Patient right profile
Case #52
The patient
Bilateral late corneal ectasia post myopic LASIK induced by eye rubbing
Identity : Ms N.T
First visit : 09/23/2015
Last Visit : 03/20/2018
50
Age (years)30
Follow-up (months)Ms N.T is a 50-year-old female with no known family history of keratoconus. She complained of a progressive decrease in visual acuity greater in the left than the right eye. She had bilateral lasik performed in 1999 at another institution. Pre-operatively, she had myopia of about -7 D in both eyes. She began grieving after a divorce in 2009, and was crying and rubbing her eyes excessively. The following year, she developed astigmatism which required glasses, and as the astigmatism progressively increased, her ophthalmologist diagnosed post-lasik ectasia. She then consulted us for a second opinion.
Her refraction at the first visit at the Rothschild foundation (on 09/23th/2015) was : Right Eye (RE) 20/20 with -1.50 (-3.25 x 85 °) and Left Eye (LE) 20/25 with -2.5 (-4.25 x 85 °).
Clinical examination with the slit lamp revealed thin and irregular corneas with bilateral Vogt’s striae 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. Vogt 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 corneal ectasia more pronounced in the left eye.
We investigated the risk factors for eye rubbing at her first visit. She told us that she cried a lot after her divorce and that rubbing her eyes gave her a sense of well-being. As for her sleeping habit, the patient slept on her sides, with her head buried in the pillow.
At the subsequent visits, she verbalised rubbing her eyes in the mornings.
We explained to the patient that since vigorous eye 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 the evolution of ectasia in her case.
We strongly advised this patient to stop eye rubbing and to change her unhealthy sleeping position.
Here are pictures of the patient’s eye profile and rubbing technique
Patient profile right
Patient profile left
Patient rubbing her eyes
Patient sleeping position (on her sides)Here are the Orbscan quadmaps, Pentacam exams, and Ocular Response Analyzer (ORA) results from the first visit .
RIGHT EYE ORBSCAN (1st VISIT). The post LASIK ectasia pattern is characterized by the asymmetry (inferior steepening on the axial map, bottom left).
LEFT EYE ORBSCAN (1st VISIT). The post LASIK ectasia pattern is characterized by the asymmetry (inferior steepening on the axial map, bottom left).
RIGHT EYE PENTACAM (1st VISIT). Similar to the Orbscan, note the asymmetric inferior steepening 
LEFT EYE PENTACAM (1st VISIT). Similar to the Orbscan, note the asymmetric inferior steepening 
RIGHT EYE OPD scan. Note the inferior steepening which creates local myopia and irregular astigmatism.
LEFT EYE OPD scan. Note the inferior steepening which create local myopia and irregular astigmatism.Difference maps were performed at each subsequent visit. No evolution has been observed between the first and last visits. The coneal ectasia is stable, more than 24 months after the patient definitively stopped rubbing her eyes .
RIGHT EYE ORBSCAN (2nd VISIT)
LEFT EYE ORBSCAN (2nd VISIT)
RIGHT EYE PENTACAM (2nd VISIT)
LEFT EYE PENTACAM (2nd VISIT)
RIGHT EYE Belin/Ambrosio Index (2nd VISIT)
LEFT EYE Belin/Ambrosio Index (2nd VISIT)
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 2nd and 3rd VISITS). The difference map (third column) demonstrates the absence of aggravation of the LASIK ectasia.
PENTACAM DIFFERENTIAL MAPS : LEFT EYE. (between 2nd and 3rd VISITS). The difference map (third column) demonstrates the absence of aggravation of the LASIK ectasia.
RIGHT EYE ORBSCAN (4th VISIT)
LEFT EYE ORBSCAN (4th VISIT)
ORBSCAN DIFFERENTIAL MAPS : RIGHT EYE
ORBSCAN DIFFERENTIAL MAPS : LEFT EYE
RIGHT EYE PENTACAM (4th VISIT)
LEFT EYE PENTACAM (4th VISIT)
PENTACAM DIFFERENTIAL MAPS : RIGHT EYE.
PENTACAM DIFFERENTIAL MAPS : LEFT EYE.Corneal ectasia post refractive surgery is an exceptional but potentially severe complication. It corresponds to a biomechanical decompensation of the cornea, which loses its regularity and whose central curvature increases. Consequently, ectasia results in the reappearance of an evolutionary myopia and astigmatism. There are several risk factors for post LASIK ectasia. The main risk factor is the presence of an undetected form of sub-clinical keratoconus existing in the unoperated cornea. As with keratoconus, the habit of repeated eye rubbing is also a risk factor, as these frictions have led to the reduction of corneal resistance before surgery, and the cornea is weakened further if rubbing is continue after the operation. Finally, post LASIK ectasia can be observed after LASIK in high myopia, when the corneal flap created is too thick and/or the volume of cornea removed too large. Thanks to the femtosecond laser which is used to create the corneal flap in LASIK today, flap thickness predictability is greatly increased and it is now possible to avoid cutting a flap that is too thick.
In our experience, the cessation of eye rubbing is the most important parameter in the control of progression of corneal deformation. In our opinion, corneal ectasia post refractive surgery, similar to keratoconus, is not an inherited disease, but the consequence of repeated mechanical trauma. Logically, the cessation of inflicted trauma leads to the eradication of the cause of deformation and thus like many cases described in this site, the cessation of eye rubbing arrests the evolution of the corneal ectasia. This website provides many other encouraging examples of this.
- Date 9 octobre 2017
- Tags Cry rubbing, Ectasia, Enjoyed eye rubbing, Eye rubbing, Female, Knuckles rubbing, Lasik, Morning rubbing, Oldest, Sleep position