Eye rubbing has not been accorded sufficient prominence in the pathogenesis of keratoconus, and over time, through the management of thousands of patients with keratoconus, we have become increasingly convinced that eye rubbing is the root cause or sine qua non for keratoconus. As such, eye rubbing is not just a « risk factor », as often coined in the medical literature, but the direct cause of a syndrome with marked corneal deformation, and which we have labeled as « keratoconus ».
The « Marfan paradox » teaches us that softer corneas do not suffer from what is commonly observed in early and mild keratoconus: instead of becoming increasingly steep and irregular, they progressively distend and get globally flatter but not irregular. In keratoconic eyes, « irregular deformation » or « warpage » may better describe the condition affecting the corneal wall than the term « ectasia », and is caused by repeated local trauma due to the shearing forces inflicted by the hands, fingers and knuckles during eye rubbing episodes. As such, the cessation of eye rubbing should prevent keratoconus to occur (« No Rub, No Cone »)