Mr. G.J is a 24-year-old male engineering student with no previous medical history, no history of ocular trauma or any known history of keratoconus in the family. He is atopic (with eczema & asthma), and complained of a progressive decrease in visual acuity greater in the left eye than in the right. He first consulted us for refractive surgery, and informed us that he had a crosslinking procedure performed for the left eye at another institution in 2013 for early keratoconus.
His refraction at the first visit (07/18th/2014) was : Right Eye (RE) 20/25 with -1 (-2 x 100 °) and Left Eye (LE) 20/40 with -4 (-4 x 60 °).
Clinical examination with the slit lamp revealed a central keratoconus more pronounced in the left eye wtih bilateral Vogt’s striae (vertical fine, whitish lines in the deep/posterior stroma and Descemet’s membrane commonly found in patients with keratoconus) and 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 central keratoconus more pronounced in the left eye.
When asked about his sleeping habits, the patient mentioned that he slept on his right side, with the head deeply buried in the pillow.
When asked about eye rubbing, the patient admitted that he rubbed his eyes when working in front of the computer, using the knuckles.
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 him to stop rubbing his eyes, and to change his unhealthy sleeping position.
Here are pictures of the patient rubbing his eyes and his profiles
In this case we find many triggers for eye rubbing like allergy, extended hours of work on the computer and an unhealthy sleeping position. Another interesting point to note is that the keratoconus in the left eye that had undergone cross-linking continued to evolve, and progression of keratoconus in both eyes was arrested only after the patient had stopped rubbing. This is demonstrative of the direct causal effect of eye rubbing on the pathogenesis and evolution of keratoconus.
As shown in this case and others in this website, cessation of eye rubbing is sufficient to prevent the progression of keratoconus, and surgical procedures (such as crosslinking) are unnecessary. Patient education and sensitisation to the deleterious effects of ocular compression and friction, as well as their associated factors and triggers (sleeping position, allergy, dry eye, prolonged work in front of the computer etc) are the best tools to prevent the onset and/or evolution of keratoconus.
In this case, the keratoconus has been stable for more than 3 years. We are planning to perform Phototherapeutic Keratectomy (PRK) in the near future. Our experience shows that performing laser surface ablation (PRK, with no flap cut) in such instances is safe for the cornea provided the patient has understood the stakes involved in eye rubbing after surgery. We also found that PRK creates a similar surgical environment to cross-linking without endothelial toxicity and much less keratocyte apoptosis (cellular death). PRK may not induce much of a stiffening effect, but the inflammation generated by the laser and by the stromo-epithelial healing response may generate a slightly different (reduced) corneal sensitivity in the long run. This surgically induced cornea desensitisation (like in cross-linking), together with post-operative pain and the fear of poor surgical outcome or failure are major deterrents to eye rubbing.