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Editor,—Eyelid swelling can be diffuse or solid, acute or chronic, isolated or part of a syndrome. The differential diagnosis of solid, chronic, and isolated eyelid swelling comprises tumours of multiple origin. We report a case of eyelid swelling which was caused by automutilation as part of Munchausen's syndrome.
A 44 year old white woman presented with bilateral lower eyelid swelling that had been present for 6 months, which made reading impossible (Fig 1). In the past she had undergone several paranasal sinus operations and 3 years earlier she had been treated for a preseptal orbital cellulitis and pansinusitis. For the past 4 years she had been bedridden because of fibromyalgia.
The swellings measured 7 × 5 × 2 cm and felt solid on palpation. Complete ocular, internal, otolaryngological, dermatological, parasitological, and psychological examination revealed no clues for the diagnosis. The swellings were surgically removed to the level of the orbital septum, the defects being covered with full thickness skin grafts. Histological examination showed chronic lymphoedema with lymphangiectasia, inflammation, and striking eosinophilia, but no conclusive diagnosis could be made at this time. During uneventful healing of the lower lids, the patient developed bilateral upper eyelid swelling. These swellings were removed as well and replaced by split skin grafts. Histology of the upper lids showed densely packed empty spaces, which almost obscured pre-existent structures such as the orbicularis muscle (Fig 2). In between a patchy infiltrate of lymphocytes, neutrophils, eosinophils, and many macrophages was seen. At high magnification (Fig 3), the empty spaces revealed a lining of macrophages as was demonstrated by positivity for the CD 68 antibody, a reaction pattern highly suggestive of a factitial process. The diagnosis of Munchausen's syndrome was made.
The patient was confronted with these results and admitted having pin-pricked herself after putting fatty ointments on her eyelids. She thought this would help the “blisters” to disappear more rapidly. After an emotional conversation, she was able to get up and walk for the first time in 4 years. The repeated psychiatric evaluation resulted in a diagnosis of a factitious disorder with physical signs superimposed on a somatisation disorder. The complaints seemed to have a function in the maintenance of the balance of power in the matrimonial relationship. The patient refused psychiatric treatment.
Factitious disorders, such as the Munchausen's syndrome, are under the patient's voluntary control and are intended to get or maintain the role of patient.1-3 Self inflicted enucleation and corneal perforation are described ophthalmological representatives of these disorders and easy to recognise.4-6 The above described swellings are a less common and more difficult to prove example of an ocular factitious disorder, although the patient's medical history might make the doctor suspicious. In summary, self inflicted disorders must be considered as a cause of eyelid swelling.
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