Self-inflicted eye injury.

case report Self-inflicted eye injury Mohammed A. Gogandy,a Abdulqader Aljarad,b Sabah S. Jastaneiah,c Abdullah M. Alfawaza From the aAnterioir Segment Unit, Department of Ophthalmology, King Abdulaziz University Hospital,King Saud University, Riyadh, Saudi Arabia; bDepartment of Psychiatry, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia; cAnterior segment Unit, Department of Ophthalmology, Specialized Medical Center Hospital, Riyadh, Saudi Arabia Correspondence: Mohammed A. Gogandy, MD · Anterior Segment Unit, Department of Ophthalmology, King Abdulaziz University Hospital, King Saud University, Riyadh, Saudi Arabia · M : 00966553553889 · · ORCID: orcid.org/0000-0003-1455-2677 Ann Saudi Med 2017; 37(3): 245-250 DOI: 10.5144/0256-4947.2017.245 Individuals with a factitious ocular disorder feign or exaggerate having an eye injury or intentionally produce an eye injury so as to assume the role of a sick person. We report two cases of selfinflicted ocular injury using needle-like foreign bodies and razor that represent possible diagnoses of Munchausen syndrome. Both patients presented with different clinical pictures that misguided the clinical diagnosis and delayed proper management. Although self-inflicted ocular injuries are rare, ophthalmologists should be aware of the possibility of their existence, particularly when caring for patients with psychiatric conditions. SIMILAR CASES PUBLISHED: 13 I ndividuals with a factitious ocular disorder feign or exaggerate having an eye injury or intentionally produce an eye injury so as to assume the role of a sick person.1 This type of injury may result in substantial ocular morbidity, ranging from minor conjunctivitis to severe forms of self-mutilation, including enucleation. Research has revealed that the majority of self-inflicted ocular injuries with an underlying psychological cause are associated with schizophrenia.2 Munchausen syndrome (factitious disorder imposed on self) is characterized by falsification of physical or psychological signs or symptoms where there are no obvious rewards explaining why the individual is deceiving others. This behavior is not explained by other mental disorders such as delusion or psychosis.3 We report two cases of selfinflicted eye disorders with a possible diagnosis of Munchausen syndrome and describe their clinical presentation. We provide a brief literature review of similar disorders. CASE 1 A 43-year-old man, working as a hospital clerk at a secondary hospital presented to the emergency department (ED) claiming that ocular trauma to the right eye was from an accidental encounter with the branch of a short palm tree. Examination of the right eye revealed a visual acuity of 20/40 and an intraocular pressure (IOP) ANN SAUDI MED 2017 MAY-JUNE WWW.ANNSAUDIMED.NET of 18 mm Hg. Multiple conjunctival lacerations with conjunctival chemosis were detected in the inferior part of the globe of the right eye. Neither corneal involvement nor lens injury was observed. Examination of the posterior segment of the right eye was normal. Examination of the left eye was also completely normal, with a visual acuity of 20/20. The presence of scleral lacerations and subconjunctival foreign bodies could not be ruled out owing to the severity of the chemosis and subconjunctival hemorrhage. For this reason, the patient was taken to the operating room to undergo surgical exploration. During surgery, neither scleral lacerations nor foreign bodies were found. Because he seemed to be doing fine postoperatively, he was discharged and sent home with topical antibiotics and steroids. Four months later, he presented again to the ED with severe redness and pain so extreme that it prevented him from sleeping. However, he denied having trauma. Examination of the right eye revealed a visual acuity of 20/80. His corneal sensation was reduced in both eyes. Blackish subconjunctival foreign bodies were observed inferiorly, for which he was taken to the operating room. Two needlelike foreign bodies that appeared to be from an orange tree (as opposed to a palm tree, which the patient had previously claimed) were extracted. Postoperatively, he was discharged and sent home. After that, he presented again with similar findings and 3 needle-like foreign bodies were removed surgically (Figures 1 and 2). 245 case report Figure 1. Two needle-like black foreign bodies observed in the inferior conjunctiva. Figure 2. Post-operatively after removal of the foreign bodies EYE INJURY keratitis, for which vancomycin, ceftazidime, and amphotericin B were injected intravitreally. Topical fortified vancomycin, ceftazidime, and amphotericin B were also prescribed hourly. Ultrasound confirmed the presence of vitritis. Culture results for vitreous tap and corneal scraping were negative for fungal elements (Figure 3). At this point, the patient’s symptoms resolved. One week later, the patient’s visual acuity was 20/80 with cataractous lens. Two months later, he presented with an IOP of 34 mm Hg (despite being on antiglaucoma medications), a dense cataract, 360 degrees of posterior synechiae, and a shallow anterior chamber. He was evaluated by the glaucoma service, and subsequently he was taken to the operating room for pars plana vitrectomy and pars plana lensectomy, and was left aphakic. Postoperatively, his vision was light perception, and his IOP was controlled on full antiglaucoma medication including oral acetazolamide. Afterward he was seen in the clinic several times with persistent pain and mildly injected conjunctiva. Despite having only a mildly elevated IOP (22 mm Hg), he complained of annoying pain and refused to use his antiglaucoma medications, requesting surgical intervention to treat his glaucoma. He then underwent cyclophotocoagulation for the right eye, which led to control of IOP without the use of medications. One month later, he presented with persistent pain and asked that his right eye be removed to relieve his pain. He was subsequently admitted to hospital, and on suspicion of a self-inflicted injury, a psychiatric consultation was obtained. During the psychiatric consultation interview, he denied having a substance abuse problem or experiencing psychiatric episodes previously. When he was confronted about the possibility of his ocular injury being self-inflicted, he became angry and defensive and asked to leave the hospital against medical advice. He was subsequently lost to follow-up. The diagnosis of Munchausen syndrome was made by the psychiatrist based on DSM-5 criteria.3 CASE 2 Figure 3. Track-like corneal infiltrate in the inferior cornea Three months later, he presented to the ED with severe pain and loss of vision. His visual acuity was light perception in the right eye. Slit lamp examination revealed corneal infiltrate in a track-like pattern, hypopyon in the anterior chamber, opened anterior lens capsule, and a dim red reflex. He was diagnosed as having post-traumatic fu (...truncated)