Case #50

The patient

Profile of right eye

Patient right profile

Bilateral Asymmetric Keratoconus induced by eye rubbing

Identity : Mr C.N
First visit : 04/18/2017
Last Visit : 09/05/2017

Age (years)
Follow-up (months)
The crosslinking controversy

Mr. C.N is a 25-year-old male with no previous medical history or known keratoconus in his family. He had been followed up in another institution, and had crosslinking performed in both eyes in 2013. The procedure did not improve his vision, and did not stop the keratoconus from progressing in both eyes. He complained of a progressive decrease in visual acuity greater in the right eye than the left. He did not receive much explanation about his disease from his previous physicians, and thus sought another opinion from us. He could not understand why keratoconus continued to evolve despite crosslinking in his case.

His refraction at the first visit at the Rothschild foundation (on 04/18th/2017) was : Right Eye (RE) 20/200 with -2.75 (-8.25 x 45 °) and Left Eye (LE) 20/60 with -2.5 (-6.75 x 135 °).

Clinical examination with the slit lamp revealed 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. Vogt’s striae are thin vertical streaks located in the posterior corneal stroma (at the level of the Descemet membrane). These folds disappear with external pressure on the globe.

Corneal topography performed at our institution showed the presence of bilateral keratoconus more pronounced in the right eye.

We investigated the risks factors for eye rubbing at the first visit. This patient disclosed known allergy to dust mites. With regards to his sleeping habit, the patient slept on his right side, with his head buried in the pillow.
When asked about the possibility of frequent eye rubbing, the patient admitted to being aware of rubbing his eyes when he awoke (he often awoke with red eyes), and in the evenings after work. Rubbing gave him a sense of well-being.

At the subsequent visits, he remembered rubbing his eyes sometimes heavily as a child,  and especially during periods of allergic episodes.

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, leading to the classic clinical presentation of keratoconus. The patient agreed that this pathway was logical and could well explain his keratoconus history. He was concerned about his previous medical follow-ups, as he was only informed that he had a genetic ophthalmic disease, and was never counselled with regards to eye rubbing and keratoconus evolution.

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

Profile of right eye

Here are the Orbscan quadmaps, Pentacam exams, and Ocular Resonse Analyzer (ORA) results of the first visit .

RIGHT EYE ORBSCAN (1st VISIT). This examination reveals a pronounced keratoconus pattern. The cornea is very aspheric, and the deformation is also asymmetric. There is marked central thinning.
LEFT EYE ORBSCAN (1st VISIT). This maps shows an advanced keratoconus.
RIGHT EYE PENTACAM (1st VISIT). This data parallels that of the Orbscan: the deformation of the cornea is pronounced.
LEFT EYE PENTACAM (1st VISIT). The pattern disclosed here mirrors that of the right eye. The corneal distortion is very pronounced.
RIGHT EYE ORA. The biomechanical examination reveals low applanation peaks, indicating a "locally more deformable" cornea.
LEFT EYE ORA. The biomechanical examination reveals low applanation peaks, indicating a "locally more deformable" cornea.

Difference maps were performed at each subsequent visit. No evolution has been observed between the first and last visits. The keratoconus is stable, more than 5 months after the patient had definitively stopped rubbing his eyes .
He began a trail with rigid contact lenses to improve his vision.

PENTACAM DIFFERENTIAL MAPS : RIGHT EYE. (between 1st and 2nd VISITS). 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 1st and 2nd visits). As for the right eye, there is no progression of the keratoconic disease.
PENTACAM DIFFERENTIAL MAPS : RIGHT EYE. (between 1st and 3rd VISITS). This difference map demonstrates the absence of keratoconus progression, coincident with the time the patient stopped rubbing his eyes.
PENTACAM DIFFERENTIAL MAPS : LEFT EYE (between 1st and 3rd 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 " result.

In this case, crosslinking was performed, but no significant benefit was observed, as the patient did not receive proper advice on the root cause of keratoconus progression in his case: EYE RUBBING.

On the other hand, crosslinking has not been conclusively proven to be clinically efficient in strengthening the cornea in vivo. No clinical study has ever evidenced any corneal stiffening after CXL in patients with keratoconus. As clearly demonstrated in this case, cessation of eye rubbing is sufficient to arrest the evolution of keratoconus, and surgery (such as crosslinking) is unnecessary. Patient education and making them aware of the importance of the deleterious effects of ocular friction and all other associated factors responsible for ocular friction (sleeping position, allergy, dry eye, prolonged work in front of the computer screen) are the best tools to prevent the occurrence and progression of keratoconus

In our experience, the cessation of eye rubbing is the most important parameter for the control of progression of corneal deformation. In our opinion, keratoconus is not an inherited disease, but the consequence of repeated mechanical trauma. Logically, the cessation of trauma leads to the eradication of the cause of the deformation and thus like many cases on this site, the cessation of eye rubbing arrests the evolution of keratoconus. This website provides many other encouraging examples to support this.