The patient
Patient right profile
Bilateral Asymmetric Keratoconus induced by eye rubbing
Identity : Ms U.N
First visit : 10/25/2016
Last Visit : 10/31/2017
Ms. U.N is a 31-year-old female with no previous medical history, or any known keratoconus in her family .
She has known allergy to pollen, and complained of a progressive decrease in visual acuity greater in the right eye than in the left.
Her refraction at the first visit (10/25th/2016) was: Right Eye (RE) 20/32 with +1.25 (-5.75 x 55 °) and Left Eye (LE) 20/20 with -1 (-1.25 x 100 °).
Clinical examination with the slit lamp suggested an irregular inferior corneal bulge more pronounced in the right eye, and traces of scarring in the corneal periphery. The posterior stroma showed bilateral Vogt’s striae.
Corneal topography revealed the presence of bilateral keratoconus more pronounced in the right eye.
She was initially followed in another institution, where she had corneal collagen cross linking performed in both eyes in 2012. She was also implanted with a corneal ring (INTACS) in the right eye in 2013. No doctor had told her about the risks of eye rubbing until our consultation.
When asked about the possibility of frequent eye rubbing, the patient admitted to rubbing her eyes when working in front of the computer, with her fists and knuckles. She sleeps on her right side. She tolds us that since she realized the crosslinking, she feld much less the desire to rub her eyes and that since her eyes scratch less.
We explained to the patient that since vigorous rubbing had preceded the drop in visual acuity, this habit may have caused the cornea to deform in her case. The patient acknowledged vigorous and sustained right eye rubbing during childhood. We strongly advised her to stop rubbing and to change her unhealthy sleeping position (causing chronic compression of her right eye).
Here are pictures of the patient rubbing her eyes and her profiles
PATIENT RIGHT PROFILE (NOTE THE INTACS)
PATIENT LEFT PROFILE
INTACS OF RIGHT EYE
PATIENT RUBBING HER EYES WITH KNUCKLES
PATIENT SHOWING HER SLEEPING POSITIONHere are the Orbscan quadmaps, Pentacam maps, OPDscan (topography and aberrometry) maps, Ocular Resonse Analyzer (ORA),and OCT Corneal epithelial maps results of the first visit .
RIGHT EYE ORBSCAN (1st VISIT). This examination reveals a pronounced keratoconus pattern. The cornea is aspheric, and the deformation is also asymmetric with inferior steepening. There is marked central thinning too.
LEFT EYE ORBSCAN (1st VISIT). This examination reveals keratoconus, but the deformity is less than that in the right eye. The cornea is aspheric, and the deformation is also asymmetric with inferior steepening. There is marked central thinning too.
RIGHT EYE PENTACAM (1st VISIT)
LEFT EYE PENTACAM (1st VISIT)
RIGHT EYE OPDscan (1st VISIT)
LEFT EYE OPDscan (1st VISIT)
RIGHT EYE ORA. Note the reduced height of the applanation peaks, and the reduced CRF (corneal resistance factor) value.
LEFT EYE ORA. Note the reduced height of the applanation peaks, and the reduced CRF (corneal resistance factor) value.
OCT EPITHELIAL MAP OF RIGHT EYE
OCT EPITHELIAL MAP OF LEFT EYEDifference maps were performed at each subsequent visit at our institution. No evolution was observed between the first and last visits. The keratoconus is stable, more than 1 year after the patient definitively stopped rubbing her eyes .
RIGHT EYE ORBSCAN (2nd VISIT). The pattern is not significantly different from the first visit at our institution.
LEFT EYE ORBSCAN (2nd VISIT). The pattern is not significantly different from the first visit at our institution.
RIGHT EYE PENTACAM (2nd VISIT). The pattern is not significantly different from the first visit at our institution.
LEFT EYE PENTACAM (2nd VISIT). The pattern is not significantly different from the first visit at our institution.
PENTACAM DIFFERENTIAL MAPS : RIGHT EYE (between 1st and 2nd VISITS). This difference map is unremarkable; there is no significant change between the two consecutive examinations; the corneal deformation did not progress.
PENTACAM DIFFERENTIAL MAPS : LEFT EYE (between 1st and 2nd VISITS). This difference map is unremarkable; there is no significant change between the two consecutive examinations; the corneal deformation did not progress.
RIGHT EYE ORBSCAN (3rd VISIT)
LEFT EYE ORBSCAN (3rd VISIT)
RIGHT EYE PENTACAM (3rd VISIT)
LEFT EYE PENTACAM (3rd VISIT)
PENTACAM DIFFERENTIAL MAPS : RIGHT EYE (between 1st and 3rd VISITS). This difference map is unremarkable; there is no significant change between the two consecutive examinations; the corneal deformation did not progress.
PENTACAM DIFFERENTIAL MAPS : LEFT EYE (between 1st and 3rd VISITS). This difference map is unremarkable; there is no significant change between the two consecutive examinations; the corneal deformation did not progress.This patient had severe keratoconus caused by chronic eye rubbing. Eye rubbing was induced by ocular pruritus and discomfort from seasonal allergy to pollen since childhood. Eye rubbing was more frequent and vigorous in the right eye. This is probably due to additional irritation of the right eye at night as a consequence of the patient’s sleeping position (right side). Cross linking and INTACS did not improve the vision of the patient. Before she was managed at our institution, this patient was not alerted to the deleterious effects of chronic eye rubbing. Her keratoconus was not stable despite cross-linking. It became stable only after she was properly informed and educated about eye rubbing and its causative effects.
Corneal cross-linking is not expected to improve vision. Corneal collagen cross-linking is, from our point of view, a practice whose effectiveness is doubtful. Our extensive experience in this field shows that stopping eye rubbing suffices to halt the progression of the disease. A possible benefit of cross-linking may be a consequent of one of its side-effects, and this is indirectly related to eye rubbing. The reduction of corneal sensitivity seen after cross-linking may reduce ocular pruritus, and this in itself can inhibit the urge to rub. This could account for the purported stabilization observed after cross-linking procedures for keratoconus.
