gold weight loading of the upper eyelid is a procedure performed for the treatment of paralytic lagophthalmos . the incidence of complications is reported to range from 0.5% to 61%1 and includes poor cosmesis , migration , extrusion , allergy , and astigmatism.2 we report herein what seems to be the first case of gold weight implantation complicated by a severe necrotic process , necessitating extensive excision of eyelid tissue as well as evisceration of the involved eye . a 44-year - old caucasian woman with a history of right - sided facial paralysis following removal of an acoustic neuroma presented to our clinic with lagophthalmos . due to continued keratopathy , implantation of a gold weight was then performed in her right upper eyelid . on postoperative day 11 , the patient presented with right eyelid swelling and erythema , as well as limitation of abduction , suggesting a possibility of orbital cellulitis . , a complete limitation of gaze was noted , followed by an afferent pupillary defect and necrosis of the lower eyelid , of the upper eyelid margins , and of the anterior ocular segment . computed tomography scan was unremarkable apart from swelling of superficial tissues . the patient was taken to the operating room where the gold weight was removed through the previous skin incision . on exploration , necrosis was noted in the upper eyelid tarsus , lower eyelid , limbus , and conjunctiva ( figure 1 ) . a full thickness biopsy of the eyelid revealed necrotic conjunctiva and skin , with diffuse acute inflammatory reaction . the antibiotic regimen was changed to intravenous vancomycin as well as piperacillin / tazobactam , which resulted in stabilization . a transcranial doppler was performed to rule out an ischemic etiology , and showed normal flow in both ophthalmic arteries . four days following removal of the gold weight , the patient developed fever of 38c , chills , tachycardia , and extreme restlessness , suggesting systemic involvement , as well as thinning and necrosis of the sclera , worsening of eyelid swelling and necrosis ( figure 2 ) . an axial computed tomography scan with contrast material demonstrated air bubbles under the eyelid as well as intraconal fat haziness , implying an infectious or inflammatory process involving the anterior and posterior parts of the orbit . the patient was taken again to the operating room where evisceration and debridement of necrotic tissue were performed ( figure 3 ) . direct smear showed gram - positive cocci , and cultures grew staphylococcus epidermidis , candida albicans , and candida glabrata . the patient s systemic condition continued to deteriorate , including fever , urinary retention , desaturation , and acidosis , and she was admitted to the intensive care unit where her systemic condition stabilized . the antibiotic regimen was changed to vancomycin , meropenem , and fluconazole . with this treatment , the patient s condition gradually improved and her ocular condition remained stable . on repeat follow - ups , a year later , this patient was admitted to the plastic surgery ward in another hospital with a 5-month - old nonhealing third - degree chemical burn of her right anterior thigh . wound a split thickness skin graft was used to cover the defect and the wound was dressed with a negative pressure dressing . by postoperative day 2 , the negative pressure dressing was found with tears over its surface and could not maintain vacuum . the patient s thigh was dressed with a twice daily sulfamylon wet - to - dry dressing . the postoperative period was remarkable , with the patient experiencing tenderness , itching , and unrest . at postoperative day 11 , instead of full closure of the wound , a full thickness third degree burn was noticed once again with no signs of infection . the patient underwent a further operation the next day under general anesthesia for debridement and placement of partial thickness skin graft . a day after the surgery , the patient tore off both the dressing and the skin graft , necessitating a third skin grafting . this time , the patient was put into a full length cast for protection and immobilization . due to an impression of self - induced damage and a high suspicion of a factitious disorder during the latter hospitalization , a psychiatric consult was made , but concluded that a diagnosis of a factitious disorder could not be made without direct evidence of self - mutilation . of the many case reports and case series describing complications after implantation of an eyelid gold weight , none presented as dramatically as in the case of this patient . the rapidity in which the patient deteriorated , the findings of gas on computed tomography , as well as the histopathologic findings of a dense inflammatory infiltrate composed predominantly of polymorphonuclear leukocytes and of thrombotic blood vessels suggested an acute infection as the etiology of this process . s. capitis and s. epidermidis , as other coagulase - negative staphylococci , are known to cause foreign - body - associated infections . however , a dramatic clinical course , as in our patient , would be extremely unusual . candida species , which were isolated only from tissues obtained in the evisceration surgery and not in the preliminary cultures , are also uncommon pathogens in such processes and are likely to have been contaminants . although the clinical course was consistent with necrotizing fasciitis involving the eyelid with a severe systemic septic syndrome , the histopathologic findings did not demonstrate involvement of the fascia , and the typical culprits of necrotizing fasciitis ( eg , streptococcus pyogenes , enterobacteriaceae , anaerobic bacteria , methicillin - resistant staphylococcus aureus ) were not isolated . eyelid involvement of necrotizing fasciitis is rare , with only 58 cases reported between 1956 and 2006 . the process usually spares vascularized structures , namely , the conjunctiva , tarsus , and eyelid margins , which were not spared in our case.3 allergy to gold is a known complication of gold weight eyelid implantation . however , it usually manifests as contact dermatitis , and histology reveals chronic lymphocytic infiltrates , matching a type iv hypersensitivity reaction ; whereas , in our case , the infiltrate included mostly polymorphonuclear leukocytes.4 our patient kept deteriorating after removal of the gold weight , further negating contact with the weight as the inciting factor . in factitious disorders , the disorders appear more frequently in females . in a 1951 article in the lancet , richard asher coined the term  munchausen syndrome  to refer to a syndrome in which patients embellish their personal history , chronically fabricate symptoms to gain hospital admission , and move from hospital to hospital.5 patients with the disorders simulate serious illness and seek and submit to unnecessary treatment , while to themselves and others they deny their true illness and , thus , avoid possible treatment for it . ultimately , patients elude meaningful therapy by abruptly leaving the hospital or failing to keep follow - up appointments.6 the unique pattern of injury to the patient s eye , as well as the repeated burns and behavior , suggest that the patient might suffer from factitious disorder , a condition that is , unfortunately , difficult to diagnose .
a 44-year - old woman , who had undergone gold - weight implantation due to facial palsy and lagophthalmos , arrived at the ophthalmology ward with eyelid swelling and erythema , which rapidly deteriorated under intravenous antibiotics to a necrotic process involving the periocular tissues , the eye , and the anterior orbit . despite prompt removal of the gold weight , 
 the patient s ocular and systemic condition continued to deteriorate , necessitating evisceration and debridement of necrotic tissue . 
 cultures showed growth of staphylococcus epidermidis , staphylococcus capitis , candida glabrata , and candida albicans , and histopathology demonstrated an acute nonspecific necrotizing panophthalmitis . 
 later on , the patient was admitted to a plastic surgery ward with recurrent severe burns of her thigh , which were highly suggestive of being self - induced , raising the possibility of self - induced damage .