Malingering (Case presentation)

Explained Malingering test via Case presentation .

1. Case Presentation MALINGERING KHULESH SAHU (Consultant Optometrist) Sai Baba Eye Hospital Raipur

2. Demographic details 25 Yr old male came to SBEH on 5 th Jan 23 Chief complaints Complains of Sudden Decreased of vision since 1 weeks History of present illness No h/o recent Oph . Consultation No h/o using glass No h/o head and ocular injury History of past illness Non-contributory Family/surgery/allergy/ General health / C urrent treatment Non-contributory Personal history NA

3. Right eye Left eye Presenting visual acuity (Unaided) 6/60 N24 at 30cm 6/36 N24 at 30cm PH NI NI Objective refraction -0.50 DS Plano/-0.50Dcyl*90 Subjective acceptance Not Accepting any power Not Accepting any power Glass Prescribed view - -

4. External examination Right eye Left eye Eyelid Flat Flat Conjunctiva Quiet Quiet Sclera Normal Normal Cornea Clear Clear Anterior chamber Normal in content and depth PACD = 1 CT Normal in content and depth PACD = 1 CT Iris Normal color and pattern Normal color and pattern Pupil R/R/R R/R/R

5. Fundus examination OD OS Optic disc size Medium size disc Medium size disc Cup/Disc retio 0.3 0.3 Optic disc Normal Normal Blood vessels Normal Normal Macula Normal Normal

6. Differential Diagnosis Amblyopia Cortical Blindness Malingering Retrobulbar Neuritis Chiasmal tumor Panic attack Psychiatric Disorder

7. Plan of Management Plan for Cyclo Refraction OD +0.25DS / -0.50DC *90 OS +0.25DS / -0.50DC*80 Malingering Test Visual evoked Potential - wnl

8. Malingering Also known as Simulation The intentional production of feigning illness Motivated by external incentives Drugs Litigation Financial compensation Avoid work/military service Evade criminal prosecution

9. Malingering Triggers Poor medical knowledge Low socioeconomic status Light sensitivity Color vision loss Blurred or decreased vision Mild injury Ocular discomfort/pain Blepharospasm

10. Types of Malingering patients Deliberate Malingerer Faking of visual problem Monetary gain Attention 2) Worrying Imposter Knowingly exaggerating visual symptoms Has a serious problem Doesn’t want problem to be overlooked /miss out

11. 3) Impressionable Exaggerator Thinks something wrong with Eyes Wants to help the doctor and make the symptoms easy to recognize 4) Suggestible innocent Convinced self of a vision problem Vary complacent not very worried about problem

12. Malingering Test Subjective Test Eye contact - Lens Fogging method Observation - Prism shift test Hand looking test - Mojon test Signature test - Duane test Surprise test Mirror test Finger to Nose test Menace test Pinhole test

13. Objective Test Optokinetic nystagmus test Pupil Psychogalvanic test Pattern visual evoked potentials ( pVEP )

14. Eye Contact Quick and easy way If Pt is making eye contact with the examiner, it means they are Malingering

15. 2) Observation Blind Pt always proceed cautiously and avoid the objects like furniture and dustbins malingerers knowingly bump into objects.

16. 3 ) Hand looking Test Asks the patient to look at their own hand Blind patient moves his hand, looks at it and says I cannot see my hand but I know where is it Malingerer moves his hand and say I am totally blind I cannot see it

17. 4) Signature Test Truly blind patients can do these Malingering patients will often not be able to do them, they will just scribble something.

18. 5) Surprise Test Suddenly if examiner makes a face or makes shocking action Truly blind Pt’s reaction will be normal Malingering Pt’s reacts something

19. 6) Mirror Test t is very useful as well as rarely used test The examiner moves the mirror towards and away from the subject and simultaneously examiner looks at the subjects eye secretly. If the subject moves his eye and look in the mirror, then it denotes that patient is able to see

20. 7) Menace Test The examiner move their hand close towards the subject eye immediately If the patient closes his eyes, it denotes that they are normal 8) Pinhole Test When the subject is asked to read the letter at distance by keeping a pinhole before good eye and bad eye is kept as it Is During the test if the patient keeps on reading the letter then the examiner slowly place out the pinhole from the trail frame without subject’s awareness. If patient is able to read then , let him continue reading till last line.

21. 9) Lens fogging method Blurred good eye by placing +10.00Ds as a fogging lens, while patient views snellen’s chart binocularly Slowly the fogging lens are removed till the acuity increases The acuity achieved represents the function of supposed bad eye.

22. 10) Prism Shift Test Placed 4PD (base out ) in front of bad eye if there is some movement in both eye so pt is malingering

23. 11) Duane Test Placed 10 PD base up lens on bad eye while pt reading binocularly if patient delay to read even a second, it’s malingering

24. Objective Test Optokinetic Nystagmus Objective method for vision assessment in uncooperative children as well as adults Rotate the OKN drum Infront of pt’s eye ,if they making pendular eye movement that mean pt has vision

25. 2) Pupil Totally blind eye has nonreactive pupil to light accept cortical blindness Unilateral vision loss, a relative afferent pupillary defect (RAPD) is usually present. 3) Psycogalvanic Test Make the patient to sit infront of slit lamp Immediately bright light is reflected on his bad eye. If the patient reacts to light by blinking /watering or some facial changes then we can conform that they are able to see the light

26. 4) Pattern visually evoked potential It’s the gold standard method to reveal the malingering To evaluate afferent visual pathway disfunction including the macula and optic nerve

27. Management Psychological support Placebo treatment ( Plano glasses , sugar tablet , various non reacting or non allergic drops ) Counseling of patients and their family members or friends Follow-up care