What is the risk of retinal tears in a patient with autism who repeatedly engages in self-inflicted temple punches?

Risk of Retinal Tears in Patients with Autism Who Engage in Self-Inflicted Temple Punches

Patients with autism who repeatedly engage in self-inflicted temple punches have a significantly increased risk of retinal tears and detachment, with studies showing nearly 8 times higher risk of retinal detachment compared to the general population. 1

Mechanism of Injury and Risk Factors

• Repetitive trauma to the head, including self-inflicted blows to the face or temple area, can cause vitreoretinal traction that may lead to retinal tears and subsequent detachment 2
• Self-inflicted ocular injuries in individuals with developmental disorders can range from corneal lacerations to vitreous hemorrhage and retinal detachment 2
• The mechanical force from repeated temple punches can cause sudden acceleration-deceleration of the vitreous, creating traction at sites of vitreoretinal adhesion 3
• Trauma-induced posterior vitreous detachment (PVD) can occur earlier than the typical age-related PVD (which normally occurs between ages 45-65) 4

Specific Risk Considerations for Patients with Autism

• Recent research demonstrates that individuals with autism spectrum disorder (ASD) have a 7.84 times higher risk of developing retinal detachment compared to matched controls 1
• Patients with ASD tend to be diagnosed with retinal diseases earlier than the general population (3.73 vs. 6.28 years from initial presentation) 1
• Self-inflicted trauma is a documented cause of ocular injury in individuals with developmental disorders, with potential for severe consequences including blindness 2
• The risk is compounded when the behavior is repetitive and chronic, as each traumatic event increases the cumulative risk 2

Clinical Manifestations and Warning Signs

• Vitreous hemorrhage and/or localized intraretinal hemorrhage may accompany traumatic PVD events 3
• The presence of vitreous pigmented cells is a critical warning sign that indicates possible retinal damage 5
• Traumatic retinal dialysis (a specific type of crescentic peripheral retinal break at the ora serrata) is commonly associated with blunt trauma 3
• Symptoms that warrant immediate evaluation include:
  • New onset or increased floaters 4
  • Flashes of light (photopsia) 4
  • Visual field defects 3
  • Decreased visual acuity 3

Management Considerations

• A thorough peripheral fundus examination using scleral depression is essential to detect any vitreoretinal pathology 5
• B-scan ultrasonography should be performed if media opacity or patient cooperation precludes adequate examination of the peripheral retina 5
• Symptomatic retinal breaks with persistent vitreoretinal traction (horseshoe or flap tears) have at least a 50% risk of progressing to clinical retinal detachment if left untreated 3
• Treatment by prompt creation of a chorioretinal adhesion around symptomatic tears reduces the risk of retinal detachment to less than 5% 3
• Traumatic dialyses and tears along the vitreous base should be managed similarly to symptomatic tears 3

Preventive Measures

• Protective equipment such as specialized helmets or protective eyewear should be considered for patients with persistent self-injurious behavior 2
• Regular ophthalmologic screening is crucial for early detection of retinal pathology in patients with autism who engage in self-injurious behavior 5
• Patient caregivers should be educated to monitor for changes in the appearance of the pupil, changes in behavior or performance level, and development of exotropia as potential signs of ocular injury 2
• Early intervention for both the underlying behavior and any detected retinal pathology is essential to prevent permanent vision loss 2

Long-term Monitoring

• Regular ophthalmologic follow-up is necessary to monitor for new retinal breaks or detachment 5
• Both eyes should be evaluated, as pathologic vitreoretinal changes can occur bilaterally even if trauma appears unilateral 5
• The risk of vision loss is significant, with documented cases of blindness resulting from self-inflicted ocular injuries in individuals with developmental disorders 2