The patient
Patient rubbing his eyes
Bilateral ectasia post LASIK induced by eye rubbing
Identity : Mr Z.L
First visit : 09/13/2013
Last Visit : 01/13/2017
Mr. Z.L is a 34-year-old male with no previous medical history other than atopy. He has no family history of keratoconus. He had myopic LASIK performed in another institution in 2010 and was never informed of the dangers of post-lasik eye rubbing. He is right-handed and sleeps on his stomach .
The patient complained of a progressive decrease in visual acuity in both eyes 2 years after the LASIK procedure and consulted his LASIK surgeon for an opinion. He was diagnosed to have post-LASIK ectasia and was advised to have corneal collagen crosslinking immediately. He then consulted us for a second opinion.
When asked about the possibility of eye rubbing, the patient admitted to rubbing his eyes frequently with his knuckles, especially when working in front of the computer, as this gave him a sense of relief. He sleeps on his stomach.
His refraction before the LASIK (2010) was: Right Eye (RE) 20/20 with -3.5 (-0.5 x 15 °) and Left Eye (LE) 20/20 with -4 (-0,5 x 0 °).
His refraction at the first visit (at the Rothschild Foundation) 3 years after LASIK (08/31th/2013) was: Right Eye (RE) 20/25 with -0,25 (-1.25 x 55 °) and Left Eye (LE) 20/20 with +0,25 (-0,75 x 110 °).
Clinical examination with the slit lamp revealed an irregular inferior corneal bulge more pronounced in the right eye. The LASIK flaps and interface were unremarkable. The rest of the ocular examination was normal.
Corneal topography revealed the presence of bilateral corneal ectasia more pronounced in the right eye.
We explained to the patient that since vigorous eye 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. We also advised him against corneal collagen cross-linking.
Here are pictures of the patient rubbing his eyes and his sleeping position
Patient rubbing his right eye
Patient sleeping positionHere a video of the patient rubbing his right eye vigorously with his palm
BEFORE THE LASIK
Here are his preoperative Orbscans and laser treatment report .
RIGHT EYE PREOPERATIVE ORBSCAN :
As you can see, the examination is strictly normal with no signs of keratoconus or ectasia susceptibility, with reassuring keratometry, pachymetry and posterior curvature.
LEFT EYE PREOPERATIVE ORBSCAN:
As you can see, the examination is strictly normal with no signs of keratoconus or ectasia susceptibility, with reassuring keratometry, pachymetry and posterior curvature.
RIGHT EYE LASER TREATMENT REPORT
LEFT EYE LASER TREATMENT REPORTAFTER THE LASIK
Here are the Orbscan maps, Visante OCT (Optical Coherence Topography) images and Ocular Response Analyzer (ORA) maps of the first visit in our institution (3 years after the LASIK)
RIGHT EYE ORBSCAN (1st VISIT). The axial curvature map (bottom left) reveals a "claw pattern", which corresponds to local irregularity (corneal deformation). The posterior surface is highly prolate (top right). The thickness map (bottom right) reveals discrete central thinning.
LEFT EYE ORBSCAN (1st VISIT) Irregularities similar to those in the right eye are seen, but these are less pronounced in this eye
OCT cross sectional image of the right cornea. The residual stromal bed at 400 µm is not too thin.
Cross sectional image of the left cornea. The residual stromal bed at 400 µm is not too thin.
RIGHT EYE ORA. The biomechanical examination reveals low applanation peaks, indicating a "locally more deformable" cornea.
LEFT EYE ORA. The biomechanical examination reveals low applanation peaks, indicating a "locally more deformable" cornea.Difference maps were performed at each subsequent visit. No evolution was observed between the first and last visits. The corneal ectasia is stable, more than 4 years after the patient definitively stopped rubbing his eyes .
RIGHT EYE ORBSCAN (2nd VISIT)
RIGHT EYE ORBSCAN (3rd VISIT)
RIGHT EYE ORBSCAN (4th VISIT)
RIGHT EYE ORBSCAN (5th VISIT)
RIGHT EYE : Belin/Ambrósio Enhanced Ectasia display from the Oculus Pentacam.
PENTACAM DIFFERENTIAL MAPS (PACHYMETRY) : RIGHT EYE (between 1st and 5th visits). The difference map (third column) demonstrates the absence of aggravation of the LASIK ectasia.
PENTACAM DIFFERENTIAL MAPS (KERATOMETRY) : LEFT EYE (between 1st and 5th visits). The difference map (third column) demonstrates the absence of aggravation of the LASIK ectasia.
LEFT EYE ORBSCAN (2nd VISIT)
LEFT EYE ORBSCAN (3rd VISIT)
LEFT EYE ORBSCAN (4th VISIT)
LEFT EYE ORBSCAN (5th VISIT)
LEFT EYE : Belin/Ambrósio Enhanced Ectasia display from the Oculus Pentacam.
PENTACAM DIFFERENTIAL MAPS (PACHYMETRY) : LEFT EYE (between 1st and 5th visits). The difference map (third column) demonstrates the absence of aggravation of the LASIK ectasia.
PENTACAM DIFFERENTIAL MAPS (KERATOMETRY) : LEFT EYE (between 1st and 5th visits). The difference map (third column) demonstrates the absence of aggravation of the LASIK ectasia.This case is very informative about the risks of eye rubbing after LASIK surgery. Following LASIK, patients often have dry eye, and this gives them a sensation of visual fatigue which is relieved by eye rubbing. In this case, the topographies were strictly normal before refractive surgery and following excimer laser ablation, the residual stroma was at an acceptable 400 μm. The repeated and sustained friction on a thinned cornea (following LASIK) afforded by eye rubbing can be particularly detrimental to the biomechanical integrity of the corneal wall and the compressive effect makes it thinner and more irregular.
Although the main risk factor for post LASIK ectasia is the presence of preoperative topographic abnormalities (e.g. « keratoconus form fruste »), eye rubbing should not be neglected as an important risk factor. Our experience shows that eye rubbing is at the core of the mechanism of post LASIK ectasia. The habit usually precedes the surgery, and may be more incessant after the surgery because of the discomfort induced by dry eye. It is therefore mandatory to alert every LASIK candidate to the dangers of pursuing or initiating vigorous and repeated eye rubbing after the surgery.
Cessation of eye rubbing stabilises the keratoconus disease process, and in our experience, crosslinking (and its potential complications) can be avoided in compliant patients who adhere to our recommendations and definitively stop rubbing their eyes.
