Patient right profile
Case #19
The patient
Bilateral Keratoconus induced by eye rubbing
Identity : Mr T.D
First visit : 05/27/2016
Last Visit : 05/23/2017
23
Age (years)12
Follow-up (months)Mr. T.D, is a 23-year-old male with no previous medical history. There is no known family history of keratoconus . He complained of a progressive decrease in visual acuity in both eyes over one year.
His refraction at the first visit (05/27th/2016) was : Right Eye (RE) 20/100 with -4.50 (-8.75 x 15°) and Left Eye (LE) 20/400 with -8 (-8,75 x 175 °).
Clinical examination with the slit lamp revealed keratoconus in both eyes with bilateral Fleischer rings (Fleischer rings are pigmented rings in the peripheral cornea, resulting from iron deposition in basal epithelial cells, in the form of hemosiderin).
Corneal topography revealed the presence of bilateral keratoconus.
When asked about the possibility of frequent eye rubbing, the patient admitted to enjoying rubbing his eyes with the knuckles & nails. And when asked about his sleeping position, he described sleeping with his head on his arm. He noticed that he often awoke with red eyes in the morning.
We advised him to change his sleeping position, and to stop rubbing his eyes.
Here are pictures of the patient rubbing his eyes and his profiles
PATIENT RIGHT PROFILE
PATIENT LEFT PROFILE
PATIENT RUBBING HIS EYES : The patient demonstrates how he rubs his left eye. The repeated contact of the hardest part of the fingers (the knuckles & nails) has probably caused permanent warpage of the cornea. Eye rubbing preceded the onset of decrease in vision and visual quality in this patient.
PATIENT SLEEPING POSITION : Here, the patient demonstrates how he positions his head when he sleeps. His orbit is compressed against the arm.Here are the Orbscan, Pentacam and OPD maps of the first visit .
RIGHT EYE ORBSCAN. Note the increased prolateness (negative asphericity) of the anterior (top right) and posterior (top left) corneal surfaces (marked island pattern). On the curvature map (bottom left), there is irregular astigmatism characterized by a marked central steepening. The thickness map (bottom right) shows central & temporal thinning.
LEFT EYE ORBSCAN. Note the increased prolateness (negative asphericity) of the anterior (top right) and posterior (top left) corneal surfaces (marked island pattern). On the curvature map (bottom left), there is irregular astigmatism characterized by a marked central steepening. The thickness map (bottom right) shows central & temporal thinning. Both the right and left eyes of this patient have reached a similar level of deformation and thinning, which is however slightly more pronounced in the left eye.
RIGHT EYE PENTACAM. The information provided by the Pentacam parallels the Orbscan data.
LEFT EYE PENTACAM. The Pentacam data is comparable to the data provided by the Orbscan.
RIGHT EYE OPD. Combined anterior topography and aberrometry shows the increase in ocular higher order aberrations (these aberrations are responsible for a reduction in optical quality). Coma, trefoil and negative spherical aberration are elevated.
LEFT EYE OPD. Combined anterior topography and aberrometry shows the increase in ocular higher order aberrations (these aberrations are responsible for a reduction in optical quality). Coma, trefoil and negative spherical aberration are elevated.Difference maps were performed at each subsequent visit. No evolution has been observed between the first and last visits. The keratoconus is stable, more than 1 year after the patient definitively stopped rubbing his eyes .
RIGHT EYE ORBSCAN (2nd VISIT)
RIGHT EYE PENTACAM (2nd VISIT)
PENTACAM DIFFERENTIAL MAPS : RIGHT EYE (between 1st and 2nd visits). No significant changes are detected. You could even argue that there may be some improvement (blue colors suggest reduced curvature, i.e. flattening). These variations are mostly caused by random noise. 
RIGHT EYE ORBSCAN (3rd VISIT)
RIGHT EYE PENTACAM (3rd VISIT)
PENTACAM DIFFERENTIAL MAPS : RIGHT EYE (between 1st and 3rd visits, which is about a year; see relevant time interval on the map). No significant changes are detected and the keratoconus is stable. 
LEFT EYE ORBSCAN (2nd VISIT)
LEFT EYE PENTACAM (2nd VISIT)
PENTACAM DIFFERENTIAL MAPS : LEFT EYE (between 1st and 2nd visits) No significant changes are detected. Like in the right eye, you can even argue that there may be some improvement (blue colors), but this is probably random noise. The cornea is stable, and there is no keratoconus progression.
LEFT EYE ORBSCAN (3rd VISIT)
LEFT EYE PENTACAM (3rd VISIT)
PENTACAM DIFFERENTIAL MAPS : LEFT EYE (between 1st and 3rd visits). No significant changes are detected. The keratoconus is stable.In this case, bilateral eye rubbing with the knuckles & nails preceded the appearance of keratoconus. The unhealthy sleeping position (arms covering the eyes) is probably responsible for the need to rub the eyes upon awakening because of the irritation from overnight compression. Both eyes have keratoconus of a similar stage. There was no known allergy or atopic background.
This case demonstrated 1 year stability since the cessation of eye rubbing.
No cross linking was necessary. The cessation of eye rubbing and eradication of any unnecessary ocular compression is the most important factor for stabilization of keratoconus of any stage.
This patient rubbed his eyes partly because he found it pleasurable. It required a lot of explanation and coaxing to persuade him to cooperate and stop his rubbing habit. In other cases where ocular allergy and pruritus coexist, it is not always easy for the patient to restrain from eye rubbing. Actions to reduce all possible risks factors for eye rubbing must be taken.
- Date 15 août 2017
- Tags Bilateral keratoconus, Enjoyed eye rubbing, Eye rubbing, Fleischer ring, Knuckles rubbing, Male, Nails rubbing, Sleep position