Patient sleeping position
Case #53
The patient
Bilateral Asymmetric Keratoconus induced by eye rubbing
Identity : Mr M.B
First visit : 03/31/2015
Last Visit : 10/17/2017
29
Age (years)31
Follow-up (months)Mr. M.B is a 29-year-old male with no previous medical history or any known keratoconus in the family. He complained of a progressive decrease in visual acuity more pronounced in the right eye than the left.
His refraction at the first visit at the Rothschild Foundation (on 03/31th/2015) was : Right Eye (RE) 20/20 with -0.25 (-0.50 x 80 °) and Left Eye (LE) 20/20 with +0.25 (-0.75 x 135 °).
Clinical examination with the slit lamp revealed thin and irregular corneas with 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 gentle pressure on the globe).
Corneal topography performed at our institution confirmed the presence of bilateral keratoconus.
We investigated the risks factors for eye rubbing a the first visit. This patient disclosed known allergy to dust mites. The patient is left handed, and sleeps on his right side, with the head buried in the pillow or head pressed against his arm
When asked about the possibility of frequent eye rubbing, the patient admitted to rubbing his eyes when he awakes (because of blurry vision), and in the evenings after work. He verbalized that eye rubbing gave him a feeling of well-being.
On subsequent visits, he also confessed to rubbing his eyes heavily when he was child during the allergic episodes which he experienced then. He often had itchy eyes upon awakening, and was prone to rub his eyes vigorously in the mornings. He first noticed problems with his vision in the form of small « light tails » around bright lights at night when he was 17. His first occupation, when he turned 18, involved working night shifts and he described how his vision gradually deteriorated from then onwards.
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 in his case. The patient agreed with this theory as it could explain well the onset and progression of keratoconus in his case. He was concerned about his previous consultation at another hospital, where he was informed that he had a genetic ophthalmic disease, and was not given any information about the causal link between his eye rubbing habits and the generation of keratoconus. .
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 RIGHT EYE WITH THE KNUCKLES
PATIENT RUBBING HIS RIGHT EYE WITH THE PULP OF HIS FINGER
PATIENT MIMICKING HIS SLEEPING POSITION ON THE SIDE
PATIENT SLEEPING POSITION ON THE FOREARM, LEADING TO EYE COMPRESSIONHere are the Orbscan quadmaps, Pentacam exams, OPD scans and Ocular ResPonse Analyzer (ORA) results of the first visit .
RIGHT EYE ORBSCAN (1st VISIT). Note the vertical asymmetry (inferior steepening), and the increased negative asphericity of the corneal surface.
LEFT EYE ORBSCAN (1st VISIT). The topographic pattern is similar to that of the right eye.
RIGHT EYE PENTACAM (1st VISIT). The topograph reveals the presence of vertical asymmetry and central thinning.
LEFT EYE PENTACAM (1st VISIT). The pattern is similar to the right eye, with inferior marked asymmetry.
RIGHT EYE OPD. The wavefront examination reveals an increase in coma-like aberration. These aberrations explain the perception of light tails around night lights, in an inferior and oblique direction.
LEFT EYE OPD. The wavefront analysis mirrors that of the right eye. Coma-like aberrations are increased and explain the visual disturbances in the patient.
RIGHT EYE ORA. The height of the applanation peaks is slightly reduced.
LEFT EYE ORA. The height of the applanation peaks is reduced; and their base enlarged.Difference maps were performed at each subsequent visit. No evolution was observed between the first and last visits. The keratoconus is stable, more than 31 months after the patient definitively stopped rubbing his eyes .
RIGHT EYE ORBSCAN (2nd VISIT). The pattern is not significantly different from the first visit at our institution.
LEFT EYE ORBSCAN (2nd VISIT). The pattern is not significantly different from the first visit at our institution.
RIGHT EYE ORBSCAN (3rd VISIT). The pattern is not significantly different from the first visit at our institution.
LEFT EYE ORBSCAN (3rd VISIT). The pattern is not significantly different from the first visit at our institution.
RIGHT EYE ORBSCAN (4th VISIT). The map shows no significant changes since the first visit at our institution.
LEFT EYE ORBSCAN (4th VISIT). The pattern is not significantly different from the first visit at our institution.
RIGHT EYE ORBSCAN (5th VISIT). The pattern is not significantly different from the first visit at our institution.
LEFT EYE ORBSCAN (5th VISIT). The pattern is not significantly different from the first visit at our institution.
RIGHT EYE ORBSCAN (6th VISIT). The pattern is not significantly different from the first visit at our institution.
LEFT EYE ORBSCAN (6th VISIT). The pattern is not significantly different from the first visit at our institution.
RIGHT EYE PENTACAM (5th VISIT)
LEFT EYE PENTACAM (5th VISIT)
RIGHT EYE PENTACAM (6th VISIT)
LEFT EYE PENTACAM (6th VISIT)
PENTACAM DIFFERENTIAL MAPS : RIGHT EYE. (between 3rd and 4th VISITS). This difference map demonstrates the stability of the corneal deformation
PENTACAM DIFFERENTIAL MAPS : LEFT EYE. (between 3rd and 4th VISITS). This difference map demonstrates the stability of the corneal deformation
PENTACAM DIFFERENTIAL MAPS : RIGHT EYE. (between 4th and 5th VISITS). This difference map demonstrates the stability of the corneal deformation.
PENTACAM DIFFERENTIAL MAPS : RIGHT EYE. (between 4th and 5th VISITS). This difference map demonstrates the stability of the corneal deformation.
PENTACAM DIFFERENTIAL MAPS : RIGHT EYE. (between 3rd and 6th VISITS). This difference map demonstrates the stability of the corneal deformation after the cessation of eye rubbing.
PENTACAM DIFFERENTIAL MAPS : LEFT EYE. (between 3rd and 6th VISITS). This maps clearly demonstrates the absence of progression of the corneal deformation.This case is typical of focal corneal deformation induced by chronic eye rubbing that started in childhood. Very often, like many other cases on this site, the eye rubbing begins in childhood and is very often related to allergy. During childhood, the cornea is more deformable and the friction applied is often more intense. Patients will usually notice a decline in vision 3 years after the onset of intense rubbing.
Following treatment of the allergy and cessation of eye rubbing, the keratoconus in this case ceased to evolve.
Chronic eye rubbing reduces the biomechanical resistance of the collagen fibers of the corneal dome and lead to corneal deformation. 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. Also, allergy must be detected and treated aggressively.
The key in the fight against keratoconus is prevention by educating patients, parents and children about the dangers of eye rubbing.
- Date 22 octobre 2017
- Tags Allergy, Asymmetric, Bilateral keratoconus, Childhood rubbing, Dry eyes, Inferior keratoconus, Male, Morning rubbing, Night shift, Sleep position