 Dr. Burns is up next and she's going to basically present a patient that I think almost all the residents are familiar with and Dr. Montel as well. We'll have a nice discussion at the end of the session. Thank you for answering. Sorry. So I'm actually going to talk about two different cases. At least we're somewhat related. I'm going to go back and forth a little bit between them. I just don't give a way to diagnosis, like I said, with the review of the literature and discussion at the end. So our first young woman presented back in 2011. She was 21 years old at the time and she was hit by a box that fell at her face, unless she was at work. She had some associated pain and redness and she had some loud blur vision out of the left eye. Her only possible history was a previous wrist injury that required multiple surgeries. Her past ocular history, she did have her business degree as a child. And she'd been on some antibiotics and occasional pain that's for the prior surgeries other than that was not on any medications. Her visual acuity on the presentation was 2020 in the right, 2030 in the left. Her pupils were normal, no APD. Her actual field of movement and visual field were full. Her left upper lid had a little bit of erythema. Her contractiva on the left side showed an area super-temporally where there was a distinct area of injection. But the remaining portion of her ophthalmic exam was unremarkable. So at the time this was thought to be just due to the injury and if it was mild, and the conservative measures that people take care of at the location, I just told her to follow up as needed. Just about a week later, the patient called in so that she was having worsening left eye pain, a deep and APD, that she really wanted to see the cornea service, and that she was having more drainage from the eye. So on exam that day, that area that was super-temporally was a lot more injected. There was a nodular area, and it did not land to the left end. So I thought at this time this was squareitis. So she started on ibuprofen, 603 times a day, and then she had this workup done, which all came back negative. So at her follow-up visit, she said that it was about four weeks later, she said that her pain and redness decreased for about a week, but then the pain returned and was way worse than it was before, and she said that she was having a lot of yellow and green discharge. Her conjunctiva at this time showed 3 plus injection, it was a little bit more poolable, and she did have some people where you land discharged. So the differential at this time was, well, maybe this is under squareitis, maybe it's infection, maybe it's GPA, or some other inflammatory entity. So a few additional labs were added, just a culture, quantitative goals, and she started on topical antibiotics, so it's looking more infectious at this time. So then again she came back, pain is worse, she says brainage is worse, it's more red, the synodule is now larger, it really does appear infected. So the big answer I brought out, was sort of the oral antibiotics and topical steroids. And at this time, so there wasn't one of the Incas that came back positive, so she was sent to the metology, infectious disease was consulted, and she was seen in ocular plastics. So now we're four months from her initial exam, her initial presentation, she's saying again that her eye pain is worsening, her visual beauty is unchanged, and now there's this new inferior nasal lesion that is elevated, it's severely injected, and it's draining this clear serous fluid. So the plan at this time is we still don't know what's going on, so let's take her to the OR and see if we can get biopsy kind of of a support what's going on. So this is her first surgery, and down about seven o'clock there's an area that is excised in a support body material with salmon and ex-planted. And then biopsy of the surrounding contract tyventine on skin cells performs at her path, grant-steen cultures, including acid-pacipicillate. The parents really looked inflammatory at that time, and so myomycin C was placed, there was a large defect, so amyocinembrain was glued and secreted to place. And in self-contract typhilodexamethasone, mycomycinic, mycomycin was placed. She's given some oral antibiotics and opioids as a topical box. So the path just showed some amorphous form body from the left eye and nonspecific chronic inflammatory changes and all the special scenes that were done on the path and all the cultures were all negative. So we're going to go to case number two. So this is a 33-year-old female veteran who presented to the U-Vas clinic after she had a three-month history of central vision out of the right eye, which had been previously seen at the VA. She had floaters, light sensitivity, she said she had swirls in her central vision and headaches from eye strain. She does have a history of dysquid lupus, a paedophilotus report here in 2010, an apodectomy and ovarian cysts. She'd previously been on plaque with albinus knot, was not currently at the time. She had some muscular pain, some tingling in her extremities, no history of SDIs. Her examination was 2,500 in the right eye, 2020 in the left, no APD, her eye check was normal. Her entry segments showed a congenital or counteracted both eyes. There was no cell, no vitreous cell, and this is her funnest photographs. So in the right eye, you can see a lot of pigmentary changes, scarring, the left eye looks normal. On autofluorescence, you can see, on autofluorescence, you can see some typo-autofluorescence and some sweet-piper-autofluorescence in the left eye is completely normal. Most I want to point out, the OCT here, you see some areas where the is-os junction is lost, more out of the periphery of the macula than apovia, you have lost all of the retinal layers. So again, similar workup was done for this young woman. Everything came back negative. So this time of the thousand, is this differential, is this pig, is this relunus, plaque weight, infectious causes. The only additional labs that were added were Bartonella, West Nile, HAP. So the thought was, well, let's bring her back. If everything's negative, this is probably inflammatory. Well, you know, it's just our ozurex. Three weeks later, she comes back. The right eye is exactly the same, but she says that the left eye is getting new spots. Her visual preview in the right is the same, but the left eye is dropped a line. And here you can see, I just put up the old picture of the right eye, but that left eye was previously foreseen as showing these hypopigments of lesions here. You can see here on FAA as well. And then we're starting to see that ISOS junction lost in the outer retina. So the thought is, okay, so now there's these new lesions in the left eye. Let's, you know, that's the eye. Let's, we should choose, basically, monocular this time. Let's try and save that left eye so that it's put an ozurex in. Think about starting to self-ceptin when we won't start it today. So let's kind of bring her back in a week. So now we're going to go back to patient number one. So just due to time, we can talk about her forever, but over the next three and a half years, she has expansion of the inflammatory symptoms to involve various areas of her, her globe, and goes into her orbit. She has 10 surgeries for exploration, debridement, further biopsies, and there's been throughout this time no conclusive data as to what's going on. I was presumed to be seen by infectious disease and this really thought to be an atypical mycobacterium. She would be started on IV antibiotics for seven to 14 days. She would report improvement of her eyes and dumps should be seen. Her inflammation would seem to be down, but she would have these episodes where she could not tarry IV antibiotics. She would get nausea, and she would have enough, basically, this unexplained drop to her pneumatic and become very anemic. So she had multiple admissions for IV antibiotics and so Fran and IV came as became a big issue with her. So this is about this time, about three and a half years later, she has complete ptosis of the left eyelid. Here you can see just the chronic and final three changes of her bulbar and helipad, congenitiva. This is an intraoperative photo. She would always have this scar tissue to be removed, and everything would just come back showing the chronic inflammatory changes for organisms wherever they're isolated. So this isn't one I meet her as in August of 2015. She's an inpatient at the time. She has intractable eye pain, orbit pain. She's needing an eye to play. She often gets pics placed to get her antibiotics. And on examination, I found these small green fibers in the color of her blanket that she would have in the hospital. And there was this question that was actually brought up on her, and I spoke to the primary team at the time about this. It was an admission before this last one that the internal medicine team had been kind of helping manage her. Had brought into question, you know, is she bloodletting? There was some blood found in the bathroom that she would have during her admission. And there was an episode where she was found to put some lotion in her hand and turn away from the camera. Although it was not clear it looked like she was putting it into her eye. So there was a team that approached her and her family while she was in the hospital that include Dr. Patel, the internal medicine team, psychiatry, and basically said we're concerned that this may be happening and that this is maybe the reason why you're not getting better but it was not very direct. It was supportive. It was non-accusatory. But just to show you kind of over the time her visual acuity went from 2030 from when I saw her to 2800. And so her continued course she basically, even despite that intervention, she did not want to see psychiatry. She did admit to depression but did not want any intervention. She had continued our worsening symptoms, new signs of infections and we really could not prove a 100% certainty that there wasn't something else going on. So ultimately she ended up within a nucleation. She later continued to have infectious signs such as an antiroborotomy and partial excretion and again another mission for IV antibiotics. She was eventually seen by ENT who did a complete excretion. In about June of 2016 was the last time she was seen in the university system that was for her ENT follow-up. I reached out to ENT to kind of find out what the last conversation was with her. They didn't get back to me. So I did look and it looks like she's being seen at IHC. She's had several missions there for their surgeries, IV antibiotics. She was on FTCA for a lot of that one point. So she's continuing to be seen in the medical field. So case number two, so again let's go back to these lesions here. So what's these we're seeing and the team Dr. Chakour and Laura Shelf that will immediately smell like lasers. So she's seen back and her vision was dropped to 24th under the remote spots in the macula. So the question was raised are there any lasers in the house and they said, yeah, we play we use them to play with the cats. So they said they basically recommended to get rid of the lasers at this point. So they've set up a hold-off on SELSA which they would start Bell Tracks Oral Pride of the Zone and again our condition was to get rid of those lasers. Unfortunately, she missed one of her follow-ups and didn't come back before weeks later and ended up having count-finger vision in the left eye and her right eye is at 26 and she's blind bilaterally now and they can see again a complete loss of all the radical layers here. So diagnosis in both of these cases is thought to be due to self-harm and we invited Paul Carlson here to kind of help us and talk about some of the literature that's available and you know because I'm not an expert and no one in this room is really an expert on this. We thought that Dr. Carlson might have some inputs. So just to review some definitions these have been looked at since medical school but factitious disorders so this is also known as month chausens. It basically results around the desire to assume a sick role for attention, reassurance, some report the rush of the experience enjoyment of deception the average health care cost from one report was estimated about $200,000 and this obviously does not include the psychological cost to health care providers a lot of times some providers get attached and roll out on the patient and just feel free and feel pretty bad afterwards. Malignering is the term for when there's an intention to monitor a game sickly and then I brought up I had a discussion of this but I wondered about payments that would go under malignering and there's psychogenic conversion disorder psychosis and other things so as far as when was the self harm of the eye first reported so there's a lot of mythological reports we all know Oedipus and also Egyptian and Nordic reports of basically self remuneration of the eyes there are three patron saints with vision and eyes and all our three are female saints who in some form or other eyes most of them have their vision restored later so ocular self harm in the medical which really became a recognized phenomenon during World War II and this is thought to be more to with malignering and the thought at that time was that basically people civilians had no benefit of being or causing ocular harm because there's financial disadvantage and the hospital was not comfortable as a home but this time it was really thought just to kind of get out of military service so there's one review of there's not a lot of information but there's one review of ocular and orbital self harm that was done by Patton in 2004 he didn't really differentiate between factitious, malignering, psychosis it was really just kind of brought up the theories behind ocular self harm and gain examples based on location of the corneal retinol etc and then there's this is the same case we talked about 31 cases in 1947 and the observations at that time were that this was more common lower ranks and the substance it was used was jacquery and castor oil plants and then there's another report on Israel in 2013 again of another 17 military causes of self harm so the ones in this review surface disease so things that can clear you in are sharply delineated lesions often times they are mistaken as repetitive infections chemicals are often used in the surface disease with retinol endocrinitis from needling or self ejecting, potential sun gazing in our patients lasers, orbital pen stencils, toothbrushes into the orbit, trochotillomania of the eyelashes and there are some regions of self harm so the one report that I found that was I think most helpful was a systematic review of 455 cases that was specific to factitious disorder so I thought this was interesting this really really calls out the previous literature and says you know there's a lot of non-evidence based recommendations going through the literature really based on anecdotal evidence there's really not good numbers so it's really the first systematic review that looked at demographics to see if there's any treatment recommendations and associations with other psychiatric disorders so they found that 600 patients were female which was interesting because again throughout the prior literature they thought that they were mostly male and again this is just what factitious is doesn't include only varying like other cases of the military for 22 years and most of the case reports were not written by psychiatrists so basically they showed that there's about 37% of cases that did have comorbidus psychiatric disorders but the thought was well this is probably because Episthom was writing these pictures the majority of them but the ones that did mention comorbid disease so the 32% of them are associated with depression personality disorder which this was the previously main association substance abuse, anxiety and suicidal ideation so one of the things that they really were able to you know add the numbers up and find these factors that were leading to the diagnosis of factitious disorder so these are kind of things that you can clue us in as practitioners to the factitious disorder so the past healthcare service use so in our first lady the fact that she had you know previous multiple surgeries under her arm might have been a clue patient history can be inconsistent and unlikely atypical presentation unsubstantiated presentation so again all of these labs would make that negative evidence of fabrication so actually like aspirations on like the warped contract for example would be an example of that and then patient behavior so maybe we could talk about this pseudo-logia fantastica or patient opposes psychiatric involvement while pursuing medical and surgical options and then investigation indicating fabrication one of the examples they give is like the use of insulin and like in our case like evidence of potential self philotomy or severe tender bloodletting and then also treatment failure so other findings that they found for the patients elected to actually induce illness or injury compared to just 20% or have each who acted out symptoms or falsely report them the occupation that was most common where it was in healthcare and laboratory of which 57% of cases were associated with such the most common profession being nursing and use of insulin and self venous section which is basically the bloodletting were commonly used and were causes that did lead to retaliation in these cases and there was not enough data to really make good treatment recommendations so again we're kind of based on anecdotal evidence at this point although you might have some other other thoughts so just real quick that they did divide all these cases by subspecialties 18 ophthalmology cases were included the age and gender fit with the overall averages most of them were surface issues I thought it was interesting that they said they included this case of two cases of Diplobia but there were no cases of functional vision loss and didn't really go over what wasn't good and what wasn't or what wasn't specifically ophthalmology so just some general approaches to this is that they're usually young with a history of working in healthcare it is associated with depression more than personality disorder so the people who are associated Successful management techniques have not been adequately studied yet in one case but we do know that getting psychiatry could involve is a good thing in one case there were 75% of patients who were confronted but only 1 in 6 acknowledged that their illness was self-induced which is a very difficult disease to deal with it could potentially have a health care ways to reduce problems with patients that's still sort of an honor so that's the best way to do it on this new paper so there are my references and does anyone have any questions or comments about these cases or Dr. Carlson so yeah this is a big often more common than we realize and the problem is is the patients who are in the bed can hear anybody got an issue the ones that I dealt with that were even more concerning the one chosen by proxy the child was the one being reflected with the eye injury parents who already had some of the air just feel like one of them Roger you're still here we were at UCLA as residents and somebody came in and tried to put his eye out with a pencil and it slipped off the bottom of the globe and it was lodged down on the maxillitis sinus and my everybody was wondering what to do the eye surgery was kind of pinned there it was doing fine and BNT came in and looked at it and didn't make sure he just pulled it out it seemed to be fine other than he had obviously had a lesion through your forenecks but from the surface I don't know the bruising so they called psychiatry to come talk to this individual and they said well what happened can you tell us about it and the psychiatrist resident psyched a human pencil this time right through through the curve and then he got back remember that, Roger? and then and while inside wanted to try to put the other eye on so in these years it was a really difficult case to deal with in his case it was a he had voices that were more psychotic in which he was holding it but just imagine this lady could easily kill herself and has ended up with a desideration over this these are strong psychological influences and that's a denial so if I could just say I think that's an important lesson it's not always helpful to get psychiatry involved imagine there was one very, very embarrassed psychiatric resident and don't forget that you do have the resource at the patient support program we do have, you know we can diagnose mental health issues we don't prescribe but I spent 12 years doing research on schizophrenia I'm very familiar with psychoses and I can help weed out these things I know that Dr. Shakur actually consulted with me on the VA woman and she was seeing a therapist so didn't want to step on toes there so we did, I think Dr. Shakur did to consult with her therapist over there at the VA but don't forget that we have this resource we see these kind of mental health issues and we can help out with our patient we were there were a couple of options we wanted to either confront the patient now she has a spouse who has four children and the affect of the patient was interesting because she never seemed to be very concerned about her vision loss but was very thrilled about the attention she was getting that might be part of it so I did ask her about lasers and I told her to get rid of the laser and she said oh I've just ordered a 10 pack from Amazon so I told her not to cancel the order but that was the extent of how much I confronted her and let the therapist go further because there was a risk of alienating the patient and losing her completely so the way to diagnose it is to look at them on the microscope and you'll see kind of little stubs disease destroys wounds or lashes and they do not go back pulling your hair or should we do most of the hair and then this is where I psychiatry I realized which is very smart avoiding the school of psychiatry that subscribes to this being part of a Freudian disease and there is a whole literature about the sexual edictus and why people do this and it gets very interesting and important why do you see it clear of that they were quite known how to talk to patients and parents people were there in the clinic especially when they covered somebody else and they would be challenged and say sorry but so what I generally do and I'm not sure this is correct and it's not written up is I put them on a prophylactic appointment and I said to them that in six weeks you are ready to get better and then I used my best hypnotic stare and it's easy and I'd like to perform you feel the rhythm back which should be on our best behavior and cheer this patient on this will say oh my god look at that all that actually coming back and it seems it was enough and I'm not sure about the psychiatric background how we deal with this this business about where it leads to exaggeration this was a real learning experience all the residents and I we also sadly developed we found these things foreign bodies we actually did find new foreign bodies and I thought you always remember those dramatic ones we have something called Robo I don't know how many of you know the history of Robo it's the oldest mad asylum the woman comes she sits there and she says I don't think I'm going to be able to see so all of us residents work around and they find nothing wrong so she pushes her finger she goes immediately to her orbit right in front of the resident and so they admit her and so they wake up the next moment we all wake up the next morning go to exactly that in the middle of the night and she spots her on the right side and so she's a dramatic this world that was written down as well as a new face so I know you're a disease and I don't quite know how you diagnosed the field fields so what's your I would just curious what your anecdotal experience is in terms of you know like what are your recommendations for us from history's getting you involved and also like any anecdotal experience and what works in 1000 years can you go back to the differential slide differential diagnosis first of all I would just say that these are very tough cases oh sorry just in the discussion in the literature so these are very difficult cases and there's not a lot in literature I think you actually did a great job of reviewing the literature there's not much for any type of factitious disorder I think this is a good differential to consider one thing that I would focus on more is psychosis again there's going back to the psychodynamic theories again I'm not going to tell you but that makes a lot of sense there's some crazy stuff there and the stories that you mentioned you know so plucking your eye out and this story in history and mythology with edifice and obviously psychiatry has had some fixation with the edical story and there's been association as Dr. Patel mentioned with the the eye being a symbol of something sexual yeah that gets kind of weird but if you look at this through the lens of psychosis there's a lot of the common themes when someone is psychotic are things that are very important very central to being human so sense, religious themes and that kind of fits with the stories in mythology and history that you see but it doesn't really fit with what we see clinically if someone has is really committed to either pulling out or doing so much damage to their eye volitionally that they seriously damage the vision that takes a lot of commitment there's some body parts that are more important intrinsically to us than others just the way that we're wired and the eye is definitely one of those and I think in that sense it kind of makes sense that there's this connection between sexual organs and the eye there's a concept in psychodynamic theory which I think is a more useful concept here this is the idea that different parts of the body develop psychologically we develop a specific attachment to them in a sense of identity with them and some parts of the body matter more than others and definitely the eye is one of those that we're looking for very effective versus eyelashes is a different story trigatillomania that's a very different process we're pulling hair from other parts of the body but someone that's intentionally doing damage to their eye in a significant way or if I was invited to urology and they were talking about a case of self-castration or someone cutting off their penis that's almost always in those cases I would say there's some significant psychotic process involved and that's what I would wonder about these two cases actually so obviously there's some a lot of psychological factors and the attention you said with the first case there was a little service on the patient was there a question of any psychotic process no I think it was she was just being depressed that was the only diagnosis I don't know but that was something they weren't considering but they didn't really mention it the attention seeped into the psychotic process not in and of itself but it certainly could go along one doesn't exclude the other you could certainly be psychotic and also enjoy the attention but to be that committed to doing that much damage over that much time it does it does make me wonder because as you pointed out in one of the slides a lot of people will when it's just for the attention it's just a subjective report that they will present or even much more superficial things but this is pretty it takes a lot of in a way that for most of us you think about even touching your eye when my kids have started to wear contacts there was all kinds of drama just putting your finger close to your eye there's this visceral reaction that we have it's very innate and so to repeatedly do this that's pretty impressive also with the laser so yeah I would be very interested to interview these patients and see but again obviously they're quite guarded someone can't be can have psychosis but be relatively intelligent or very intelligent and relatively high functioning and able to be very offended and suggest that they're doing this right and insist this is not self-induced several I remember that literally took videos showing them doing this and then they go over the excuse that only you misunderstood and that's where the first few items here are fictitious disorder versus malingering Ashley did a nice job describing the different motivations between those we'll talk about these concepts in terms of primary gain versus secondary gain primary gain associated with fictitious disorder is really for the primary gain is psychological gain and that is very hard to challenge people will be very defended against any other interpretation and will go to great lengths and will be very offended versus malingering that would be secondary gain and that would include pain medications as you assume so yeah it's just any external factor people don't tend to be as personally invested they may be upset but usually that passes and they'll just go on to but it doesn't have the personal quality that the primary gain situation so fictitious disorder that is a touch diagnosis there is it's not a diagnosis you want to jump to because there are good outcomes and prognosis is quite poor I think it's conversion disorder also so another somatic form disorder where primary psychological gain is the main issue but there tends to be a better outcome with conversion disorder than with fictitious disorder I think in the limited literature would support that as well and those are patients where they often induce the conversion disorder patients do tend to respond better to suggestion to this kind of positive attitude this fictitious disorder I don't typically see that as being beneficial but as positive as possible but still there is so much at stake psychologically for the person that it's it's just tough in fictitious disorder would there be any benefit of functionally removing the source of secondary gain for instance letting the spouse for instance such as with the second case we suspect that getting attention from the spouse was partially responsible and making the spouse aware for instance that this may be happening may remove that source of secondary gain would that be helpful it can be and I would say that's probably the most effective approach generally is so having over aggressive confrontation is pretty much never helpful it is helpful and appropriate to share information and raise concern but I think the chance, the best shot that you have of making a difference in this person's outcome is to address that psychological need and if you can approach it in a way that's we don't understand there's some things that make us think that there may be some something that's getting in your eye that's damaging and if you're doing something bad or what's happening here this can be very stressful and we'd really like to help and the stress of your vision we'd like to help support you with that and if there's any way that psychology psychiatry and the primary team can develop a rapport to address the psychological needs that's the best chance but again, usually if someone is this invested in pursuing this extreme of a method particularly in these cases if these are just back in the sport the chances of success are pretty slim we would definitely want to try I think in these cases if you're suspecting this definitely involves psychiatry it is a fine line to walk and approaching it as even this chronic pain chronic illness whatever inflammation is stressful in itself and it would be helpful to talk about that with a counselor whatever to build that rapport that relationship that then you can dig a little bit deeper and get to those other issues but without that that confrontation you're going to run away and I think it's going to be most effective if the the mental health intervention is embedded within the primary the primary service if the patient sees that as part of their it's part of the ophthalmology team obviously we're not going to lie to them we're going to tell them who we are but if we can present that as working together I think that's more likely to be successful which is why we have patient support programs with mental health component and the functional and the physical and then with going back to psychosis in these cases again there's much more opportunity for more immediate intervention so if schizophrenia substance induced thought disorders with a psychotic disorder those are things that we can treat aggressively and effectively and then maybe