse retinopathy) refers to a photochemical toxicity and resultant injury to retinal tissues, usually occurring at the fovea. This entity is commonly associated with sun-gazing or eclipse viewing and often results in mild-to-moderate visual acuity deficit and/or central or paracentral scotoma.

Sun-gazing by psychiatric patients has been the subject of interest for long. Sun-gazing epidemics have been reported earlier within psychiatric hospitals.[1] Jaspers, in 1968, noted that some patients with schizophrenia were able to “sun-gaze” without apparent discomfort. Other authors have noted this phenomena with schizophrenia mostly.[2] It has been reported in sun-gazing under the influence of lysergic acid diethylamide and cocaine,[3] in individuals with obsessional symptoms, in Tourette's Syndrome,[4] and in some types of neurotic illness.[5] In 1970, Anaclerio and Wicker reported of solar retinopathy in 27 psychiatric patients in the St. Elizabeth Hospital in Washington DC.[1] All the patients had a diagnosis of schizophrenia. Kamp et al. reported two cases of solar retinopathy of which one patient suffered from chronic undifferentiated schizophrenia and the other had a diagnosis of bipolar affective disorder (BPAD) mania.[6] Here, we report a case of solar photoretinitis in a case of bipolar mood disorder who indulged in sun-gazing during acute manic phase.


  Case Report Top


A 31-year-old married male was brought with complaints of violent and aggressive behavior, anger outbursts, decreased need for sleep, impulsive buying, decline in his appetite, and unrestrained behavior for the last 5 days for admission. Detailed evaluation showed that he was a known case of BPAD with last four episodes of mania. There was no history of any substance abuse. History showed poor drug compliance and hence relapse. There were no medical comorbidities as well as no significant positive family history. His mental status examination revealed an increase in his psychomotor activity, decreased need for sleep, elated mood, over familiarity, inappropriate sexual advances, increase in the rate and quantum of speech and grandiose delusions. He was started on treatment as per the protocol.

During his 2nd day in the ward, his hyperactivity and aggression decreased enough to engage in an interview. As a passing remark, the patient mentioned blurring of vision. Although bedside tests for acuity of vision were normal, anticholinergics were stopped. On the next day, he reported that he was able to read fine print of newspaper with difficulty. A detailed review of history with the parents (who live separately) brought out that the patient's neighbor had remarked that he was continuously staring at the sun from his terrace ritualistically for 2–3 days in a row. The patient confirmed the same and stated that it was a kind of phenomenon where the sun energy would transcend him and give him power. An urgent opinion was sought from ophthalmology unit. The visual acuity in the right eye was 6/24 and the left eye was 6/18. Retinoscopy showed foveal reflex absent in both eyes, macular edema more on his right eye than on his left. Small, yellowish-white spot in the center of foveal region surrounded by an area of faint, grey, and granular pigmentation seen in both eyes [Figure 1] and [Figure 2]. He was diagnosed with solar retinopathy. The patient was immediately started on a short course of steroids, namely, T. Prednisolone 20 mg three times a day for 3 days. He was advised to keep his eyes shut or wear dark goggles. He was also discouraged from using his phone, laptop, and even against watching television. In 2–3 days, patient's vision gradually started improving with resolution of edema. He was given a final diagnosis of BPAD with solar retinopathy. He was advised to review with psychiatry and ophthalmology after 2 weeks on discharge.
Figure 1: Fundus photograph of index patient – right eye – showing macular hole-like picture

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Figure 2: Fundus photograph of index patient – left eye – showing macular hole-like picture

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  Discussion Top


Sun worship was part of many ancient cultures, including ours. Middle-aged people also realized the harm of gazing at sun directly. Socrates advised to only look at an eclipse through its reflection in water. Eminent early astronomers were victims of solar retinopathy including Galileo. In modern days, cases were reported in fighter pilots, who peered through the sun, people who work in welding industry, young children, and the mentally ill are victims of such retinal damage.

In psychiatry, solar retinopathy has been reported mostly in schizophrenia and rarely in mania. The photophobic tendency in depression and photophilic tendency when in mania has also been given some thought. Theories of dopamine as a retinal neuromodulator having a role in retinal response and photophilic behavior in patients with schizophrenia have been reported.[7]

To the best of our knowledge, only two cases of solar photo retinitis have been reported occurring in mania worldwide.[6],[8] Patients typically present with visual acuity of 20/30–20/100 after gazing at the sun. Symptoms would include blurred vision, central/paracentral scotoma, dyschromatopsia/metamorphopsia, photophobia, and headache. It is usually bilateral, as in our case, but asymmetric involvement may also occur.

There is no investigation of choice to diagnose solar retinopathy. Fluorescein angiography can show dye leakage in the acute phase as well as window transmission defect in the later phase of the disease but not ideal for diagnosing solar retinopathy. However, Jain et al.[9] have demonstrated the usefulness of optical coherence tomography.

There are no standard treatment guidelines for solar retinopathy. Reviews suggest the use of short-term systemic steroids for resolution of the macular edema. Antioxidant drugs and low vision aids have also been tried. Education remains the best method for the prevention of retinal damage.

It may occur more often than reported as (i) patients may not always report it, (ii) relatives may fail to report it unless specifically asked, (iii) psychiatrist may consider them as part of anticholinergic medication effects, and (iv) because of the slow spontaneous resolution that eventually occurs it goes unnoticed. In view of the potential retinal damage, it should not be overlooked. A psychiatrist should be alert to the possibility of solar retinopathy occurring in psychotic states.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Anaclerio AM, Wicker HS. Self-induced solar retinopathy by patients in a psychiatric hospital. Am J Ophthalmol 1970;69:731-6.  Back to cited text no. 1
    
2.
Gerbaldo H, Thaker G, Cassady S. Sun gazing and photophilia in schizophrenia. Am J Psychiatry 1991;148:693.  Back to cited text no. 2
    
3.
Steinkamp PN, Watzke RC, Solomon JD. An unusual case of solar retinopathy. Arch Ophthalmol 2003;121:1798-9.  Back to cited text no. 3
    
4.
Kobylski TP, Licamele WL. Sun gazing by patients with Tourette's disorder. Am J Psychiatry 1991;148:394.  Back to cited text no. 4
    
5.
Favazza AR. Literature on sun gazing. Am J Psychiatry 1991;148:281-2.  Back to cited text no. 5
    
6.
Kamp PS, Dietrich AM, Rosse RB. Sun gazing by psychiatric patients. Am J Psychiatry 1990;147:810-1.  Back to cited text no. 6
    
7.
Gerbaldo H, delas Carreras C, Moran M, Thaker G, Demisch L, Tamminga C. Photophobic and photomanic behavior in psychoses. Schizophr Res 1990;3:74-5.  Back to cited text no. 7
    
8.
Devadason DS, Mahmood S, Stanga PE, Bishop PN. Solar retinopathy in a patient with bipolar affective disorder. Br J Ophthalmol 2006;90:247.  Back to cited text no. 8
    
9.
Jain A, Desai RU, Charalel RA, Quiram P, Yannuzzi L, Sarraf D, et al. Solar retinopathy: Comparison of optical coherence tomography (OCT) and fluorescein angiography (FA). Retina 2009;29:1340-5.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2]



 

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