A 15-year-old boy was referred from a local ophthalmologist with a suspected diagnosis of unilateral chronic pseudomembranous conjunctivitis, unresponsive to topical antibiotic/steroid treatment.
On presentation, his unaided visual acuity was 20/20, N6 OU. The OS was normal and OD showed freely movable, reddish brown–stained cottony/ropy material in inferior fornix. There was no evidence of any intense inflammatory reaction except few follicles and congestion of lower fornix [Fig. 1a]. The rest of the conjunctiva and cornea were clear [Fig. 1b and c].
Careful inspection of the material under slit-lamp microscope showed a cotton material with red (?kumkum) and brown (?coffee) powders [Fig. 2a]. Therefore, the patient was asked to report back on reappearance of symptoms. However, the patient went to washroom and came out with alleged reappearance of symptoms. While white cotton was noted in right lower fornix [Fig. 2b], a long cotton piece was recovered from his pant pocket [Fig. 2c]. Therefore, a diagnosis of factitious conjunctivitis was confirmed. The patient was referred to psychology counselor where he and his parents were counseled in detail.
Factitious disorders are conditions in which symptoms or physical signs are intentionally produced by patient to feign illness.
The diagnosis of such factitious disorders is notoriously difficult due to its integral features such as deception and denial. In our case, the eye was relatively quiet for such a large amount of “membranes” to form. Variable history about duration of reappearance of membranes after removal aroused the suspicion. Moreover, there was involvement of right lower fornix in the right-handed patient. Although various cases of unilateral or bilateral factitious disease are described in ophthalmic literature, to the best of our knowledge, this is the second reported case of factitious conjunctivitis in India.
To conclude, a strong suspicion in cases with inconsistent history and disproportionate signs and symptoms helps to consider a diagnosis of factitious disorder, the definitive treatment of which lies with psychiatric counseling.
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