No More Than Meets The Eye

The patient's mother was frantic, and her doctors were baffled. Despite months of treatment by several specialists, the 9-year-old's eye still looked infected.

It was the fourth doctor who saw the girl in as many months, Chevy Chase corneal specialist Roy Rubinfeld, who used a simple strategy to uncover the disturbing cause of a malady that had stumped his colleagues. The problem, he discovered, had little to do with ophthalmology.

For weeks, the routine had been the same: The girl would use prescribed eyedrops and the problem would clear, only to return a week or two later with a vengeance. If the problem was viral, commonly known as pinkeye, it would have cleared without treatment. If it was bacterial conjunctivitis, as several doctors had diagnosed, the progressively stronger series of eyedrops should have long since vanquished it.

Doctors had considered herpes, but the discharge was too copious. Maybe, they thought, the problem was acanthamoeba, a rare infection associated with hot tub or contact lens use -- except the girl hadn't been near either.

Like the other physicians who had treated her, Rubinfeld faced a dilemma: The potent eyedrops she used produce significant inflammation, which made it difficult to determine whether the discharge and redness reflected lingering infection or were a side effect of the medication .

He pondered other possible causes. Could an embedded foreign body -- a speck of dirt or tiny piece of grass -- be the culprit? A careful examination revealed nothing.

Maybe it was a festering sinus infection. Topical antibiotic drops wouldn't have helped, because long-term sinus infections require oral antibiotics. To check, he pressed on the nasolacrimal duct, where the nose and inner corner of the eye meet. A sinus infection would have caused pressure or pain -- maybe even some discharge. Again, nothing. Besides, the girl didn't have a fever, runny nose or other characteristic sinus symptoms.

He zeroed in on another factor: his young patient's demeanor.

"Usually a girl that age acts like, 'Get me out of the eye doctor's office.' But this one wasn't doing that. She seemed to like the attention,'" he recalled.

Acting on a hunch that her problem might not have an organic cause, Rubinfeld devised a potentially risky test. He patched the eye, then signed his name across the patch, tape and her cheek.

"There was no way she could take it off without us knowing," he said, "but it was a real risk because if it was bacterial conjunctivitis it would get much worse." A patch provides the moist, dark environment that is a perfect breeding ground for bacteria, he noted.

Rubinfeld said nothing to the girl's mother, but told the pair to return the next day.

When the eye surgeon removed the patch, his suspicions were confirmed.

"There," he recalled, "was a healthy-looking eyeball."

After Rubinfeld asked a few questions, the girl admitted that she'd caused the recurrent infection herself by sticking little pieces of toilet paper in her eye. She told Rubinfeld and her shocked mother that she'd been having problems. Both were referred to a therapist.

Rubinfeld said he has since seen a few similar cases -- usually in young girls whose self-inflicted eye injury is an expression of emotional difficulties. Such self-injurious behavior can signal several mental health problems, according to Montgomery County child psychiatrist Michael Brody.

In his clinical experience, Brody said, the most likely are depression or obsessive-compulsive disorder. Less likely is a rare syndrome called Munchausen, in which a person fakes symptoms in order to receive attention from doctors and to undergo medical procedures, including surgery. Munchausen's patients are typically adults, but cases in children have been reported.

Although faking illness is a strategy commonly employed by children to get out of going to school or to avoid other situations, in many cases it is not considered pathological. Brody sees a crucial distinction between an action designed to avoid a test and this girl's behavior, which spanned months.

"It's one thing to fake a cough or a stomachache," he said. "It's another thing to stick something in your eye. That's a little too Greek tragedy -- especially since a lot of people have a fear of blindness."

Often a child's choice of body part can be revealing, observed Brody , a spokesman for the American Academy of Child and Adolescent Psychiatry.

"You don't have to be a psychiatrist to figure out this kid might have seen something she didn't want to see. Nine-year-olds tend to be very concrete" in their reasoning. The attention from her mother and doctors reflects a phenomenon known in psychological circles as "secondary gain" -- a benefit that accrues from being sick but is not the primary motivator of a particular behavior.

"It can also be seen as part of the message she's trying to communicate, which is: 'Help me,' " Brody said.

"The worry with cases like this is that these kids may be at risk for other flamboyant, self-destructive behaviors" when they get older.

If you have a medical mystery that's been solved, e-mail us atmedicalmysteries@washpost.com.