Ophthal Plast Reconstr Surg, Vol. 31, No. 1, 2015
sentinel lymph node status in 612 stage I or II melanoma patients. J Clin Oncol 1999;17:976–83. 4. Tuomaala S, Kivelä T. Sentinel lymph node biopsy guidelines for conjunctival melanoma. Melanoma Res 2008;18:235. 5. Pfeiffer ML, Savar A, Esmaeli B. Sentinel lymph node biopsy for eyelid and conjunctival tumors: what have we learned in the past decade? Ophthal Plast Reconstr Surg 2013;29:57–62. 6. Ravaglia C, Gurioli C, Casoni GL, et al. Sarcoid-like lesion is a frequent benign cause of lymphadenopathy in neoplastic patients. Eur Respir J 2013;41:754–5. 7. Rubinstein I, Baum GL, Yellin A, et al. Sarcoidosis: a cause of bilateral hilar lymphadenopathy after excision of malignant melanoma of the arm. South Med J 1985;78:1139–40. 8. Bässler R, Birke F. Histopathology of tumour associated sarcoidlike stromal reaction in breast cancer. An analysis of 5 cases with immunohistochemical investigations. Virchows Arch A Pathol Anat Histopathol 1988;412:231–9. 9. Mackenzie, Retsas S. Malignant melanoma co-existing with sarcoidosis: Implications for prognosis and management. Melanoma Res. 1996;6:71–2. 10. Yukawa M, Satoh T, Takayama K, et al. Cutaneous sarcoid reaction in a patient with bladder cancer. Eur J Dermatol 2010;20:235. 11. Cohen PR, Kurzrock R. Sarcoidosis and malignancy. Clin Dermatol 2007;25:326–33. 12. Seve P, Schott AM, Pavic M, et al. Sarcoidosis and melanoma: a referral center study of 1,199 cases. Dermatology 2009;219:25–31. 13. Tsunoda K, Onodera H, Akasaka T. Case of malignant melanoma associated with a sarcoid reaction. J Dermatol 2011;38:939–42. 14. Berthod G, Lazor R, Letovanec I, et al. Pulmonary sarcoid-like granulomatosis induced by ipilimumab. J Clin Oncol 2012;30:e156–9. 15. Heinzerling LM, Anliker MD, Müller J, et al. Sarcoidosis induced by interferon-α in melanoma patients: incidence, clinical manifestations, and management strategies. J Immunother 2010;33:834–9. 16. Wilgenhof S, Morlion V, Seghers AC, et al. Sarcoidosis in a patient with metastatic melanoma sequentially treated with anti-CTLA-4 monoclonal antibody and selective BRAF inhibitor. Anticancer Res 2012;32:1355–9. 17. Sacks EL, Donaldson SS, Gordon J, et al. Epithelioid granulomas associated with Hodgkin’s disease: clinical correlations in 55 previously untreated patients. Cancer 1978;41:562–7. 18. Steinfort DP, Tsui A, Grieve J, et al. Sarcoidal reactions in regional lymph nodes of patients with early stage non-small cell lung cancer predict improved disease-free survival: a pilot case-control study. Hum Pathol 2012;43:333–8. 19. Shields CL, Ramasubramanian A, Mellen PL, et al. Conjunctival squamous cell carcinoma arising in immunosuppressed patients (organ transplant, human immunodeficiency virus infection). Ophthalmology 2011;118:2133–2137.e1. 20. Paridaens AD, Minassian DC, McCartney AC, et al. Prognostic factors in primary malignant melanoma of the conjunctiva: a clinicopathological study of 256 cases. Br J Ophthalmol 1994;78:252–9. 21. Tuomaala S, Toivonen P, Al-Jamal R, et al. Prognostic significance of histopathology of primary conjunctival melanoma in Caucasians. Curr Eye Res 2007;32:939–52.
Beauty is in the Eye of the Beholder: Body Dysmorphic Disorder in Ophthalmic Plastic and Reconstructive Surgery Lindsay K. McConnell, B.S.E.*, Wendy W. Lee, M.D.†, Donald W. Black, M.D.‡, and Erin M. Shriver, M.D.§ Abstract: Despite the fact that up to 15% of patients in an aesthetic surgery practice have body dysmorphic disorder (BDD), little has been written about the condition in the oculoplastic literature. The authors describe 3 patients with
Case Reports
suspected BDD who presented with perceived periocular defects. To appear “Asian,” a 39-year-old Hispanic woman underwent over 30 surgeries. She developed disfiguring scars and lagophthalmos with corneal scarring, remained unsatisfied, and tragically committed suicide. A 52-yearold woman with moderate dermatochalasis underwent a blepharoplasty to improve her vision and appearance and help her gain employment. Despite a good outcome, she remained dissatisfied and blamed the surgeon for her unemployment. Finally, a 73-year-old woman presented demanding treatment for brow rhytids causing severe emotional distress. She was denied intervention due to unrealistic expectations. These patients are suspected to be suffering from BDD. Increased awareness is critical as BDD patients often remain unsatisfied after surgical intervention and are in need of psychiatric care.
I
n the United States, up to 15% of patients who seek aesthetic surgery have body dysmorphic disorder (BDD).1 The statistics show that patients with BDD are likely to seek care from oculoplastic surgeons, but to date, little has been written about the condition in the ophthalmic or oculoplastics literature. Dr. Guy Massry recently highlighted the need for awareness of this disorder in the Aesthetic Abstracts and Citations section of the May/June 2013 Ophthalmic Plastic and Reconstructive Surgery.2 Three oculoplastics cases are presented, displaying the spectrum of the severity of BDD in adherence with the principles of the Declaration of Helsinki and in compliance with the Health Insurance Portability and Accountability Act of 1996.
CASE REPORTS Case 1. A 39-year-old Hispanic woman presented to triage with blurry vision, pain, photophobia, and tearing in the left eye. She was noted to have significant lagophthalmos with exposure keratopathy and was referred to the oculoplastics clinic. Her exam was remarkable for a visual acuity of 20/20 OD and 20/100 OS with a relative afferent pupillary defect OS. She had bilateral lagophthalmos with nonanatomic high lateral canthi, bilateral anterior lamellar deficiency, bilateral preauricular hypertrophic scaring, bilateral exposure keratopathy, and a corneal scar OS (Figs. A and B). Her intraocular pressures were 41 mm Hg OD and 46 mm Hg OS, and her optic nerve cup to disc ratios were 0.5 OD and 0.9 OS. The patient’s past medical history was significant for depression, migraine headaches, hypothyroidism, hypertension, and Raynaud disease. As a teenager, she became obsessed with wanting to “look Asian” and traveled across the country in search of a surgeon who would fulfill her goals. Her Accepted for publication August 21, 2013. *Carver College of Medicine, University of Iowa, Iowa City, Iowa, U.S.A.; †Department of Ophthalmology Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida; and Departments of ‡Psychiatry, and §Ophthalmology and Visual Sciences, University of Iowa Carver College of Medicine, Iowa City, Iowa, U.S.A. Presented at American Society of Ophthalmic Plastic and Reconstructive Surgery 2012 Fall Symposium, November 2012, Chicago, IL, by Erin M. Shriver, M.D. Supported by Florida Lions Eye Bank; The authors acknowledge the support of an unrestricted grant to The University of Iowa Department of Ophthalmology and Visual Sciences and Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, from Research to Prevent Blindness, Inc. New York, NY. Dr. Black receives research support from AstraZeneca. He receives royalties from American Psychiatric Publishing, Oxford University Press, and UpToDate. The authors have no financial or conflicts of interest to disclose. Address correspondence and reprint requests to Erin Shriver, M.D., Carver College of Medicine, Department of Ophthalmology and Visual Sciences, University of Iowa, 11196F PFP, 200 Hawkins Dr., Iowa City, IA, 52242. E-mail: [email protected]
© 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
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skin resurfacing, 2 face lifts, and 2 coronal brow lifts as a young adult. In her mid-twenties, she developed exposure keratopathy with bilateral corneal ulcers. She had surgery to lower both lateral canthi which were then revised on 3 occasions, followed by bilateral lateral tarsorrhaphies and then several severings of the tarsorrhaphies. Her most recent surgery, 7 months prior to presentation, consisted of a face and neck lift, rhinoplasty, upper labioplasty, upper eyelash grafts, poly-L-lactic acid injections in the nasojugal grooves, and bilateral lateral canthoplasties. After this operation, she developed an infection in the face lift flap that resulted in disfiguring scaring. She also had eye irritation which was treated with tobramycin/dexamethasone 4 times per day for 7 months. In total, this patient had over 30 procedures in 24 years. Her subsequent eye complications prevented the patient from maintaining employment. She remained single and never married with limited social support. Priority was given to treating her glaucoma because of increased intraocular pressures secondary to continued use of topical steroids and severe cupping of her left optic nerve. The patient was started on lubrication for exposure keratopathy in addition to dorzolamide/timolol twice a day and latanoprost 4 times a day for presumed steroid induced open angle glaucoma. At her 2-day follow up, her intraocular pressures had responded, but the patient was not concerned about glaucoma or permanent visual loss. Rather, she remained fixated on seeking further surgical revision of her lateral canthi with the ultimate goal of a corneal transplant on the left and improved “Asian” eyes. The authors declined further surgical intervention as it was felt that the patient’s priorities were not in line with her best interest. She refused to follow up with the oculoplastics service or a glaucoma specialist and expressed intent to seek out another surgeon for revision canthoplasties. It was learned that she tragically took her own life 5 years after presenting to this clinic. Case 2. A 55-year-old woman presented complaining of droopy eyelids with excess skin. She recently had been laid off from her job at a department store and was convinced that a blepharoplasty to reduce her hooding would improve her vision and appearance and allow her to find a new job. She was noted to have visually significant moderate dermatochalasis and underwent a functional blepharoplasty without complication. Her postoperative course was unremarkable, except that 2 weeks postoperatively the patient had a job interview and was convinced that she was not hired secondary to mild residual eyelid edema. At the 3-month follow up, the surgeon noted appropriate healing of the surgical wound and was pleased with the aesthetic outcome. The patient, however, continually examined her eyelids and remained fixated on the curvature of the incision and degree of residual skin present. She was furious with the surgeon for “ruining” her opportunity to find employment. The surgeon attempted to discuss the patient’s concerns; however, the patient became irate, refused follow up, and stated that the surgeon was “terrible and should not be operating.”
(A) Patient 1 with a high lateral canthus and corneal scar. (B) Patient 1 with lateral canthal and preauricular hypertrophic scarring. (C) Patient 3 with brow rhytids and a deep superior sulcus.
first bilateral canthopexy, bilateral blepharoplasty, and coronal brow lift were performed when she was fifteen years old. Postoperatively, she desired further elevation of the lateral canthus and subsequently underwent 3 canthopexy revisions, laser
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Case 3. A 73-year-old woman presented to the oculoplastics clinic demanding surgical treatment for right brow rhytids which were causing her severe emotional distress (Fig. C). The patient had already undergone bilateral upper eyelid blepharoplasty, a face lift, left upper eyelid ptosis repair, and a right lower eyelid entropion repair, and she was recently denied further procedures by her previous surgeon. She had poor skin tone with brow rhytids consistent with her age and a deep superior sulcus; however, her degree of associated emotional distress and unrealistic expectations led the authors to decline intervention. The patient remained fixated on her rhytids and was intent on
© 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
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Case Reports
TABLE 1. DSM V diagnostic criteria for body dysmorphic disorder4 1. Preoccupation with 1 or more perceived defects or flaws in physical appearance that are not observable or appear slight to others. 2. At some point during the course of the disorder, the individual performed repetitive behaviors (e.g., mirror checking, excessive grooming, skin picking, reassurance seeking) or mental acts in response to appearance concerns. 3. The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. 4. The appearance preoccupation is not better explained by concerns with body fat or weight in an individual whose symptoms meet diagnostic criteria for an eating disorder.
TABLE 2. Screening questions and signs of body dysmorphic disorder Screening Questions7:
Signs9:
What area in particular concerns you and why? Has the defect caused you great emotional distress? Has the defect impacted your social life? What treatment outcome do you expect? Do you take time to check the defect? How much time do you spend concealing the defect? Does this defect affect you sexually? What treatments have you sought for this condition? Does this defect impair your ability to perform at work or school?
receiving additional aesthetic surgery elsewhere with the belief that it would improve her quality of life.
DISCUSSION Body dysmorphic disorder, which was originally called imagined ugliness syndrome, was first recognized in the Diagnostic and Statistical Manual of Mental Disorders, Third Edition— Revised (DSM-III-R) in 1987.3 In the recently released DSM-5, the criteria for diagnosis of BDD were moved to the chapter on Obsessive-Compulsive and Related Disorders (Table 1).4 These criteria describe a patient who is preoccupied with a perceived physical defect, or multiple defects, that cause significant distress or impairment in daily functioning. Patients most frequently focus on defects involving their skin, hair, and nose, and they are likely to think about the perceived flaw an average of 3 to 8 hours per day.4 Body dysmorphic disorder affects 2.4% of the U.S. adult population equally in both sexes.4 The average age of onset is 16 to 17 years old, but it may also present in older adults who are overly concerned with their aging appearance.4 Disease onset before 18 years of age is more likely associated with suicide attempts, increased comorbidity, and gradual disorder onset, while adult onset BDD often has an acute disease progression.4 Major depression is the most common comorbid disorder in patients with BDD, and greater than 50% of these patients will have suicidal ideations.4,5 Additional comorbidities lead to impaired psychosocial functioning and include mood disorder, social phobia, obsessive-compulsive disorder, paranoid personality disorder, and avoidant personality disorder.6 Although the specific etiology remains unknown, numerous theories have been suggested regarding contributing factors to this psychiatric disorder. Several of the proposed factors as cited by Mackley7 include disturbed emotional input as a child, alteration of the neurochemical milieu of the brain caused by inflammatory mediators after a medical illness, and frontal lobe atrophy. No controlled studies have been published to confirm or refute any of these hypotheses. While BDD is a chronic disease, with the help of evidence-based treatment from a psychiatrist, improvement is likely.8 Psychiatrists are able to use a combination of cognitive behavioral therapy and serotonin-reuptake inhibitors to better the patient’s functioning and quality of life.8 Patients with
Unusual, demanding behavior Excessive requests for aesthetic procedures Dissatisfaction with previous procedures Poor insight Excessive concern with nonexistent deformity Impaired functioning Reassurance seeking Camouflaging Expectation that aesthetic surgery with solve all problems
BDD are usually not aware of their psychiatric disease and will not seek mental health care on their own, so it is the surgeon’s responsibility to refer the patient for psychiatric care. Most of those with BDD present to surgeons as they seek aesthetic treatments in an attempt to improve their perceived defect. Despite the fact that there is no uniformly accepted screening questionnaire, using the signs and questions in Table 2, surgeons can identify at-risk patients and provide them with a psychiatry consultation. Answers that may raise a red flag include if the patient thinks about the perceived defect for >1 hour per day, blames lack of success on the defect (such as in Case 2), uses time-consuming techniques to hide the defect, or has a history of self-surgery to correct the defect.9 Patients will often be on their “best behavior” while meeting with the physician, and for this reason, it is best to use a team approach in soliciting input from support staff regarding a patient’s insight.10 If the surgeon is unsure whether a patient has BDD, at a minimum the patient should be brought back for a second preoperative consultation.10 Identifying those with BDD is beneficial for the patient and the surgeon because patients with BDD often respond poorly to procedures and are likely to escalate complaints and “bear grudges” against their physician.9 Eighty-one percent of patients with BDD who undergo surgery are dissatisfied with their postoperative result, and they are likely to find a new defect and request additional surgery.6,9 Patients with BDD have been known to take legal action or act violently toward their surgeon.11 The 3 cases presented show the spectrum of patients with BDD and serve to demonstrate that these patients are likely to receive care in oculoplastics clinics more often than expected. In the tragic outcome of the first case, surgeons served as enablers of the patient’s self-disruptive behavior ultimately leading to her disfiguring and disabling results. A better understanding of her psychological condition and the fortitude to say “no” to patients desiring unnecessary surgery could have prevented the progression of her disabling condition. In this era where patients are the consumers and satisfaction is a top priority, the physician must make decisions based on each patient’s well-being. Although surgical intervention was declined, the authors were not direct with a recommendation to seek psychiatric therapy and therefore missed an important opportunity. Perhaps the lack of knowledge of the strong association between BDD and depression kept the authors from
© 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
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delving deeper into her emotional state. Recommending psychiatric evaluation to a patient is a very sensitive subject that must be approached carefully and tactfully. Goin and Goin12 propose taking a nonthreatening approach by saying something along the lines of: “Operations that change the shape of the body may have all sorts of psychological effects—many that are beneficial but some that can be quite disturbing. You and I need some help in figuring out how this operation is going to affect you. Making up your mind to have an elective surgical operation is a major decision, one we shouldn’t make lightly. I would like to refer you to a psychiatrist who is an expert in helping people understand their feelings about their bodies and how they may react to operations that change the body.” A patient’s refusal to accept referral to a psychiatrist for evaluation could be considered a contraindication for surgery, as it demonstrates a lack of insight on the part of the patient.10 The patients in Cases 2 and 3 were lost to follow up, and in retrospect, they should have been offered a psychiatric consultation. There are different opinions on the role of surgery in treating BDD patients with actual anatomical defects. Some believe that the diagnosis of BDD is an absolute contraindication to surgery, while others believe that the patients with BDD and anatomic or perceived defects may benefit from surgery.9,13 The authors’ experience with the patient in Case 2 lead them to agree with Jakubietz et al.9 and favor BDD as a contraindication to surgical intervention. Preoperatively, the possibility that the patient in Case 2 may remain unemployed despite undergoing surgery was discussed, and she seemed to understand this; however, postoperatively, she clearly was not able to think rationally. Other well-respected authors believe that there should be a graded response depending on the type and severity of the deformity. In Morselli and Boriani’s recent letter to the editor in Plastic and Reconstructive Surgery,13 they delineate classification of the disorder based on the severity of the deformity and whether the deformity is objective (unanimously agreed on by all observers) or subjective (not agreed on by all observers). Graded treatment options range from surgery and psychological support by the surgeon to psychotherapy.13 It is important for surgeons to keep in mind the prevalence of BDD in their patient population, considering the elevated rates of dissatisfaction and escalation, in addition to the mental health comorbidities present in these patients. The first step in helping patients with BDD is to spread awareness of the disorder and the possibility for tragic outcomes. Surgeons main method for aiding patients is surgery, and for this reason, it is difficult for them not to offer “help” doing what they do best.13 Surgeons tend to rely on surgeries for problem solving and in turn neglect to ask the question of “Why?” In his book How Doctors Think, Groopman states that “finding something may be satisfactory, but not finding everything is suboptimal.”14 By including BDD in this thought process when interacting with patients who seek aesthetic surgery, physicians are less likely to hastily schedule a patient for surgery. In the future, a better understanding of the criteria for diagnosis of BDD, the etiology, and the spectrum of successful treatments will allow for a holistic approach to care for patients such as the 3 presented in this case series. Physicians must overcome the “tendency toward action rather than inaction,” which may be sparked by patient pressure, and stop to consider the patient’s best interest.14 The decision of whether to operate is ultimately the surgeon’s responsibility.13 One must remember one of the principle precepts of medical ethics: “first, do no harm.”
ACKNOWLEDGMENT The authors would like to acknowledge the contributions of Ms. Patricia Duffel and Dr. David T. Tse.
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REFERENCES 1. Ishigooka J, Iwao M, Suzuki M, et al. Demographic features of patients seeking cosmetic surgery. Psychiatry Clin Neurosci 1998;52:283–7. 2. Massry GG. Aesthetic abstracts and citations. Ophthal Plast Reconstr Surg 2013;29:234–5. 3. Castle DJ, Rossell S, Kyrios M. Body dysmorphic disorder. Psychiatr Clin North Am 2006;29:521–38. 4. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, DC: American Psychiatric Association, 2013. 5. Altamura C, Paluello MM, Mundo E, et al. Clinical and subclinical body dysmorphic disorder. Eur Arch Psychiatry Clin Neurosci 2001;251:105–8. 6. Veale D, Boocock A, Gournay K, et al. Body dysmorphic disorder. A survey of fifty cases. Br J Psychiatry 1996;169:196–201. 7. Mackley CL. Body dysmorphic disorder. Dermatol Surg 2005;31:553–8. 8. Phillips KA, Rogers J. Cognitive-behavioral therapy for youth with body dysmorphic disorder: current status and future directions. Child Adolesc Psychiatr Clin N Am 2011;20:287–304. 9. Jakubietz M, Jakubietz RJ, Kloss DF, et al. Body dysmorphic disorder: diagnosis and approach. Plast Reconstr Surg 2007;119:1924–30. 10. Sarwer DB, Spitzer JC. Body image dysmorphic disorder in persons who undergo aesthetic medical treatments. Aesthet Surg J 2012;32:999–1009. 11. Sarwer DB. Awareness and identification of body dysmorphic disorder by aesthetic surgeons: results of a survey of american society for aesthetic plastic surgery members. Aesthet Surg J 2002;22:531–5. 12. Goin JM, Goin MK. Changing the Body: Psychological Effects of Plastic Surgery. Baltimore, MD: Williams & Wilkins; 1981. 13. Morselli PG, Boriani F. Should plastic surgeons operate on patients diagnosed with body dysmorphic disorders? Plast Reconstr Surg 2012;130:620e–622e. 14. Groopman J. How Doctors Think. New York, NY: Houghton Mifflin Company, 2007.
Granular Cell Tumor Masquerading as a Chalazion: A Case Report Ryan T. Scruggs, M.D.*†, and Evan H. Black, M.D., F.A.C.S.*† Abstract: Granular cell tumors were first described in the 1920s and since then have been commonly found throughout the body. They are rarely found in periorbital, orbital, and ocular structures. The authors present a patient with a 2-year history of a lesion that had been previously excised as a presumed chalazion without pathologic analysis. The lesion recurred, and histopathological analysis following complete resection revealed a granular cell tumor. This case is an example of a rare periocular tumor. Although only an isolated case, it provides support for the recommendation that excised lesions be sent to pathologic study, particularly those with an atypical clinical course.
G
ranular cell tumors are a relatively common lesion throughout the body; however, they are rarely found in the globe and periorbital tissues. Granular cell tumors of the orbit are also
Accepted for publication August 21, 2013. *Department of Ophthalmology, Ophthalmic Plastic, Orbital and Reconstructive Surgery, Kresge Eye Institute, Wayne State University School of Medicine, Detroit; and †Department of Ophthalmology, Oakland University, William Beaumont School of Medicine, Royal Oak, Michigan, U.S.A. The authors have no financial or conflicts of interest to disclose. Address correspondence and reprint requests to Ryan T. Scruggs, M.D., Department of Ophthalmology, Kresge Eye Institute, Detroit, MI 48201. E-mail: [email protected]
© 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
sentinel lymph node status in 612 stage I or II melanoma patients. J Clin Oncol 1999;17:976–83. 4. Tuomaala S, Kivelä T. Sentinel lymph node biopsy guidelines for conjunctival melanoma. Melanoma Res 2008;18:235. 5. Pfeiffer ML, Savar A, Esmaeli B. Sentinel lymph node biopsy for eyelid and conjunctival tumors: what have we learned in the past decade? Ophthal Plast Reconstr Surg 2013;29:57–62. 6. Ravaglia C, Gurioli C, Casoni GL, et al. Sarcoid-like lesion is a frequent benign cause of lymphadenopathy in neoplastic patients. Eur Respir J 2013;41:754–5. 7. Rubinstein I, Baum GL, Yellin A, et al. Sarcoidosis: a cause of bilateral hilar lymphadenopathy after excision of malignant melanoma of the arm. South Med J 1985;78:1139–40. 8. Bässler R, Birke F. Histopathology of tumour associated sarcoidlike stromal reaction in breast cancer. An analysis of 5 cases with immunohistochemical investigations. Virchows Arch A Pathol Anat Histopathol 1988;412:231–9. 9. Mackenzie, Retsas S. Malignant melanoma co-existing with sarcoidosis: Implications for prognosis and management. Melanoma Res. 1996;6:71–2. 10. Yukawa M, Satoh T, Takayama K, et al. Cutaneous sarcoid reaction in a patient with bladder cancer. Eur J Dermatol 2010;20:235. 11. Cohen PR, Kurzrock R. Sarcoidosis and malignancy. Clin Dermatol 2007;25:326–33. 12. Seve P, Schott AM, Pavic M, et al. Sarcoidosis and melanoma: a referral center study of 1,199 cases. Dermatology 2009;219:25–31. 13. Tsunoda K, Onodera H, Akasaka T. Case of malignant melanoma associated with a sarcoid reaction. J Dermatol 2011;38:939–42. 14. Berthod G, Lazor R, Letovanec I, et al. Pulmonary sarcoid-like granulomatosis induced by ipilimumab. J Clin Oncol 2012;30:e156–9. 15. Heinzerling LM, Anliker MD, Müller J, et al. Sarcoidosis induced by interferon-α in melanoma patients: incidence, clinical manifestations, and management strategies. J Immunother 2010;33:834–9. 16. Wilgenhof S, Morlion V, Seghers AC, et al. Sarcoidosis in a patient with metastatic melanoma sequentially treated with anti-CTLA-4 monoclonal antibody and selective BRAF inhibitor. Anticancer Res 2012;32:1355–9. 17. Sacks EL, Donaldson SS, Gordon J, et al. Epithelioid granulomas associated with Hodgkin’s disease: clinical correlations in 55 previously untreated patients. Cancer 1978;41:562–7. 18. Steinfort DP, Tsui A, Grieve J, et al. Sarcoidal reactions in regional lymph nodes of patients with early stage non-small cell lung cancer predict improved disease-free survival: a pilot case-control study. Hum Pathol 2012;43:333–8. 19. Shields CL, Ramasubramanian A, Mellen PL, et al. Conjunctival squamous cell carcinoma arising in immunosuppressed patients (organ transplant, human immunodeficiency virus infection). Ophthalmology 2011;118:2133–2137.e1. 20. Paridaens AD, Minassian DC, McCartney AC, et al. Prognostic factors in primary malignant melanoma of the conjunctiva: a clinicopathological study of 256 cases. Br J Ophthalmol 1994;78:252–9. 21. Tuomaala S, Toivonen P, Al-Jamal R, et al. Prognostic significance of histopathology of primary conjunctival melanoma in Caucasians. Curr Eye Res 2007;32:939–52.
Beauty is in the Eye of the Beholder: Body Dysmorphic Disorder in Ophthalmic Plastic and Reconstructive Surgery Lindsay K. McConnell, B.S.E.*, Wendy W. Lee, M.D.†, Donald W. Black, M.D.‡, and Erin M. Shriver, M.D.§ Abstract: Despite the fact that up to 15% of patients in an aesthetic surgery practice have body dysmorphic disorder (BDD), little has been written about the condition in the oculoplastic literature. The authors describe 3 patients with
Case Reports
suspected BDD who presented with perceived periocular defects. To appear “Asian,” a 39-year-old Hispanic woman underwent over 30 surgeries. She developed disfiguring scars and lagophthalmos with corneal scarring, remained unsatisfied, and tragically committed suicide. A 52-yearold woman with moderate dermatochalasis underwent a blepharoplasty to improve her vision and appearance and help her gain employment. Despite a good outcome, she remained dissatisfied and blamed the surgeon for her unemployment. Finally, a 73-year-old woman presented demanding treatment for brow rhytids causing severe emotional distress. She was denied intervention due to unrealistic expectations. These patients are suspected to be suffering from BDD. Increased awareness is critical as BDD patients often remain unsatisfied after surgical intervention and are in need of psychiatric care.
I
n the United States, up to 15% of patients who seek aesthetic surgery have body dysmorphic disorder (BDD).1 The statistics show that patients with BDD are likely to seek care from oculoplastic surgeons, but to date, little has been written about the condition in the ophthalmic or oculoplastics literature. Dr. Guy Massry recently highlighted the need for awareness of this disorder in the Aesthetic Abstracts and Citations section of the May/June 2013 Ophthalmic Plastic and Reconstructive Surgery.2 Three oculoplastics cases are presented, displaying the spectrum of the severity of BDD in adherence with the principles of the Declaration of Helsinki and in compliance with the Health Insurance Portability and Accountability Act of 1996.
CASE REPORTS Case 1. A 39-year-old Hispanic woman presented to triage with blurry vision, pain, photophobia, and tearing in the left eye. She was noted to have significant lagophthalmos with exposure keratopathy and was referred to the oculoplastics clinic. Her exam was remarkable for a visual acuity of 20/20 OD and 20/100 OS with a relative afferent pupillary defect OS. She had bilateral lagophthalmos with nonanatomic high lateral canthi, bilateral anterior lamellar deficiency, bilateral preauricular hypertrophic scaring, bilateral exposure keratopathy, and a corneal scar OS (Figs. A and B). Her intraocular pressures were 41 mm Hg OD and 46 mm Hg OS, and her optic nerve cup to disc ratios were 0.5 OD and 0.9 OS. The patient’s past medical history was significant for depression, migraine headaches, hypothyroidism, hypertension, and Raynaud disease. As a teenager, she became obsessed with wanting to “look Asian” and traveled across the country in search of a surgeon who would fulfill her goals. Her Accepted for publication August 21, 2013. *Carver College of Medicine, University of Iowa, Iowa City, Iowa, U.S.A.; †Department of Ophthalmology Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida; and Departments of ‡Psychiatry, and §Ophthalmology and Visual Sciences, University of Iowa Carver College of Medicine, Iowa City, Iowa, U.S.A. Presented at American Society of Ophthalmic Plastic and Reconstructive Surgery 2012 Fall Symposium, November 2012, Chicago, IL, by Erin M. Shriver, M.D. Supported by Florida Lions Eye Bank; The authors acknowledge the support of an unrestricted grant to The University of Iowa Department of Ophthalmology and Visual Sciences and Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, from Research to Prevent Blindness, Inc. New York, NY. Dr. Black receives research support from AstraZeneca. He receives royalties from American Psychiatric Publishing, Oxford University Press, and UpToDate. The authors have no financial or conflicts of interest to disclose. Address correspondence and reprint requests to Erin Shriver, M.D., Carver College of Medicine, Department of Ophthalmology and Visual Sciences, University of Iowa, 11196F PFP, 200 Hawkins Dr., Iowa City, IA, 52242. E-mail: [email protected]
© 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
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skin resurfacing, 2 face lifts, and 2 coronal brow lifts as a young adult. In her mid-twenties, she developed exposure keratopathy with bilateral corneal ulcers. She had surgery to lower both lateral canthi which were then revised on 3 occasions, followed by bilateral lateral tarsorrhaphies and then several severings of the tarsorrhaphies. Her most recent surgery, 7 months prior to presentation, consisted of a face and neck lift, rhinoplasty, upper labioplasty, upper eyelash grafts, poly-L-lactic acid injections in the nasojugal grooves, and bilateral lateral canthoplasties. After this operation, she developed an infection in the face lift flap that resulted in disfiguring scaring. She also had eye irritation which was treated with tobramycin/dexamethasone 4 times per day for 7 months. In total, this patient had over 30 procedures in 24 years. Her subsequent eye complications prevented the patient from maintaining employment. She remained single and never married with limited social support. Priority was given to treating her glaucoma because of increased intraocular pressures secondary to continued use of topical steroids and severe cupping of her left optic nerve. The patient was started on lubrication for exposure keratopathy in addition to dorzolamide/timolol twice a day and latanoprost 4 times a day for presumed steroid induced open angle glaucoma. At her 2-day follow up, her intraocular pressures had responded, but the patient was not concerned about glaucoma or permanent visual loss. Rather, she remained fixated on seeking further surgical revision of her lateral canthi with the ultimate goal of a corneal transplant on the left and improved “Asian” eyes. The authors declined further surgical intervention as it was felt that the patient’s priorities were not in line with her best interest. She refused to follow up with the oculoplastics service or a glaucoma specialist and expressed intent to seek out another surgeon for revision canthoplasties. It was learned that she tragically took her own life 5 years after presenting to this clinic. Case 2. A 55-year-old woman presented complaining of droopy eyelids with excess skin. She recently had been laid off from her job at a department store and was convinced that a blepharoplasty to reduce her hooding would improve her vision and appearance and allow her to find a new job. She was noted to have visually significant moderate dermatochalasis and underwent a functional blepharoplasty without complication. Her postoperative course was unremarkable, except that 2 weeks postoperatively the patient had a job interview and was convinced that she was not hired secondary to mild residual eyelid edema. At the 3-month follow up, the surgeon noted appropriate healing of the surgical wound and was pleased with the aesthetic outcome. The patient, however, continually examined her eyelids and remained fixated on the curvature of the incision and degree of residual skin present. She was furious with the surgeon for “ruining” her opportunity to find employment. The surgeon attempted to discuss the patient’s concerns; however, the patient became irate, refused follow up, and stated that the surgeon was “terrible and should not be operating.”
(A) Patient 1 with a high lateral canthus and corneal scar. (B) Patient 1 with lateral canthal and preauricular hypertrophic scarring. (C) Patient 3 with brow rhytids and a deep superior sulcus.
first bilateral canthopexy, bilateral blepharoplasty, and coronal brow lift were performed when she was fifteen years old. Postoperatively, she desired further elevation of the lateral canthus and subsequently underwent 3 canthopexy revisions, laser
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Case 3. A 73-year-old woman presented to the oculoplastics clinic demanding surgical treatment for right brow rhytids which were causing her severe emotional distress (Fig. C). The patient had already undergone bilateral upper eyelid blepharoplasty, a face lift, left upper eyelid ptosis repair, and a right lower eyelid entropion repair, and she was recently denied further procedures by her previous surgeon. She had poor skin tone with brow rhytids consistent with her age and a deep superior sulcus; however, her degree of associated emotional distress and unrealistic expectations led the authors to decline intervention. The patient remained fixated on her rhytids and was intent on
© 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
Ophthal Plast Reconstr Surg, Vol. 31, No. 1, 2015
Case Reports
TABLE 1. DSM V diagnostic criteria for body dysmorphic disorder4 1. Preoccupation with 1 or more perceived defects or flaws in physical appearance that are not observable or appear slight to others. 2. At some point during the course of the disorder, the individual performed repetitive behaviors (e.g., mirror checking, excessive grooming, skin picking, reassurance seeking) or mental acts in response to appearance concerns. 3. The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. 4. The appearance preoccupation is not better explained by concerns with body fat or weight in an individual whose symptoms meet diagnostic criteria for an eating disorder.
TABLE 2. Screening questions and signs of body dysmorphic disorder Screening Questions7:
Signs9:
What area in particular concerns you and why? Has the defect caused you great emotional distress? Has the defect impacted your social life? What treatment outcome do you expect? Do you take time to check the defect? How much time do you spend concealing the defect? Does this defect affect you sexually? What treatments have you sought for this condition? Does this defect impair your ability to perform at work or school?
receiving additional aesthetic surgery elsewhere with the belief that it would improve her quality of life.
DISCUSSION Body dysmorphic disorder, which was originally called imagined ugliness syndrome, was first recognized in the Diagnostic and Statistical Manual of Mental Disorders, Third Edition— Revised (DSM-III-R) in 1987.3 In the recently released DSM-5, the criteria for diagnosis of BDD were moved to the chapter on Obsessive-Compulsive and Related Disorders (Table 1).4 These criteria describe a patient who is preoccupied with a perceived physical defect, or multiple defects, that cause significant distress or impairment in daily functioning. Patients most frequently focus on defects involving their skin, hair, and nose, and they are likely to think about the perceived flaw an average of 3 to 8 hours per day.4 Body dysmorphic disorder affects 2.4% of the U.S. adult population equally in both sexes.4 The average age of onset is 16 to 17 years old, but it may also present in older adults who are overly concerned with their aging appearance.4 Disease onset before 18 years of age is more likely associated with suicide attempts, increased comorbidity, and gradual disorder onset, while adult onset BDD often has an acute disease progression.4 Major depression is the most common comorbid disorder in patients with BDD, and greater than 50% of these patients will have suicidal ideations.4,5 Additional comorbidities lead to impaired psychosocial functioning and include mood disorder, social phobia, obsessive-compulsive disorder, paranoid personality disorder, and avoidant personality disorder.6 Although the specific etiology remains unknown, numerous theories have been suggested regarding contributing factors to this psychiatric disorder. Several of the proposed factors as cited by Mackley7 include disturbed emotional input as a child, alteration of the neurochemical milieu of the brain caused by inflammatory mediators after a medical illness, and frontal lobe atrophy. No controlled studies have been published to confirm or refute any of these hypotheses. While BDD is a chronic disease, with the help of evidence-based treatment from a psychiatrist, improvement is likely.8 Psychiatrists are able to use a combination of cognitive behavioral therapy and serotonin-reuptake inhibitors to better the patient’s functioning and quality of life.8 Patients with
Unusual, demanding behavior Excessive requests for aesthetic procedures Dissatisfaction with previous procedures Poor insight Excessive concern with nonexistent deformity Impaired functioning Reassurance seeking Camouflaging Expectation that aesthetic surgery with solve all problems
BDD are usually not aware of their psychiatric disease and will not seek mental health care on their own, so it is the surgeon’s responsibility to refer the patient for psychiatric care. Most of those with BDD present to surgeons as they seek aesthetic treatments in an attempt to improve their perceived defect. Despite the fact that there is no uniformly accepted screening questionnaire, using the signs and questions in Table 2, surgeons can identify at-risk patients and provide them with a psychiatry consultation. Answers that may raise a red flag include if the patient thinks about the perceived defect for >1 hour per day, blames lack of success on the defect (such as in Case 2), uses time-consuming techniques to hide the defect, or has a history of self-surgery to correct the defect.9 Patients will often be on their “best behavior” while meeting with the physician, and for this reason, it is best to use a team approach in soliciting input from support staff regarding a patient’s insight.10 If the surgeon is unsure whether a patient has BDD, at a minimum the patient should be brought back for a second preoperative consultation.10 Identifying those with BDD is beneficial for the patient and the surgeon because patients with BDD often respond poorly to procedures and are likely to escalate complaints and “bear grudges” against their physician.9 Eighty-one percent of patients with BDD who undergo surgery are dissatisfied with their postoperative result, and they are likely to find a new defect and request additional surgery.6,9 Patients with BDD have been known to take legal action or act violently toward their surgeon.11 The 3 cases presented show the spectrum of patients with BDD and serve to demonstrate that these patients are likely to receive care in oculoplastics clinics more often than expected. In the tragic outcome of the first case, surgeons served as enablers of the patient’s self-disruptive behavior ultimately leading to her disfiguring and disabling results. A better understanding of her psychological condition and the fortitude to say “no” to patients desiring unnecessary surgery could have prevented the progression of her disabling condition. In this era where patients are the consumers and satisfaction is a top priority, the physician must make decisions based on each patient’s well-being. Although surgical intervention was declined, the authors were not direct with a recommendation to seek psychiatric therapy and therefore missed an important opportunity. Perhaps the lack of knowledge of the strong association between BDD and depression kept the authors from
© 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
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Ophthal Plast Reconstr Surg, Vol. 31, No. 1, 2015
Case Reports
delving deeper into her emotional state. Recommending psychiatric evaluation to a patient is a very sensitive subject that must be approached carefully and tactfully. Goin and Goin12 propose taking a nonthreatening approach by saying something along the lines of: “Operations that change the shape of the body may have all sorts of psychological effects—many that are beneficial but some that can be quite disturbing. You and I need some help in figuring out how this operation is going to affect you. Making up your mind to have an elective surgical operation is a major decision, one we shouldn’t make lightly. I would like to refer you to a psychiatrist who is an expert in helping people understand their feelings about their bodies and how they may react to operations that change the body.” A patient’s refusal to accept referral to a psychiatrist for evaluation could be considered a contraindication for surgery, as it demonstrates a lack of insight on the part of the patient.10 The patients in Cases 2 and 3 were lost to follow up, and in retrospect, they should have been offered a psychiatric consultation. There are different opinions on the role of surgery in treating BDD patients with actual anatomical defects. Some believe that the diagnosis of BDD is an absolute contraindication to surgery, while others believe that the patients with BDD and anatomic or perceived defects may benefit from surgery.9,13 The authors’ experience with the patient in Case 2 lead them to agree with Jakubietz et al.9 and favor BDD as a contraindication to surgical intervention. Preoperatively, the possibility that the patient in Case 2 may remain unemployed despite undergoing surgery was discussed, and she seemed to understand this; however, postoperatively, she clearly was not able to think rationally. Other well-respected authors believe that there should be a graded response depending on the type and severity of the deformity. In Morselli and Boriani’s recent letter to the editor in Plastic and Reconstructive Surgery,13 they delineate classification of the disorder based on the severity of the deformity and whether the deformity is objective (unanimously agreed on by all observers) or subjective (not agreed on by all observers). Graded treatment options range from surgery and psychological support by the surgeon to psychotherapy.13 It is important for surgeons to keep in mind the prevalence of BDD in their patient population, considering the elevated rates of dissatisfaction and escalation, in addition to the mental health comorbidities present in these patients. The first step in helping patients with BDD is to spread awareness of the disorder and the possibility for tragic outcomes. Surgeons main method for aiding patients is surgery, and for this reason, it is difficult for them not to offer “help” doing what they do best.13 Surgeons tend to rely on surgeries for problem solving and in turn neglect to ask the question of “Why?” In his book How Doctors Think, Groopman states that “finding something may be satisfactory, but not finding everything is suboptimal.”14 By including BDD in this thought process when interacting with patients who seek aesthetic surgery, physicians are less likely to hastily schedule a patient for surgery. In the future, a better understanding of the criteria for diagnosis of BDD, the etiology, and the spectrum of successful treatments will allow for a holistic approach to care for patients such as the 3 presented in this case series. Physicians must overcome the “tendency toward action rather than inaction,” which may be sparked by patient pressure, and stop to consider the patient’s best interest.14 The decision of whether to operate is ultimately the surgeon’s responsibility.13 One must remember one of the principle precepts of medical ethics: “first, do no harm.”
ACKNOWLEDGMENT The authors would like to acknowledge the contributions of Ms. Patricia Duffel and Dr. David T. Tse.
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REFERENCES 1. Ishigooka J, Iwao M, Suzuki M, et al. Demographic features of patients seeking cosmetic surgery. Psychiatry Clin Neurosci 1998;52:283–7. 2. Massry GG. Aesthetic abstracts and citations. Ophthal Plast Reconstr Surg 2013;29:234–5. 3. Castle DJ, Rossell S, Kyrios M. Body dysmorphic disorder. Psychiatr Clin North Am 2006;29:521–38. 4. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, DC: American Psychiatric Association, 2013. 5. Altamura C, Paluello MM, Mundo E, et al. Clinical and subclinical body dysmorphic disorder. Eur Arch Psychiatry Clin Neurosci 2001;251:105–8. 6. Veale D, Boocock A, Gournay K, et al. Body dysmorphic disorder. A survey of fifty cases. Br J Psychiatry 1996;169:196–201. 7. Mackley CL. Body dysmorphic disorder. Dermatol Surg 2005;31:553–8. 8. Phillips KA, Rogers J. Cognitive-behavioral therapy for youth with body dysmorphic disorder: current status and future directions. Child Adolesc Psychiatr Clin N Am 2011;20:287–304. 9. Jakubietz M, Jakubietz RJ, Kloss DF, et al. Body dysmorphic disorder: diagnosis and approach. Plast Reconstr Surg 2007;119:1924–30. 10. Sarwer DB, Spitzer JC. Body image dysmorphic disorder in persons who undergo aesthetic medical treatments. Aesthet Surg J 2012;32:999–1009. 11. Sarwer DB. Awareness and identification of body dysmorphic disorder by aesthetic surgeons: results of a survey of american society for aesthetic plastic surgery members. Aesthet Surg J 2002;22:531–5. 12. Goin JM, Goin MK. Changing the Body: Psychological Effects of Plastic Surgery. Baltimore, MD: Williams & Wilkins; 1981. 13. Morselli PG, Boriani F. Should plastic surgeons operate on patients diagnosed with body dysmorphic disorders? Plast Reconstr Surg 2012;130:620e–622e. 14. Groopman J. How Doctors Think. New York, NY: Houghton Mifflin Company, 2007.
Granular Cell Tumor Masquerading as a Chalazion: A Case Report Ryan T. Scruggs, M.D.*†, and Evan H. Black, M.D., F.A.C.S.*† Abstract: Granular cell tumors were first described in the 1920s and since then have been commonly found throughout the body. They are rarely found in periorbital, orbital, and ocular structures. The authors present a patient with a 2-year history of a lesion that had been previously excised as a presumed chalazion without pathologic analysis. The lesion recurred, and histopathological analysis following complete resection revealed a granular cell tumor. This case is an example of a rare periocular tumor. Although only an isolated case, it provides support for the recommendation that excised lesions be sent to pathologic study, particularly those with an atypical clinical course.
G
ranular cell tumors are a relatively common lesion throughout the body; however, they are rarely found in the globe and periorbital tissues. Granular cell tumors of the orbit are also
Accepted for publication August 21, 2013. *Department of Ophthalmology, Ophthalmic Plastic, Orbital and Reconstructive Surgery, Kresge Eye Institute, Wayne State University School of Medicine, Detroit; and †Department of Ophthalmology, Oakland University, William Beaumont School of Medicine, Royal Oak, Michigan, U.S.A. The authors have no financial or conflicts of interest to disclose. Address correspondence and reprint requests to Ryan T. Scruggs, M.D., Department of Ophthalmology, Kresge Eye Institute, Detroit, MI 48201. E-mail: [email protected]
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