Case #3

The patient

Patient rubbing his eye

Unilateral keratoconus wih atopy, stable since the first visit

Identity : Mr K.K
First visit : 09/03/2013
Last visit : 02/07/2017

27
Age (years)
41
Follow-up (months)
What’s the rub ? (CRST Europe april 2017)

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

The patient demonstrates how he rubs his right eye. The direct contact of the knuckles on the eyeball (through the closed eyelids) is particularly harmful for the corneal dome. Interestingly, when asked to show how they rubbed their eyes, most patients would spontaneously rub one eye, which is the eye that they rubbed more frequently.

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

ORBSCAN RIGHT EYE CASE3RIGHT EYE ORBSCAN (1st VISIT) : The keratoconus is relatively centered: 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), irregular astigmatism characterized by a marked infero-nsasl steepening is obvious. The thickness map (bottom right) shows central thinning.
ORBSCAN LEFT EYE CASE3LEFT EYE ORBSCAN (1st VISIT) : This examination is almost unremarkable, but on the curvature map (bottom left), a slight inferior steepening is noticeable.
RIGHT EYE PENTACAM (1st VISIT)
LEFT EYE PENTACAM (1st VISIT)
ORA RIGHT EYE CASE3ORA RIGHT EYE. The applanation peaks are low and slightly irregular.
ORA CASE3 LEFT EYEORA LEFT EYE. The applanation peaks are low and irregular.

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.

RIGHT EYE ORBSCAN (2nd VISIT)
LEFT EYE ORBSCAN (2nd VISIT)
RIGHT EYE ORBSCAN (3rd VISIT)
LEFT EYE ORBSCAN (3rd VISIT)
RIGHT EYE ORBSCAN (4th VISIT)
LEFT EYE ORBSCAN (4th VISIT)
RIGHT EYE ORBSCAN (5th VISIT)
LEFT EYE ORBSCAN (5th VISIT)
PENTACAM DIFFERENTIAL MAPS : RIGHT EYE. The 3rd column is obtained by subtracting the most recent examination data from the previous one, point by point. Green colors correspond to zero or negligible changes. Blue colors correspond to some improvement (flattening),
PENTACAM DIFFERENTIAL MAPS : LEFT EYE. No significant changes are detected.

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.