This case presentation discusses a patient presenting with sudden decreased vision in both eyes. Differential diagnoses included malingering. A series of subjective and objective tests were performed to evaluate for malingering. Subjective tests included observations of eye contact and reaction, hand-looking, signature ability, surprise response, mirror and menace reflex tests. Objective tests included optokinetic nystagmus, pupil examination, psychogalvanic response and pattern visual evoked potentials. The results of testing supported malingering as the correct diagnosis for this patient's symptoms. Management involved psychological support, placebo treatments and counseling.

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

2. Demographic
details
25 Yr old male came to SBEH on 5th 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 /
Current 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
1) 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. 1) 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
1) 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