The patient
Patient right profile
Bilateral Keratoconus induced by eye rubbing
Identity : Mr W.N
First visit : 06/20/2016
Last Visit : 03/28/2017
Mr.W.N is a 20-year-old male policeman with no previous medical history or any known keratoconus in his family. He was offered corneal collagen cross-linking in another institution and consulted us for a second opinion. The patient has known allergy to dust mites, and complained of a progressive decrease in visual acuity more pronounced in the right eye than in the left .
His refraction at the first visit (06/20th/2016) was : Right Eye (RE) 20/50 with +4.5 (-5.75 x 70 °) and Left Eye (LE) 20/25 with +0.25 (-2.75 x 110 °).
Clinical examination with the slit lamp suggested an irregular inferior corneal bulge more pronounced in the right eye. We found also 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), and tarsal papillae (indicating chronic ocular allergy) in both eyes.
Corneal topography revealed the presence of bilateral keratoconus more pronounced in the right eye.
When asked about the possibility of frequent eye rubbing, the patient admitted to rubbing his eyes with his knuckles when working in front of the computer. He is right-handed and sleeps on the stomach, with the head lying on his right arm.
We explained to the patient that vigorous and chronic eye rubbing may have caused the cornea to deform permanently in his case. We strongly advised this patient to stop eye rubbing, and to change his unhealthy sleeping position.
Here are pictures of patient rubbing his eyes and profiles
PATIENT RIGHT EYE PROFILE
PATIENT LEFT EYE PROFILE
PATIENT DEMONSTRATING HOW HE RUBS HIS EYES. The "forceps rubbing pattern", where the thumb rubs one eye, and the index finger the other eye" results in a deformation which is more severe in the eye rubbed by the thumb.
PATIENT SHOWING HOW HE RUBS HIS EYES (USING THE KNUCKLES)
PATIENT SHOWING HIS UNHEALTHY SLEEPING POSITION. The extended compression of the right orbit exposes the right eye to increased heat and contamination by irritants and allergens.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). The deformation of the cornea is characterized by vertical asymmetry and increased prolateness.
LEFT EYE ORBSCAN (1st VISIT). The keratoconus here is slightly less pronounced than in the right eye.
RIGHT EYE PENTACAM (1st VISIT). As for the Orbscan, the Pentacam maps reveal marked asymmetry.
LEFT EYE PENTACAM (1st VISIT). The deformation in the left eye is similar to that of the right eye (vertical asymmetry), although slightly less pronounced than that of the right eye.
RIGHT EYE OPDscan (1st VISIT). The vertical asymmetry at the corneal plane results in the induction of vertical coma. This higher order aberration cannot be corrected by spectacles. It can induce the perception of ghost images.
LEFT EYE OPDscan (1st VISIT). The vertical coma and coma-like aberrations are the predominant high order aberrations.
RIGHT EYE ORA. The height of the peaks is reduced.
LEFT EYE ORA. The height of the peaks is markedly reduced. The value of the corneal hysteresis (CH) is slightly reduced as well.Difference maps were performed at each subsequent visit. No evolution was observed between the first and last visits. The keratoconus is stable, more than 9 months after the patient definitively stopped rubbing his eyes .
RIGHT EYE ORBSCAN (2nd VISIT)
RIGHT EYE ORBSCAN (3rd VISIT)
RIGHT EYE ORBSCAN (4th VISIT)
RIGHT EYE PENTACAM (4th VISIT)
PENTACAM DIFFERENTIAL MAPS : RIGHT EYE (2nd to 4th VISITS). The 3rd column (subtraction map) demonstrates the absence of progression.
LEFT EYE ORBSCAN (2nd VISIT)
LEFT EYE ORBSCAN (3rd VISIT)
LEFT EYE ORBSCAN (4th VISIT)
LEFT EYEPENTACAM (4th VISIT)
PENTACAM DIFFERENTIAL MAPS : LEFT EYE (2nd to 4th VISITS). This map does not reveal any progression; the 3rd column, calculated as the difference between the two other examinations (obtained at two different time points) shows an almost "null " resultEye rubbing has preceded the onset of keratoconus by many years, in a context of chronic atopy and perennial ocular allergy. The specific rubbing pattern (compression of the eyes with the thumb and index finger of the same hand) often results in a markedly asymmetric deformation, more pronounced in the eye rubbed by the thumb. Logically, the cessation of eye rubbing case has interrupted the progression of keratoconus in this case.
