The patient
Bilateral Keratoconus induced by eye rubbing,
stable since the first visit
Identity : Ms F.T
First visit : 01/06/2017
Last Visit : 01/09/2018
Ms. F.T is a 32-year-old teacher, with no previous medical history or any known history of keratoconus in the family. She initially consulted us for refractive surgery suitability. She complained of a progressive decrease in visual acuity in both eyes over the last 5 years.
Ms E.M is right handed and sleeps on her right side, with the head buried in the pillow .
Her refraction at first visit was : Right eye (RE): 20/20 -1.75 (-4 x 35°) and Left eye (LE) 20/20 – 0.25 (-3.75 x 165°).
Slit lamp examination revealed signs of keratoconus with Fleischer rings and tarsal papillae in both eyes (Fleischer rings are pigmented rings in the peripheral cornea, resulting from iron deposition in basal epithelial cells, in the form of hemosiderin).
She has been wearing rigid gas permeable contact lenses since the age of 26, and it was then that her eye rubbing habit started. She confessed that she would rub her eyes more than 10 times during the day, especially during extended periods of work in front of the computer, and after removal of the contact lenses .
We strongly advised this patient to stop rubbing her eyes.
Here are pictures of the patient rubbing her eyes and her profiles
LEFT PROFILE
RIGHT PROFILE
SLEEPING POSITION
PATIENT RUBBING HER EYESHere are the Orbscan with SCORE Analyzer maps, ORA (Ocular Response Analyser) and Visante OCT (Optical Coherence Tomography) results of the first visit.
ORBSCAN RIGHT EYE. Typical mild keratoconus pattern.
ORBSCAN LEFT EYE. Typical keratoconus pattern with marked toricity and inferior steepening.
SCORE ANALYZER RIGHT EYE. This is positive for keratoconus.
SCORE ANALYZER LEFT EYE. This is positive for keratoconus.
ORA RIGHT EYE. The signals are unremarkable, despite a slight reduction in the first applanation peak.
ORA LEFT EYE. Hysteresis is in the normal range, but the first peak has reduced amplitude and reduced slope.
OCT RIGHT EYE. Cross-sectional image of the right cornea. As opposed to the common interpretation of what the "ectasia" term suggests, there is no obvious central corneal bulging but an impercetible yet visually significant corneal deformation.
OCT LEFT EYE. Cross sectional image of the left cornea. This is similar to the right eye.Difference maps were performed at each subsequent visit. No evolution has been observed between the first and last visits. The keratoconus is stable for more than 12 months .
This patient has completely stopped rubbing his eyes and has changed his sleeping position .
ORBSCAN RIGHT EYE (2nd VISIT)
ORBSCAN DIFFERENTIAL MAPS : RIGHT EYE (between 1st and 2nd visits)
ORBSCAN RIGHT EYE (3rd VISIT)
ORBSCAN DIFFERENTIAL MAPS : RIGHT EYE (between 2nd and 3rd visits). The corneal surface is stable.
PENTACAM DIFFERENTIAL MAPS : RIGHT EYE (between 2nd and 3rd visits). The difference map (third column) shows the absence of changes between the 2nd and 3rd visits (i.e there is stabilization).
ORBSCAN RIGHT EYE (4th VISIT)
PENTACAM RIGHT EYE (4th VISIT)
PENTACAM DIFFERENTIAL MAPS : RIGHT EYE (between 3rd and 4th visits). The difference map (third column) shows the absence of changes between the 3rd and 4th visits (i.e there is stabilization).
ORBSCAN LEFT EYE (2nd VISIT)
ORBSCAN DIFFERENTIAL MAPS : LEFT EYE (between 1st and 2nd visits)
ORBSCAN LEFT EYE (3rd VISIT)
ORBSCAN DIFFERENTIAL MAPS: LEFT EYE (between 2nd and 3rd visits). This pattern could suggest that the deformation is slightly reduced! However, it is more probably some random noise.
PENTACAM DIFFERENTIAL MAPS : LEFT EYE (between 2nd and 3rd visits). There is no change in the corneal shape between the 2nd and 3rd visits.
ORBSCAN LEFT EYE (4th VISIT)
PENTACAM LEFT EYE (4th VISIT)
PENTACAM DIFFERENTIAL MAPS : LEFT EYE (between 3rd and 4th visits). The difference map (third column) shows the absence of changes between the 3rd and 4th visits (i.e there is stabilization).This case is another example where eye rubbing is not associated with or induced by allergy, but instead is a consequence of late night work and extended work in front of the computer, which causes visual fatigue associated with dry eye. This visual fatigue is relieved by eye rubbing, which eventually becomes a habit.
The importance of the position of sleep is often neglected. An unhealthy sleeping position results in repeated and prolonged trauma to the cornea; this triggers eye rubbing in the mornings upon awakening. In some cases, we prescribe a nocturnal eye protection shell, which shields the eye and eyelids from extended contact with the linen, pillow and bed, and also allows the patient to be more aware of possible rubbing.
We also note in this case a common risk factor for eye rubbing: the use of rigid gas permeable contact lenses. These lenses often cause discomfort when worn which encourages eye rubbing when removed at the end of the day.
The repeated and sustained friction on the eye evoked by eye rubbing are deleterious to corneal stability and responsible for pathological deformation of the cornea (warpage), culminating in the classic picture of keratoconus. The strict cessation of eye rubbing, together with efficient dry eye management, are key in the prevention of progression of keratoconus.
