Case #45

The patient

Patient right profile

Bilateral Asymmetric Keratoconus induced by eye rubbing

Identity : Mr Q.T
First visit : 07/07/2017
Last Visit : 01/12/2018

Age (years)
Follow-up (months)
No rub, no cone: the keratoconus conjecture

Mr Q.T, is a 40-year-old male with no known keratoconus in his family. He has a history of atopy (eczema). He first consulted us for a refractive surgery suitability assessment. He had never been suspected of or diagnosed with keratoconus before. The patient complained of a progressive decrease in visual acuity greater in the left eye than the right.

His refraction at the first visit (07/07th/2017) was: Right Eye (RE) 20/20 with -1 (-2 x 90 °) and Left Eye (LE) 20/20 with -3 (-0.25 x 135 °).

Clinical examination with the slit lamp revealed a thin cornea with Vogt’s striae (fine whitish lines in the posterior stroma) and Fleischer ring (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.

Systematic corneal topography performed routinely for all refractive surgery candidates revealed bilateral keratoconus, more pronounced in the left eye.

When asked about his sleeping habit, the patient revealed that he sleeps on his stomach, with head in the pillow (« pillow hugging« ). He is right handed, and often awoke with red eyes in the morning.

At the first visit, when asked  about possible rubbing habits, the patient denied any eye rubbing. We then asked him to pay attention to possible rubbing episodes, and gave him an appointment for a review visit one month later. We prescribed him physiological serum and artificial tears as lubricants to soothe the ocular surface.

At the second visit, the patient confessed that he had become aware that he rubbed his right eye several times a day, especially in the mornings with the knuckles of his right hand. He also alluded to rubbing his eyes at work in front of the computer screen and late at night to relieve ocular fatigue. He described a gesture that he would perform many times a day: he would rub his left eye with the knuckle of his right index finger which were passed under his glasses (refer to the video below). This resulted in a shift of the eyeglass frame to the same side (right side) as the hand rubbing the eye, which is an indirect sign of eye rubbing in eyeglass wearers (« offset glasses sign« ). Mr P.S claimed that he had stopped rubbing his eyes since being made aware of the bad habit.

In this case, the asymmetry between the right eye and left eye deformation is striking. It is strongly correlated to his rubbing and work habits.

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 his case. We strongly advised this patient to stop eye rubbing, and to change his unhealthy sleeping position.

Here are pictures of the patient rubbing his eyes and his profiles

PATIENT RUBBING HIS EYES. He used various technique, including repeating "palming", with vigorous frictions on the orbits.

Here are the Orbscans quadmaps with SCORE ANALYSER results, Pentacam maps, OPDscan (topography and aberrometry) maps and Ocular Response Analyzer (ORA) results of the first visit .

RIGHT EYE ORBSCAN (1st VISIT). The distortion of the right cornea is obvious, and accompanied by central thinning and increased negative asphericity of the anterior and posterior corneal surface.
LEFT EYE ORBSCAN (1st VISIT). The corneal deformation has a gross pattern similar to that of the right eye. It is slightly more pronounced on the left eye.
RIGHT EYE SCORE. The SCORE is positive, in the range of mild keratoconus.
LEFT EYE SCORE. The score could not be calculated given insufficient exposure of the cornea (axial curvature map).
RIGHT EYE PENTACAM (1st VISIT). The asymmetry and central thinning parallels the Orbscan maps features.
LEFT EYE PENTACAM (1st VISIT); The irregular deformation of the the anterior and posterior corneal surfaces is obvious (elevation maps, right column). There is a marked paracentral inferior thinning (bottom left, pachymetry map). The curvature map (top left) shows a pronounced inferior steepening.
RIGHT EYE OPDscan (1st VISIT). The corneal deformation induces a marked elevation of high order aberration (coma, trefoil).
LEFT EYE OPDscan (1st VISIT). The marked asymetry of the anterior corneal surface results in an elevation of the coma-like aberrations.
RIGHT EYE ORA. The height of the second aplanation peak is reduced, and the base of the peaks is slightly enlarged.
LEFT EYE ORA. The peaks are distorted, with a reduction in height and an enlargement of their base.
OCT EPITHELIAL MAPPING : RIGHT EYE. The epithelial layer has irregular thickness, with a paracentral thinning in the vicinity of the corneal apex.
OCT EPITHELIAL MAPPING : LEFT EYE. There is marked thinning of the epithelial layer in the temporal - paracentral area (in the area of the apex of the cornea).

Difference maps have been performed at each subsequent visit. No evolution has been observed between the first and last visit. The keratoconus is still stable, more than 6 months after the patient has definitely stopped to rub his eyes .

PENTACAM DIFFERENTIAL MAPS : RIGHT EYE (between 1st and 2nd visits). The difference map (third column) and its related indices demonstrate the absence of evolution of the corneal deformation.
PENTACAM DIFFERENTIAL MAPS : LEFT EYE (between 1st and 2nd visits). The difference map démonstrates the absence of progression of the corneal deformation.
PENTACAM DIFFERENTIAL MAPS : RIGHT EYE (between 1st and 3rd visits). The difference map (third column) and its related indices demonstrate the absence of evolution of the corneal deformation.
PENTACAM DIFFERENTIAL MAPS : LEFT EYE (between 1st and 3rd visits). The difference map (third column) and its related indices demonstrate the absence of evolution of the corneal deformation.
The patient’s initial denial about his eye rubbing habits is not uncommon. Many patients fail to admit to rubbing their eyes at the first consultation simply because they are not aware of their habit. It was only at the second visit, after being sensitised to the ill-effects of eye rubbing, that the patient realised that he was rubbing unconsciously. He admitted to be overwhelmed with work, and was under chronic stress, and rubbing was a form of relaxation to him, and thus he would rub repetitively throughout the day.
Another interesting point about this case is the deformation of the spectacle frame as a consequence of the rubbing gesture (« offset glasses sign« ). It is not surprising, therefore, that a similar force conveyed to the corneas by the rubbing could cause them to deform progressively and eventually adopt the typical morphological features seen in keratoconus.
The simple act of cessation of the rubbing habit in this case resulted in the stabilisation of corneal deformation, thus arresting the progression of keratoconus.