Mr. K.K is a 27-year-old trader, with no known history of keratoconus in the family. He has atopic eczema and a known allergy to dust mites. He complained of a progressive decrease in visual acuity in the right eye for several months.
His Refraction was : Right eye (RE): 20/32 -4 (-3 x 40 °) and Left eye (LE) 20/20 -1.75 (-0.5 x 160 °).
Slit lamp examination revealed a keratoconus pattern with a Fleischer ring in the right eye. The left eye was unremarkable. (Fleischer rings are pigmented rings in the peripheral cornea, resulting from iron deposition in basal epithelial cells, in the form of hemosiderin)
When asked about a possible eye rubbing habit, the patient admitted to enjoying rubbing his eyes in the morning when he awakes and at work. He spends many hours in front of the computer and works till late in the evening and night. He is right-handed and declared that he only rubs his right eye.
He sleeps on his right side, with the head buried in the pillow.
We provided him some explanation about the plausible effect of eye rubbing on the onset of keratoconus. We strongly advised this patient to pay attention to possible subconscious rubbing episodes, and to stop eye rubbing indefinitely.
Here is a picture of the patient rubbing his eyes
Difference maps were performed at each subsequent visit. No evolution has been observed between the first and last visits. The keratoconus is stable for over 4 years. The next visit is in a year.
This patient has stopped rubbing his eyes. No progression has occurred, and the patient’s vision is stable in the right eye. Deformation in the left eye has also been avoided.
In this case, many factors responsible for eye rubbing are present: atopy and allergies, extended computer work, irregular work schedules with frequent night shifts, and finally an unhealthy sleeping position.
The association between atopy / allergy and eye rubbing is well documented. Atopy and allergy are also associated with keratoconus. In our opinion, this association is redundant, as what is more pertinent in this context is the association between keratoconus and eye rubbing. Atopic and allergic patients who do not rub their eyes frequently and vigorously are not susceptible to developing the corneal deformation seen in keratoconus.
Prolonged work in front of the computer is responsible for dry eye caused by a reduced blinking rate and subsequent increased tear film evaporation. This triggers ocular surface irritation and the desire to rub the eyes. Rubbing neutralizes the irritation and allows a re-lubrication of the ocular surface.
Night-shift work is also associated with dry eye . The lack of sleep is often relieved by eye rubbing which provides a sense of well-being to the patient.
Finally, we observed that the position of sleep is often related to the side of the keratoconus in unilateral or highly asymmetric cases. The prolonged compression on the eye and orbit may result in a local increase in temperature, and the lack of oxygenation and prolonged contact with the pillow (& allergens) during the night may be responsible for a desire to rub the eyes upon awakening.
All these factors were explained to the patient during his first visit. He stopped rubbing his eyes and changed his sleeping position. As a result the keratoconus in the right eye has not evolved over the last 4 years, and no keratoconus has appeared in the left eye.