Case #1

The patient

Patient right profile

Unilateral keratoconus, stable since the first visit.

Identity : Mr T.N
First visit : 12/10/2015
Last visit : 10/12/2017

23
Age (years)
24
Follow-up (months)
Eye rubbing : a sine qua non for keratoconus

Mr. T.N, is a 23-year-old male student with no previous medical history or any known keratoconus in his family. He first came to us for a refractive surgery suitability assessment. The patient complained of a progressive decrease in visual acuity in the right eye.

His refraction at the first visit (12/10th/2015) was: Right Eye (RE) 20/20 with -1 (-2 x 90 °) and Left Eye (LE) 20/20 with -3 (-0.25 x 135 °).

Clinical examination with the slit lamp revealed Vogt’s striae (fine whitish lines in the posterior stroma) and Fleischer ring (Fleischer rings are pigmented rings in the peripheral cornea, resulting from iron deposition in basal epithelial cells, in the form of hemosiderin), in the right eye.

Systematic corneal topography, performed for every refractive surgery candidate, revealed unilateral keratoconus in the right eye. The left eye topography showed only mild irregularity on the curvature map.

The patient is right-handed and sleeps on his right side with head in the pillow (« pillow hugging »).

When asked about possible rubbing habits, the patient denied eye rubbing at the first visit. His mother, however, who was with him during the consultation, claimed that she witnessed her son rubbing his eyes very often, for many years.

At the second visit, the patient confessed to becoming more aware of rubbing his eyes several times a day, especially in the mornings with his right hand, using the knuckles.

The patient’s mother took a photo of her son sleeping to demonstrate his sleeping posture, and this was presented to us.

We explained to the patient that since vigorous rubbing had preceded the drop in visual acuity, this habit may have caused the cornea to deform in his case. We strongly advised this patient to stop rubbing his eyes and to change his unhealthy sleeping position.

Here are pictures of the patient rubbing his eyes and his sleeping posture

PATIENT RUBBING HIS RIGHT EYE : Note the use of the knuckles to rub.

PATIENT SLEEP POSITION : Note the head buried deeply in the pillow (pillow hugging) and the direct contact of the pillow with the right eye (compression + heating responsible for local inflammation and irritation).

Patient right profile
Patient left profile

Here is a video of the patient rubbing his right eye

Here are the Orbscan quadmaps with SCORE ANALYZER assessment, Pentacam maps, OPDscan and Ocular Response Analyzer (ORA) results of the first visit .

RIGHT EYE ORBSCAN (1st VISIT). This examination shows severe deformation with inferior steepening, evocative of frank keratoconus.
LEFT EYE ORBSCAN (1st VISIT). This Orbscan examination is unremarkable.
RIGHT EYE SCORE ANALYZER . The score is a composite index, which includes several parameters and allows us to quantify the degree of corneal deformation and thinning. Here the SCORE is highly positive, which suggests a keratoconus.
LEFT EYE SCORE ANALZER. The SCORE is negative, suggesting the absence of significant corneal deformation.
RIGHT EYE PENTACAM (1st VISIT). This examination confirms the Orbscan data; the cornea is thinned centrally, and shows excessive inferior prolateness.
LEFT EYE PENTACAM (1st VISIT). The Pentacam map is unremarkable.
RIGHT EYE PENTACAM : Belin/Ambrósio enhanced ectasia display
LEFT EYE PENTACAM : Belin/Ambrósio enhanced ectasia display
RIGHT EYE OPD
LEFT EYE OPD
ORA RIGHT EYE. The hysteresis and the peak heights are a bit less than average. This might account for a slight weakening caused by chronic rubbing.
ORA LEFT EYE. The hysteresis and the peaks heights are a bit less than average too , which means this cornea is deformable as well.

Difference maps were performed at each subsequent visit. No evolution was observed between the first and last visits. The keratoconus is stable, more than 2 years after the patient definitively stopped rubbing his eyes .

At the second visit, the patient acknowledged that he had come to realize his eye rubbing habit, and the preferential rubbing of the right eye. He informed us that the rubbing was so intense that it generated a « little noise », and admitted that kicking the habit was difficult to do.

RIGHT EYE ORBSCAN (2nd VISIT)
RIGHT EYE PENTACAM (2nd VISIT)
RIGHT EYE ORBSCAN (3rd VISIT)
RIGHT EYE PENTACAM (3rd VISIT)
PENTACAM DIFFERENTIAL MAPS : RIGHT EYE (between 2nd and 3rd VISITS). The difference map demonstrates the absence of progression.
RIGHT EYE ORBSCAN (4th VISIT)
RIGHT EYE PENTACAM (4th VISIT)
PENTACAM DIFFERENTIAL MAPS : RIGHT EYE (between 3rd and 4th VISITS). The difference map demonstrates the absence of progression.
RIGHT EYE ORBSCAN (5th VISIT)
RIGHT EYE PENTACAM (5th VISIT)
ORBSCAN DIFFERENTIAL MAPS : RIGHT EYE (between 1st and 5th VISITS). The difference map demonstrates the absence of progression.
PENTACAM DIFFERENTIAL MAPS : RIGHT EYE (between 1st and 5th VISITS). The difference map demonstrates the absence of progression.
LEFT EYE ORBSCAN (2nd VISIT)
LEFT EYE ORBSCAN (2nd VISIT)
RIGHT EYE ORBSCAN (3rd VISIT)
LEFT EYE PENTACAM (3rd VISIT)
PENTACAM DIFFERENTIAL MAPS : LEFT EYE (between 2nd and 3rd visits). The difference map shows the absence of change between the two examination time points.
LEFT EYE ORBSCAN (4th VISIT)
LEFT EYE PENTACAM (4th VISIT)
PENTACAM DIFFERENTIAL MAPS : LEFT EYE (between 3rd and 4th VISITS). The difference map shows the absence of change between the two examination time points.
LEFT EYE ORBSCAN (5th VISIT)
LEFT EYE PENTACAM (5th VISIT)
ORBSCAN DIFFERENTIAL MAPS : LEFT EYE (between 1st and 5th VISITS). The difference map shows the absence of change between the two examination time points.
PENTACAM DIFFERENTIAL MAPS : LEFT EYE (between 1st and 5th VISITS). The difference map shows the absence of change between the two examination time points.

It is interesting to note the concordance between unilateral rubbing of the right eye and the unilateral (right) location of the keratoconus. The patient has also been sleeping on his right side since childhood. Unilateral chronic eye irritation related to the extended compression of the right eye on the pillow induces the patient to rub his right eye during the day. At night, the right eye is exposed to local heating and contamination by irritants (allergens from laundry products, dust mites, etc.). These repeated frictions eventually cause the deformation and thinning (by redistribution of the ground substance of the cornea) typically seen in keratoconus.

While he denied eye rubbing at the first visit, his mother, fortunately accompanying him, could alert him to the habit which he was not aware of. Many patients, like Mr S.M, are not conscious of their eye rubbing, or aware of its deleterious effects, and believe it to be a banal and harmless maneuver. It is important therefore, in all patients with keratoconus, to elucidate the history of eye rubbing, and then counsel the patients accordingly to change their habits.

In this case, like the many other cases in this website, the keratoconus ceased to evolve after the patient definitively stopped rubbing his eyes.

Conclusion: