The patient
Patient right profile
Bilateral Asymmetric Keratoconus induced by eye rubbing
Identity : Mr U.B
First visit : 01/10/2014
Last Visit : 03/07/2017
Mr. U.B is a 28-year-old male computer scientist with no previous medical history or any known keratoconus in the family. He complained of a progressive decrease in visual acuity in both eyes. The patient is right-handed and sleeps on the right side with his head lying on the right hand.
His refraction at the first visit (01/10th/2014) was : Right Eye (RE) 20/20 with +0.75 (-4.25 x 70 °) and Left Eye (LE) 20/20 with -1 (-3.25 x 125 °).
Clinical examination with the slit lamp suggested bilateral corneal thinning more pronounced in the left eye . We also found bilateral Vogt’s striae and Fleischer rings (Fleischer rings are pigmented rings in the peripheral cornea, resulting from iron deposition in basal epithelial cells, in the form of hemosiderin) in both eyes. The tear film Break Up Time (BUT) was also pathological (< 8 seconds) in both eyes, which reflected chronic ocular dryness.
Corneal topography revealed the presence of bilateral keratoconus, more pronounced in the left eye.
At his first visit, when asked about the possibility of frequent eye rubbing, the patient admitted to rubbing fairly frequently when working in front of the computer screen. He worked mostly at night and his eyes felt permanently dry. Rubbing his eyes gave him a sense of relief.
We explained to the patient that since vigorous eye rubbing had preceded the drop in visual acuity, this habit may have caused his cornea to deform, resulting in the keratoconic changes observed in his case.
We strongly advised this patient to stop rubbing his eyes, and treated the dry eye problem with intensive lubrication in the form of gels and artificial tears.
Here are pictures of the patient rubbing his eyes and his profiles
PATIENT RIGHT PROFILE
PATIENT LEFT PROFILE
PATIENT SHOWING HIS SLEEPING POSITION. This posture creates a local compression and irritation of the ocular surface and eyelids.
PATIENT RUBBING HIS EYES. He usually rubs his eyes with the pulps of his fingers, in lateral and circular motions.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 corneal deformation is obvious, characterized by an increased prolateness accompanied with an inferior steepening. The apex of the deformation is slightly lower than average.
LEFT EYE ORBSCAN (1st VISIT). The corneal deformation of the left eye is more pronounced than that of the right eye. It is characterized by increased prolateness and asymmetry. The central thinning (bottom right) is obvious.
RIGHT EYE PENTACAM (1st VISIT). This examination shows data similar to the Orbscan examination. The corneal warpage is characterized by an increase prolateness with the zone of maximal curvature decentered inferiorly.
LEFT EYE PENTACAM (1st VISIT). The increased prolateness is responsible for the island pattern of the anterior and posterior (bottom right) elevation maps. 
RIGHT EYE OPDscan (1st VISIT). The combined wavefront and corneal analysis is dominated by the consequence of corneal irregularity: there is marked increase in coma, trefoil and related aberrations. This explains the loss of visual quality and symptoms such as ghosting.
LEFT EYE OPDscan (1st VISIT)
RIGHT EYE ORA.. The reduced height of the peaks is suggestive of impaired corneal biomechanics.
LEFT EYE ORA. The height of the peak is reduced, which is suggestive of impaired corneal biomechanics.Difference maps were performed at each subsequent visit. No evolution was observed between the first and last visits. The keratoconus is stable more than 3 years after the patient had definitively stopped rubbing his eyes . The successive topography maps and difference maps are shown here.
RIGHT EYE ORBSCAN (2nd VISIT)
RIGHT EYE ORBSCAN (3rd VISIT)
ORBSCAN DIFFERENTIAL MAPS : RIGHT EYE. The bluish color suggests a possible flattening of the cornea between two consecutive visits, but is in reality an artefact. The corneal deformation is permanent, and this apparent flattening is due to lower repeatability of examinations on keratoconic corneas. There is no real change in the corneal shape in this case.
PENTACAM DIFFERENTIAL MAPS : RIGHT EYE. The difference map (3rd column) shows the absence of change in the corneal shape between these two examinations. There is no keratoconus progression.
RIGHT EYE ORBSCAN (4th VISIT)
LEFT EYE ORBSCAN (2nd VISIT)
LEFT EYE ORBSCAN (3rd VISIT)
ORBSCAN DIFFERENTIAL MAPS : LEFT EYE. As for the right eye, there is no significant change in the corneal distortion over time (the keratoconus is stable).
PENTACAM DIFFERENTIAL MAPS : LEFT EYE. The 3rd column demonstrates the absence of keratoconus progression (greenish colors: no change).
LEFT EYE ORBSCAN (4th VISIT)
RIGHT EYE ORBSCAN (5th VISIT)
ORBSCAN DIFFERENTIAL MAPS : RIGHT EYE. This difference map demonstrates the absence of change between these examinations.
RIGHT EYE ORBSCAN (6th VISIT)
PENTACAM DIFFERENTIAL MAPS : RIGHT EYE. The 3rd column (difference map) demonstrates the absence of progression of the keratoconus.
PENTACAM DIFFERENTIAL MAPS : RIGHT EYE. This difference map demonstrates the stability of the keratoconus over time (since the cessation of eye rubbing).
LEFT EYE ORBSCAN (5th VISIT)
ORBSCAN DIFFERENTIAL MAPS : LEFT EYE. The difference map suggests an improvement or reduction in the corneal astigmatism. This however is likely to be artifactual, as there is lower repeatability of topography on highly distorted corneas.. There is no progression of the keratoconus here.
LEFT EYE ORBSCAN (6th VISIT)
PENTACAM DIFFERENTIAL MAPS : LEFT EYE. The 3rd column demonstrates the absence of change between the compared examinations.
PENTACAM DIFFERENTIAL MAPS : LEFT EYE. This difference map shows the absence of progression of the keratoconus. The yellow zone (slight steepening) occurs in an area where the corneal surface is flat, and this must not be interpreted as a progression.
PENTACAM DIFFERENTIAL MAPS : RIGHT EYE (between 2014 and 2018). There is no keratoconus progression.
PENTACAM DIFFERENTIAL MAPS : LEFT EYE (between 2014 and 2018). There is no keratoconus progression.This case constitutes another evidence for eye rubbing being the root cause of keratoconus. Keratoconus is not a primitive dystrophy, but is instead a mechanical disease. Without eye rubbing , without repeated mechanical stress, there is no deformation of the corneal dome, and thus no keratoconus.
The cessation of eye rubbing resulted in the stabilization of the corneal deformation in this case. The difference maps performed over time demonstrate the absence of progression of the keratoconus. Some of these maps even suggest a possible improvement in the shape of the cornea, despite no other therapy but the cessation of eye rubbing being performed. Although the changes are likely to be artifactual, the topographic improvement could possibly be attributed to epithelial smoothing, as the cessation of eye rubbing promotes a more stable ocular surface.
