The patient
Illustration picture
Bilateral Asymmetric Keratoconus induced by eye rubbing
Identity : Ms M.W
First visit : 10/13/2008
Last Visit : 06/12/2018
Ms M.W is a 45 year-old female with no previous medical history or any known keratoconus in her family. She has atopic background (asthma, eczema).
Her refraction at the first visit (10/13th/2008) was: Right Eye (RE) 20/25 with -0.25 (-5.5 x 30 °) and Left Eye (LE) 20/25 with -0.25 (-3.25 x 155 °).
Clinical examination with the slit lamp suggested a paracentral inferior thinning more pronounced in the right eye .
Corneal topography revealed the presence of bilateral keratoconus more pronounced in the right eye.
The patient disclosed that she had rubbed her eyes regularly in the past (during childhood), with her knuckles. She confessed that she used to rub her eyes at work front of computer screen.
She also used to sleep on her stomach, on both sides.
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. We strongly advised this patient to stop rubbing her eyes.
Here are pictures of the patient rubbing her eyes and her profiles
PATIENT RIGHT EYE PROFILE
PATIENT LEFT EYE PROFILE
PATIENT RUBBING HER EYES WITH KNUCKLES
PATIENT SLEEP POSITION (ON STOMACH AND SIDES)Here are the Orbscan quadmaps with SCORE Analyser, OPDscan (topography and aberrometry) maps, Ocular Response Analyzer (ORA) and OCT results of the first visit .
RIGHT EYE ORBSCAN (1st VISIT). The distortion of the cornea is responsible for a high toricity and negative asphericity. It is accompanied by a central thinning. The cornea is steeper inferiorly.
LEFT EYE ORBSCAN (1st VISIT). The topographic features displayed in the left eye are similar to that of the right eye.
RIGHT EYE SCORE. The SCORE is a topographic index which enables us to quantify the level of deformation and thinning of the cornea. It is strongly positive in this case, indicating advanced keratoconus.
LEFT EYE SCORE. The SCORE is elevated but at a lesser value than the right eye. This suggests that keratoconus is more advanced in the right than the left eye.
RIGHT EYE OPDscan (1st VISIT). The severe asymmetry of the cornea results in a typical increase in coma-like aberration, which cannot be corrected by spectacles and explain the loss of visual quality and symptoms such as monocular diplopia.
LEFT EYE OPDscan (1st VISIT). As for the right eye, there is marked increase in high order aberrations, such as coma, trefoil, and secondary astigmatism.
RIGHT EYE ORA. The height of the applanation peaks is low. The CH (corneal hysteresis) value is reduced.
LEFT EYE ORA. The peaks deformation (lowering) and the reduction of the hysteresis value (CH) are characteristic.
RIGHT EYE OCT. The increased prolateness and slight asymmetry of the corneal profile are visible.
LEFT EYE OCT. RIGHT EYE OCT. The increased prolateness and slight asymmetry of the corneal profile are visible. Note the focal thinning, which is probably adjacent to the zone where the forces of the rubbing movements are directed.Difference maps were performed at each subsequent visit. No evolution was observed between the first and last visits (as seen from the careful inspection of the consecutive Orbscan maps, and the more recent subtraction maps obtained with the Pentacam). The keratoconus is stable, more than 9 years after the patient had definitively stopped rubbing her eyes.
RIGHT EYE ORBSCAN (2nd VISIT)
RIGHT EYE ORBSCAN (3rd VISIT)
RIGHT EYE ORBSCAN (4th VISIT)
RIGHT EYE ORBSCAN (5th VISIT)
RIGHT EYE ORBSCAN (6th VISIT)
PENTACAM DIFFERENTIAL MAPS : RIGHT EYE (2015 to 2017). A "greenish" map (third column) means "no difference" between the compared examinations.
LEFT EYE ORBSCAN (2nd VISIT)
LEFT EYE ORBSCAN (3rd VISIT)
LEFT EYE ORBSCAN (4th VISIT)
LEFT EYE ORBSCAN (5th VISIT)
LEFT EYE ORBSCAN (6th VISIT)
PENTACAM DIFFERENTIAL MAPS : LEFT EYE (2015 to 2017). As for the right eye, there is no keratoconus progression between 2015 and 2017
RIGHT EYE ORBSCAN (7th VISIT)
LEFT EYE ORBSCAN (7th VISIT)
RIGHT EYE PENTACAM (7th VISIT)
LEFT EYE PENTACAM (7th VISIT)
PENTACAM DIFFERENTIAL MAPS : RIGHT EYE (2015 to 2018).
PENTACAM DIFFERENTIAL MAPS : LEFT EYE (2015 to 2018).
PENTACAM DIFFERENTIAL MAPS : RIGHT EYE (between 2015 to 2018). 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 2015 to 2018). This difference map is unremarkable; there is no significant change between the two consecutive examinations; the corneal deformation did not progress.This case demonstrates that the cessation of eye rubbing is the key factor in the stabilisation of keratoconus. In our opinion, this disease is primarily caused by vigorous eye rubbing. The fact that keratoconus progression is invariably arrested when patients stop rubbing their eyes is a strong argument in favor of eye rubbing being the root cause of keratoconus.
