Case #51

Case #51

The patient

Patient right profile

Bilateral Keratoconus induced by eye rubbing

Identity : Mr M.T
First visit : 06/28/2016
Last Visit : 03/20/2018

26
Age (years)
21
Follow-up (months)
Eye rubbing: the cause of keratoconus.

Mr. M.T is a 26-year-old male trader with allergy to pollen. He has no known history of keratoconus in his family. He complained of a progressive decrease in visual acuity greater in the right eye than the left eye.

His refraction at the first visit at the Rothschild foundation (on 06/28th/2016) was : Right Eye (RE) 20/25 with -1.75 (-4.75 x 35 °) and Left Eye (LE) 20/60 with -2.5 (-7.25 x 155 °).

Clinical examination with the slit lamp revealed bilateral Vogt’s striae, Fleischer ring and tarsal papillae. 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).

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

We investigated the risks factors for eye rubbing at the first visit. The patient disclosed known allergy to dust mites and pollen. He admitted to rubbing his eyes intensively during his teenage years especially during his many allergic crises, and in the mornings when he awakes.

With regards to his sleeping habit, the patient informed us that he is left-handed and sleeps on his left side.

At the subsequent visits, he recalled rub his eyes sometimes heavily, before his teenage years, during childhood, due again to some allergic episodes. He also became conscious of rubbing his eyes at work, where the environment was dusty, and he had since stopped after his first visit.

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.

We strongly advised this patient to stop the eye rubbing, to change his unhealthy sleep position and to seek the opinion of a doctor specialising in allergies .

Here are pictures of patient rubbing his eyes and profiles

Patient right eye profile.
Patient left eye profile
Patient rubbing his eyes with knuckles
Patient showing his sleep position (on sides)

Here are the Orbscan quadmaps, Pentacam exams, OPD scans 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 (inferior). There is marked central thinning.
LEFT EYE ORBSCAN (1st VISIT). This maps shows an advanced keratoconus similar to the right, with inferior deformation and central thinning.
RIGHT EYE PENTACAM (1st VISIT). This data parallels that of the Orbscan: the deformation of the inferior cornea is pronounced.
LEFT EYE PENTACAM (1st VISIT). The pattern disclosed here mirrors that of the right eye.
RIGHT EYE OPD scan. Note the inferior steepening which creates local myopia.
LEFT EYE OPD scan. Note the inferior steepening which creates local myopia.
RIGHT EYE ORA. The hysteresis is low, and the height of the peaks is reduced. This reveals the presence of weakened corneal biomechanics.
LEFT EYE ORA. The hysteresis is low, and the height of the peaks is reduced. This reveals the presence of weakened corneal biomechanics.

Difference maps were performed at each subsequent visit. No evolution was observed between the first and last visits. The keratoconus is still stable, more than 15 months after the patient had definitively stopped rubbing his eyes.

RIGHT EYE ORBSCAN (2nd VISIT)
LEFT EYE ORBSCAN (2nd VISIT)
RIGHT EYE PENTACAM (2nd VISIT)
LEFT EYE PENTACAM (2nd VISIT)
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 keratoconus disease.
RIGHT EYE ORBSCAN (3rd VISIT)
LEFT EYE ORBSCAN (3rd VISIT)
RIGHT EYE PENTACAM (3rd VISIT)
LEFT EYE PENTACAM (3rd VISIT)
PENTACAM DIFFERENTIAL MAPS : RIGHT EYE. (between 1st and 3rd VISITS). This difference map demonstrates the absence of keratoconus progression, coincident with the moment 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.
RIGHT EYE ORBSCAN (4th VISIT)
LEFT EYE ORBSCAN (4th VISIT)
RIGHT EYE PENTACAM (4th VISIT)
LEFT EYE PENTACAM (4th VISIT)
PENTACAM DIFFERENTIAL MAPS : RIGHT EYE
PENTACAM DIFFERENTIAL MAPS : LEFT EYE

Chronic eye rubbing can reduce the biomechanical resistance of the collagen fibers of the corneal dome and lead to the deformation of the latter. This biomechanical mechanism is more likely to account for the disparity between right and left eye involvement (patients often rub one eye more than the other), and the focal nature of keratoconus, which has recently been evidenced.

In our experience, the cessation of eye rubbing is the most important parameter in the control of the 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 of this.

  • Date 8 octobre 2017
  • Tags Allergy, Bilateral keratoconus, Childhood rubbing, Dry eyes, Enjoyed eye rubbing, Eye rubbing, Fleischer ring, Inferior keratoconus, Knuckles rubbing, Lens removal rubbing, Male, Morning rubbing, Sleep position, Work rubbing

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