Ocular Munchausen’s Syndrome induced by introduction of ant’s particles into the conjunctival fornices

Abstract

Munchausen’s Syndrome is a factitious disorder in which patients manipulate physicians through misrepresented signs and symptoms. The authors describe an 18-year-old woman with self-induced inoculation of ant’s particles inside her conjunctival fornices of both eyes. The crushed particles was confirmed to be crushed ant’s particles. Munchausen Syndrome can be seen with ophthalmic manifestations and should be considered in the differential diagnoses when ocular abnormalities cannot be explained. A sympathetic and supportive approach is therefore required and these patients should be urgently referred to a psychiatrist.

Introduction

Munchausen Syndrome is a factitious disorder in which patients knowingly harm themselves for subconscious psychological reasons in order to be hospitalized.¹

Munchausen Syndrome was first described by Asher (1951), when he dedicated the syndrome to Baron K. F. Von Munchausen. (1720-97), A retire German soldier who travelled widely recounting dramatic and untruthful stories.1, 2

We report a case of a young female patient self-inflected her eye by inserting ant’s particles into the lower Conjunctival fornices of both eyes. This case represents the first report of ocular Munchausen’s Syndrome induced by ant’s particles.

Case report

Eighteen years old woman was accompanied her parents to the Ophthalmic Emergency Department of our institute complaining of redness, pain in both eyes for the last one month after which she noticed ants creeping over the eye surface going out from the eyes. She was seen in a private clinic and she brought crushed ants particles pertaining, it was taken out from the eye. She was medically free, single with no history of previous medications. The patient appeared calm and cooperative.

Ocular examination revealed Best-Corrected Visual Acuity (BCVA) of 20/20 bilaterally. Intra-ocular Pressure (IOP) was normal in both eyes. Slit Lamp examination of both eyes revealed normal lids and conjunctiva with no foreign bodies. No other abnormal findings were present in the left anterior and posterior segment.

The crushed insect’s particle they brought was sent to the laboratory. The results confirm crushed ants particles (Figs. 1 and 2). When we suggested that she was inserting the ant’s particles inside her eyes, she denied that. The incongruity of history and physical signs allowed a possible diagnosis of Munchausen’s Syndrome. Psychiatric referral was discussed with the patient and her family but refused by her family. They left the ER and refused photography.

Fig. 1.

Crushed ants particles.

Fig. 2.

Crushed ants particles (high magnification).

Discussion

Ocular Munchausen Syndrome is uncommon. Reported manifestations include orbital emphysema requiring exenteration, periorbital abscesses, subconjunctival hemorrhages, keratoconjuctivitis due to calcareous concretions, superficial punctate keratophathy, corneal alkali burns, intractable corneal erosions, nystagmus, mydriasis, decreased visual acuity, diplopia, and eye perforation.3, 4, 5, 6, 7, 8, 9 We are unaware of any previously reported cases of Munchausen syndrome induced by introduction of ant’s particles into the conjunctival fornices. Self-inflicted eye damage has been described mainly in girls and young women.3, 4, 6, 9 Our patient is 18 years old healthy girl.

Diagnosis of Munchausen Syndrome is difficult to make in the ophthalmic department and should be one of exclusion. Similarities exist among patients with Munchausen syndrome, patients with somatoform disorders, and malingerers. All these patients often present dramatically and embellish their symptoms to create a sense of urgency. They often resist attempts at a detailed history and physical examination. However, unlike those with somatoform disorders and malingers; Munchausen patients have little or no ability to control their self-destructive behavior. A sympathetic and supportive approach is therefore required and these patients should be urgently referred to psychiatrist with experience in factitious disorders. Even with psychotherapy, which is often refused, the prognosis remains poor.¹⁰

Ophthalmologists are often faced with psychiatric patients, but patients with factitious disorders are particularly challenging.¹¹ Recognition of this psychopathology is important to prevent potentially severe eye damage.

Suggestion of the need for the psychiatric referral usually leads patients to abscond.

Our patient and her parents absconded when she was asked about psychiatric, social problems-in accordance with the literature findings.

They then may represent fresh to another hospital to begin a further series of pretenses and investigations.⁵ These are potentially damaging to the patients and lead to waste of health care resources. Ophthalmologist must be prepared to identify these patients, follow them on a regular basis and support them as best as they can.