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doi: 10.1136/bjo.2009.171595published online June 24, 2010Br J Ophthalmol

J Polat, E Feinberg and S S Crosbyretinopathy as a result of forced solar gazingOcular manifestations of torture: solar

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LETTER

Ocular manifestations of torture:solar retinopathy as a resultof forced solar gazingSolar retinopathy as a result of sun gazing

has been well documented and occurs asa result of thermal and photochemicalprocesses after solar exposure.1 Althoughsolar exposure is usually a result of deliberatesun gazing, forced sun gazing can also beused as a torture method.

Torture is prevalent worldwide. In 2007,the Amnesty International documentedcases of torture and other cruel, inhuman ordegrading treatment in 81 countries.2

It is important for clinicians to be awareof the physical manifestations of torturebecause they are not always obvious. Torturemethods are often devised to leave minimallong-term physical indications but often

have tremendous psychological impact.3

Survivors will often not disclose the experi-ence of their torture with their physician,and the diagnosis may be missed.4

CASEA 58-year-old West African man was referredto an ophthalmology clinic by his primarycare physician with a chief complaint ofdifficulty reading and discomfort and blur onmore than momentary reading. His medicalhistory included torture in Cameroon 3 yearsearlier. On two consecutive days, he wastaken from his cell and at gunpoint forced to

stare at the sun for a duration that he be-lieves was about an hour each day. Hepossessed no means for measuring time. Hewas threatened with death if he looked awayor closed his eyes, and did observe theexecution of another prisoner for failure tocomply. He described great pain and blurredvision afterwards, but he felt that he recov-ered and was able to see well at close rangeand distance until recently when he devel-oped difficulty reading.

On examination, the distance visual acuitywas 20/20 in both eyes on the Snellen testwithout correction. Uncorrected near acuitywas J7 in either eye. With appropriate pres-

byopic correction, his near vision improved toJ0 in both eyes.Fundus examinationof thelefteye showed an atrophic area with pigmentmigration, shaped like two overlappingcircles, approximately 1 mm in diameter. Onretinal photographs, the lesion was exactlythesame distance temporal to thefoveaas thedisc was nasal to the foveal umbo (see figure1). The right fundus was normal. The visualfields were normal.

Diagnostic impressions were presbyopia inboth eyes and solar burn in left eye secondaryto torture by forced sun gazing. Theappearance of the lesion is classic for the latelesion of solar gazing after the initial oedemaof the neurosensory retina has faded. Thepatient was certain that he had lookeddirectly at the sun, but the location of theunilateral burn suggested that he had insteadinstinctively arranged his gaze to place theimage on the optic nerve head oculus dexterand temporal to the fovea oculus sinister tominimise pain. Because there was no opticatrophy, the lighter colour of the optic nervepresumably converted less light energy toheat than the darker fundus, including theretinal pigment epithelium and the choroidalpigment, and optic nerve tissue was not lost.In addition, the size of the extrafoveal lesionis comparable with the foveal lesions ofpatients seen with solar injury to the fovea.5

Treatment with presbyopic correction elim-inated his presenting symptoms.

DISCUSSIONIn this report, we document that forced sungazing can also be used as a physical torturemethod, which can result in solar retinop-athy. Psychological sequelae may also bepresent in torture survivors, such as symptomsof post-traumatic stress disorder and majordepression. If a physician identifies a patientas being a survivor of torture, it is importantfor them to be aware of programmes thatspecialise in the care of torture survivorssuch as the International Rehabilitation

Council for Torture Victims.6In summary, this is a unique report of

forced sun gazing used as a torture methodand resulting in solar retinopathy. Unlikewith deliberate sun gazing, where solarburns are usually located foveal or perifoveal,torture victims may shift their eyes, causingsolar burns offset from the retina. In the casepresented in this report, an affidavit andtestimony were given in court documenting

the ophthalmic findings, which contributedto the patient being granted political asylum.

J Polat,1 E Feinberg,2 S S Crosby3,4

1University School of Medicine, Boston, Massachusetts,USA; 2Department of Ophthalmology, Boston UniversitySchool of Medicine, Boston, Massachusetts, USA;3Department of Medicine, Boston University School ofMedicine, Boston, Massachusetts, USA; 4Department ofHealth Law, Bioethics and Human Rights, BostonUniversity School of Public Health, Boston,Massachusetts, USA

Correspondence to S S Crosby, Section of GeneralInternal Medicine, Boston Medical Center, Crosstown 2,801 Massachusetts Avenue, Boston, MA 02118, USA;scrosby@bu.edu

Competing interests None.

Patient consent Obtained.

Ethics approval This study was conducted with theapproval granted by the institutional review board of theBoston University School of Medicine.

Provenance and peer review Not commissioned;externally peer reviewed.

Accepted 20 December 2009

Br J Ophthalmol2010;-:1.doi:10.1136/bjo.2009.171595

REFERENCES1. Istock TH. Solar retinopathy: a review of literature and

case report. J Am Optom Assoc 1985;56:374e81.

2. Amnesty International. Amnesty International report

2008: at a glance. 2008:http://archive.amnesty.org/

air2008/eng/facts-and-figures.html (accessed 30 Jun

2009).

3. Iacopino V, Allden K, Keller A. Examining asylum

seekers: a health and professionals guide to medical and psychological evaluations of torture. Boston:

Physicians for Human Rights, 2001.

4. Miles SH, Freedman AM. Medical ethics and torture:

revising the declaration of Tokyo. Lancet

2009;373:344e8.

5. Yannuzzi LA, Fisher YL, Krueger A, et al. Solar

retinopathy: a photobiological and geophysical analysis.

Trans Am Ophthalmol Soc 1987;85:120e58.

6. International Rehabilitation Council for Torture Victims.

http://www.irct.org/ (accessed 2 Jul 2009).

Figure 1 Fundi of patient showing scar temporal to the fovea in left eye secondary to solar burn.

Polat J, Feinberg E, Crosby SS. Br J Ophthalmol (2010). doi:10.1136/bjo.2009.171595 1 of 1

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