Factitious keratoconjunctivitis

Abstract

Dear Editor, Factitious disorders although rarely encountered, may cause a significant ocular morbidity ranging from a minor conjunctivitis to severe forms of self-mutilation, including enucleation. They are characterized by signs or symptoms that are intentionally produced or feigned by a person solely to assume the ′sick role′.1 Disastrous consequences can be prevented by early diagnosis and treatment. A ten-year-old girl presented with redness, photophobia and copious discharge from both eyes for three weeks. Visual acuity was 20/40 in both eyes. Examination showed copious brownish, granular discharge in the lower fornices. Follicular response and hyperemia was noted in the inferior conjunctiva, with punctate keratitis in lower 2/3rd of cornea of either side. There was no regurgitation on pressure over the lacrimal sac; anterior and posterior segments were otherwise unremarkable. Conjunctival swab was sent for Gram's staining and culture/sensitivity examination for aerobic and anerobic bacteria and she was prescribed ofloxacin eye drops and a tear substitute. At follow-up visit, parents reported improvement in redness and photophobia, although the discharge continued to appear at variable intervals [Fig. 1]. Light microscopy of the discharge showed few cellular elements mixed with brown particulate matter of varying sizes. Some particles were refractile, showing birefringence and were reported to be suggestive of sand [Fig. 2]. Culture/sensitivity showed a significant growth of Escherichia coli.Figure 1: Right eye showing brownish granular discharge and follicles in the inferior tarsal conjunctiva at follow-up visitFigure 2: (a) Wet smear preparation of the discharge showing coarse irregular particles of varying sizes (b) Some of the particles showing birefringence when viewed under a polarizerA factitious disorder resulting from instillation of mud in the eyes was suspected and to confirm our diagnosis, she was kept under strict observation for 24h, with both eyes patched. The patch was marked with an arrow, for documentation of removal and repositioning. Next day there was no discharge and the congestion had also subsided remarkably. When confronted, although in denial initially, the child admitted self-manipulation after sympathetic persuasion. Psychiatric opinion for an in-depth evaluation was suggested, but the parents refused referral. Nature of the disease was explained to the parents and the child was counselled and discharged on topical gentamicin and a tear substitute. Her signs and symptoms soon resolved and no recurrence of factitious behavior was reported later. Factitious disorders remain a diagnostic challenge. Unlike malingering, where illness is feigned for a material gain, here the motive is purely psychological.1 A more severe and chronic form is the Munchausen's syndrome, characterized by a triad of simulated illness, pathological lying (pseudologia fantastica) and doctor shopping (peregrination).1 Factitious conjunctivitis with varied patterns of corneal involvement has been previously reported. Causative agents included acid, topical anesthetics, chalk pieces and dental plaque.234 Typically, the more accessible inferior conjunctiva is involved.4 Corneal lesions include punctate epitheliopathy, linear abrasions, well delineated ulcers and intractable recurrent corneal erosions.234 Ocular disturbances in such patients are refractory to conventional therapy, but patching serves a diagnostic and therapeutic role. Alternatively, temporary total tarsorrhaphy has been suggested.5 Comprehensive management, however, includes addressing the underlying psycho-social problem. In our case, since the parents refused referral, we were unable to identify the underlying emotional need of the patient, although we do believe that through her factitious behavior, she was expressing a strong cry for help. We are grateful to Dr. R. S. Deswal for his invaluable guidance and would also like to thank Dr. Daya Sadiq for all her help.