Truth, Lies, and Ophthalmology

When dealing with functional vision loss, knowing the correct terminology is the first step. We use the terms “functional,” “non-organic” or “non-physiological” vision loss to describe patients who appear to be describing problems that don’t appear to have a physical basis. But bedded within this larger term are subgroups – patients who have had a conversion reaction, in which visual loss is unconscious or involuntary, versus those who may be malingering or have factitious disorder (meaning there is deliberate, feigned visual loss, which may have various motives). But we don’t use these terms – just larger blanket terms, such as “non-organic.” Why?

The first and perhaps most important reason is that to make a distinction is to speak to the state of mind of the patient. And should you end up on the witness stand or in deposition with a lawyer, you don’t want to find yourself being quizzed on your psychiatric credentials. It’s not our area of expertise. We don’t want to assume we know why our patient is behaving in this way. The second reason is that such behavior exists on a spectrum, so the reasons for the patient’s behavior may not be so black and white; for example, a patient may have genuinely experienced a small amount of visual impairment, but then exaggerated their symptoms because they want to make sure their doctor doesn’t miss it. In any case, understanding the distinction is valuable for the management of these patients.

Look for indifference or hostility

Conversion reaction patients lie within a wide age range and sometimes exhibit “la belle indifference,” which means an inappropriate response – almost an indifference – to their symptoms. They aren’t feigning illness because of an underlying agenda to meet their own goals, and so they tend to be pleasant and cooperative. They are also notoriously suggestible, which is how they became convinced of their illness in the first place. As I discuss below, this can be helpful during management and testing.

In contrast, patients who are malingering are often young adults. They’re likely to be under pressure at work or with their finances, often have a history of recent trivial trauma, and are frequently hostile to the person examining them. The hostility can take different forms. In my experience, these are usually the patients who arrive late, announce that they have to leave early, and take issue with your methods, making comments, such as “You’re just doing the same test as the other doctor,” or “You’re not going to use those lights, are you? The other doctor did that, and I had a headache for three days!”

The recent trivial trauma they’ve experienced is often job-related. A common scenario is a patient who had a splash of some sort into their eye. The eye was irrigated and patched, but when the patch came off two days later – bam! – it was blind, and has remained blind ever since.

Control your frustration – but also listen to it

Patients who arrive in our office already displaying aggressive or hostile behavior can be upsetting for us as physicians, but it’s also a very helpful diagnostic clue; it can be an indication to at least suspect that a patient has a hidden agenda. Most of your patients are visiting you because they want to get better, and have no reason to create friction with a doctor who is on their side and looking out for their best interests.

But anger from a patient isn’t the only clue – if you feel yourself becoming upset or frustrated, that’s another one. Don’t fall prey to this, reacting with a comment, such as “Well, do those other doctors know what you had? I guess not, because that’s why I’m examining you!” Instead, take a step back from the situation, assess what’s happening and consider your own frustration, because it’s a helpful piece of data.

Another diagnostic clue is the sunglass sign. These patients come in wearing dark glasses (sometimes more than one pair) and a hat with a brim, and have their collar popped. You have to peel each layer off to examine them and as you do so, they appear to be in agony: “Oh my God, no! Don’t do that!” They act almost like a vampire being unmasked...

There are a number of examination techniques that we can use to diagnose non-organic visual loss, which generally fall into three categories – we demonstrate things like inconsistencies in vision, or non-physiologic responses like tunnel vision and, on a good day, we manage to document that the vision is good – ideally we manage to somehow get 20/20 vision out of the “bad” eye or demonstrate a full field of vision.

Using the power of suggestion

You’ve performed your tests and you’re confident that you have a case of non-organic vision loss – what can you do about it? In many cases, the power of suggestion can be key to treatment. You already know that patients with conversion reaction are suggestible, and so may be equally suggestible to the idea that their condition is improving.

Malingering patients may maintain that their vision is poor, but they often don’t know the right answer to give to your questions. Instead, they look for any clues that will help them to convince you of their feigned illness. So if you say, “I’m going to double the size of this letter; it’s now twice as large,” it might get a response of “Oh, okay, I can see that now.” And telling them, “This lens should clear the problem right up,” might prompt them to agree that, “Yes, it does.”

Every doctor likely has their own way of dealing with these patients; some physicians have quite broad philosophical differences on the topic, while others only differ in the terms they use. There are physicians who use “magic eyedrops” and tell patients that they will clear up vision problems. I’m personally not so comfortable with that approach, as it does feel somewhat dishonest. And I don’t tell patients that I’ve found something and that I’m going to fix it. Instead, I take a three-step approach – and though the following isn’t based on research data, I have found it to be effective.

Step 1: the introduction

The first step is to introduce the topic. Explain, in a non-judgmental way, that you believe the problem is not physiological. Use phrases like:

“Your vision is better than you think it is.”

“Your eyes are playing tricks on you.”

“Your brain is capable of seeing better.”

“Your brain isn’t letting in the good vision.”

“Should you end up on the witness stand, you don’t want to find yourself being quizzed on your psychiatric credentials.”

Step 2: the explanation

Next comes the explanation, which is key to the process. I start with something like this:

“Obviously, your vision was very poor when this started. You were legally blind in that eye after what happened (the splash, or the hit on the head). How scary that must have been for you! If I were you, I would have been thinking, ‘Oh my gosh, what if it doesn’t get better? What if I can’t work and support my family? What if it just never goes away?’ Those thoughts were so scary, that your brain went into a spasm. Meanwhile, your vision has improved, and the problem has gone away. But now, your brain is not letting the vision in.”

My residents used to call this the “brain spasm speech.” I know it perhaps sounds a little foolish to tell the patient it’s not them, but their brain – and you may expect that some patients would be incredulous. But I’ve found that it works. You can use your own terms and explain it in your own way; the crucial aspect is that it must be non-judgmental. You’re telling the patient that there is an explanation for their problem and that if they can just relax, they will see an improvement.

Step 3: the prediction

Finally, you offer the patient a prediction on how their vision will improve. For example, I might tell them that their vision will improve every day, clearing from the outside to the center. And I’ll likely offer a timeframe over which they will see total recovery: “You’ll see some improvement tomorrow, more on Friday. By Sunday you’ll be almost better, and on Monday morning, your vision will be back to normal, which means you can return to normal life.” I’ll then hand them a note clearing them to go back to work, which I will have prepared before I even enter the room. I won’t recommend any further testing (I have already completed all the testing I need to make my diagnosis at this stage) and I won’t suggest a return visit. It’s important not to give the patient the wrong message; we don’t want them to think, “Wait. If I’m okay, why do I have to come back? Why are you ordering another test, if my vision is fine?”

The clear message you’re trying to send (especially to someone who is purposefully trying to deceive you, such as a malingerer) is this: “I’m giving you the best deal you’re going to get. I’m not going to unmask you in front of your spouse or your employer. I’m not asking you to give back the money you’ve been receiving for the last six weeks. I’m not asking you to admit that you are feigning vision problems. But this is finished. I’ve got to go to work on Monday and so do you. You should take this deal.”

Note that this is deliberately intended to be coercive. At such appointments, I behave differently than I usually do with a patient. Normally, I make a point of trying to make it easy for them to tell me how they feel by giving them time and space and by letting them ask questions. I portray this with my body language, for example by leaning back in my chair. In contrast, when I’m managing a malingerer, I don’t want to know what the patient thinks about it; instead, I need to convey a simple message: “Here’s the deal. Take it.”

Be confident in your diagnosis

The technique can be applied in different ways, with different language, but the five essential elements are:

• A non-judgmental explanation of the problem
• An explanation of how vision will clear
• A timeline for when it will be back to normal
• A return to work note
• No offer of further testing, and no return visit.

For conversion disorder, this offers reassurance and a strong suggestion that the patient is okay, that they’re already getting better, and that there is nothing to worry about. For the patient deliberately feigning illness, you’re not judging or unmasking them, but telling them that “the play” has ended.

It is important that you are confident in your diagnosis (as always) – and that you are able to convey that confidence when speaking with the patient. But it isn’t always easy in such cases. If you don’t feel confident or you don’t feel comfortable, consider sending the patient to a neuroophthalmologist. We may also find some of these patients challenging, but they are definitely within the scope of our field – and we are always happy to help.

Valerie Purvin has been on the faculty of the Indiana University Medical Center for over 30 years with a busy clinical practice in a large, subspecialized ophthalmology group in Indianapolis, Indiana, USA. She has published on a range of topics, generally focusing on issues that arise in caring for patients with neuro-ophthalmic disorders including ischemic optic neuropathy, inflammatory optic neuropathies, and visual complications of medications.

Tales of the Unexpected

Truth, Lies, and Ophthalmology