The patient
Patient right profile
Bilateral Keratoconus induced by eye rubbing
Identity : Ms I.E
First visit : 01/12/2016
Last Visit : 07/03/2018
Ms. I.E is a 29-year-old female with a history of chronic allergies in her childhood. Her brother had been recently diagnosed with keratoconus. She came to us for a second opinion, after being diagnosed with keratoconus in another hospital in Paris. She said that she had received no explanation there but was just told « you have keratoconus », and that the doctor indicated an « urgent need for cross-linking ». She was not questioned about eye rubbing habits and allergies.
Her refraction at the first visit (01/12th/2016) was : Right Eye (RE) 20/32 with -2.25 (-2.75 x 40 °) and Left Eye (LE) 20/20 with +0.25 (-2.5 x 145 °).
Clinical examination with the slit lamp revealed a suspicion of an irregular inferior corneal bulge more pronounced in the right eye. We also found bilateral Fleischer rings (Fleischer rings are pigmented rings in the peripheral cornea, resulting from iron deposition in basal epithelial cells, in the form of hemosiderin).
Corneal topography revealed the presence of bilateral keratoconus more pronounced in the right eye.
At her first visit with us, we interrogated her about her eye rubbing and sleeping habits. The patient admitted to rubbing her eyes very frequently, especially in the mornings. With regards to her sleeping habit, the patient informed us that she sleeps on her right side with her head « pushing » on the arm. She is right-handed.
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. She confessed that she had rubbed her eyes very often in her childhood, as she suffered from allergic conjunctivitis. She also informed us that astigmatism was noted in her eyes when she turned 18.
We strongly advised this patient to stop eye rubbing and to change her unhealthy sleeping position to avoid chronic compression on the right eye.
Here are pictures of the patient rubbing her eyes and her profiles
PATIENT RIGHT EYE PROFILE
PATIENT LEFT EYE PROFILE
PATIENT SHOWING HOW SHE RUBS HER EYES (with knuckles). This particular rubbing habit is frequently seen in patients with bilateral severe keratoconus.
PATIENT SHOWING HER UNHEALTHY SLEEPING POSITION (head on fists)Here are the Orbscan quadmaps, Pentacam maps, OPDscan (topography and aberrometry) maps and Ocular Response Analyzer (ORA) results of the first visit.
RIGHT EYE ORBSCAN (1st VISIT). This is a typical keratoconus pattern.
LEFT EYE ORBSCAN (1st VISIT). As for the right eye, the left eye shows marked irregularity and steepening.
RIGHT EYE PENTACAM (1st VISIT). The Pentacam data resembles the Orbscan data. showing irregularity and central marked steepening.
LEFT EYE PENTACAM (1st VISIT). The keratoconus pattern is less pronounced than in the right eye.
RIGHT EYE OPDscan (1st VISIT). The distortion of the wavefront is caused by the severe corneal deformation. It cannot be fully corrected with spectacles.
LEFT EYE OPDscan (1st VISIT). There is evidence of coma, trefoil, secondary astigmatism and negative spherical aberration, all of which cannot be corrected with spectacles.
RIGHT EYE ORA. There is marked reduction in the height of the peaks and in the corneal hysteresis (CH) value.
LEFT EYE ORA. Note the reduction in the height of the peaks and in the corneal hysteresis (CH) value. This reduction is less pronounced than in the right eye.Difference maps were performed at each subsequent visit. No evolution was observed between the first and last visits. The keratoconus is stable, more than 2 years after the patient had definitively stopped rubbing her eyes .
RIGHT EYE ORBSCAN (2nd VISIT)
RIGHT EYE PENTACAM (2nd VISIT)
PENTACAM DIFFERENTIAL MAPS : RIGHT EYE (1st and 2nd VISITS)
RIGHT EYE ORBSCAN (3rd VISIT)
RIGHT EYE PENTACAM (3rd VISIT)
PENTACAM DIFFERENTIAL MAPS : RIGHT EYE (2nd and 3rd VISITS)
RIGHT EYE ORBSCAN (4th VISIT)
RIGHT EYE PENTACAM (4th VISIT)
PENTACAM DIFFERENTIAL MAPS : RIGHT EYE (3rd and 4th VISITS)
PENTACAM DIFFERENTIAL MAPS : RIGHT EYE (1st to 4th VISITS). The blue color on the 3rd column suggests the presence of a spontaneous flattening! It is most presumably a fluctuation, but certainly demonstrates the stability of the keratoconus since the cessation of eye rubbing.
RIGHT EYE ORBSCAN (5th VISIT)
RIGHT EYE PENTACAM (5th VISIT)
PENTACAM DIFFERENTIAL MAPS : RIGHT EYE (4th to 5th VISITS). The blue color on the 3rd column suggests the presence of a spontaneous flattening! It is most presumably a fluctuation, but certainly demonstrates the stability of the keratoconus since the cessation of eye rubbing.
PENTACAM DIFFERENTIAL MAPS : RIGHT EYE (between 2016 and 2018). There is no keratoconus progression.
LEFT EYE ORBSCAN (2nd VISIT)
LEFT EYE PENTACAM (2nd VISIT)
PENTACAM DIFFERENTIAL MAPS : LEFT EYE (1st and 2nd VISITS)
LEFT EYE ORBSCAN (3rd VISIT)
LEFT EYE PENTACAM (3rd VISIT)
PENTACAM DIFFERENTIAL MAPS : LEFT EYE (2nd and 3rd VISITS)
LEFT EYE ORBSCAN (4th VISIT)
RIGHT EYE PENTACAM (4th VISIT)
PENTACAM DIFFERENTIAL MAPS : LEFT EYE (3rd and 4th VISITS)
PENTACAM DIFFERENTIAL MAPS : LEFT EYE (1st to 4th VISITS). The blue color on the 3rd column suggests the presence of a spontaneous flattening! It is most presumably a fluctuation, but certainly demonstrates the stability of the keratoconus since the cessation of eye rubbing.
LEFT EYE ORBSCAN (5th VISIT)
LEFT EYE PENTACAM (5th VISIT)
PENTACAM DIFFERENTIAL MAPS : LEFT EYE (4th to 5th VISITS). The blue color on the 3rd column suggests the presence of a spontaneous flattening! It is most presumably a fluctuation, but certainly demonstrates the stability of the keratoconus since the cessation of eye rubbing.
PENTACAM DIFFERENTIAL MAPS : LEFT EYE (between 2016 and 2018). There is no keratoconus progression.This is a classic example of bilateral keratoconus induced by eye rubbing. Eye rubbing preceded the onset of the corneal deformation by several years. Cessation of eye rubbing resulted in the stabilization of the deformation (no keratoconus progression). The patient can next be fitted with rigid gas permeable contact lenses to restore vision.
It is important to explain to teenagers with allergies and allergic tendencies the importance of refraining from eye rubbing.
