Mr. P.M is a 29-year-old male with no previous medical history, or any known history of keratoconus in the family. He was myopic in both eyes (- 7.5D) and had LASIK performed in 2009 in another institution. He complained of a progressive decrease in visual acuity in both eyes for 3 years when he first presented to us. He informed us that he had symptomatic dry eye following LASIK, and that he would rinse his eyes with tap water and then rub them vigorously to relieve his discomfort. Digital pressure on his eyes gave him a sense of well being.
He is right-handed and sleeps on his left side, with the head buried in the pillow .
At the first visit to our Center, his refraction was : Right eye (RE): 20/25 with -2 (-2.75 x 175°), Left eye (LE) 20/40 with -10 (-2.5 x 170 °)
Slit lamp examination revealed circular flap cuts with a Fleischer ring on both corneas (Fleischer rings are pigmented rings in the peripheral cornea, resulting from iron deposition in basal epithelial cells, in the form of hemosiderin).
Corneal topography confirmed the presence of bilateral corneal ectasia.
We advised the patient to stop rubbing both eyes immediately and to change his unhealthy sleeping position.
Here are pictures of the patient rubbing his eyes and his profiles
This case reveals that post-LASIK dry eye causing discomfort and visual fatigue can induce a patient to rub their eyes vigorously in an attempt to relieve their symptoms. Such repeated and sustained mechanical trauma on a thinned cornea (post-LASIK) can be particularly detrimental to the biomechanical integrity of the corneal wall. Corneal deformation ensues, culminating in what we term « Post-LASIK ectasia« .
Eye rubbing is often neglected in the management of post LASIK ectasia. Although other important risk factors for ectasia exist (eg abnormal pre-operative topography, low residual stromal bed thickness, young patient age etc), the role of eye rubbing in inducing mechanical weakening of the cornea must not be overlooked. Our experience shows that eye rubbing is at the core of the mechanism of post LASIK ectasia, as it usually precedes the surgery (hence the particular abnormal topography pattern pre-operatively), and continues after (in an attempt to alleviate the discomfort induced by dry eye). It is therefore mandatory to sensitize every LASIK candidate to the dangers of pursuing or initiating vigorous and repeated eye rubbing after the surgery.
The cessation of eye rubbing promotes stabilization of the corneal deformation, and in our experience, corneal collagen cross-linking (and its potential complications) can be avoided in patients who co-operate with and adhere to our recommendations to definitively stop rubbing their eyes.