Case #55

Case #55

The patient

Patient right profile

Unilateral Asymmetric Keratoconus induced by eye rubbing

Identity : Mr P.A
First visit : 11/22/2016
Last Visit : 10/17/2017

Age (years)
Follow-up (months)

Mr. P.A is a 29-year-old male with no previous medical history or family history of keratoconus. He complained of a progressive decrease in visual acuity greater in the right eye than the left for 7 years. He has known allergy to dust mites, and rubbed his eyes frequently during childhood (especially the right eye).

His refraction at the first visit at the Rothschild Foundation (on 11/22th/2016) was : Right Eye (RE) 20/60 with -3.00 (-3.25 x 50 °) and Left Eye (LE) 20/35 with -2.5 (-0.75 x 135 °).

Clinical examination with the slit lamp suggested an irregular inferior corneal bulge in the right eye 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 pressure on the globe).

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

At the first visit, when asked about the possibility of eye rubbing, he admitted to rubbing his eyes incessantly while at work. Since undertaking the job as a computer engineer, he found that he had to rub his eyes more frequently to relieve digital eye strain.  He also gave a history of frequent eye rubbing during childhood due to allergies causing itchy eyes.

He is right handed and sleeps on his right side, with the head buried in the pillow.

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.

We strongly advised this patient to stop rubbing his eyes and to change his unhealthy sleeping position. We also prescribed him eye shields for use while sleeping. 

Here are pictures of patient rubbing his eyes and profiles

Patient right profile
Patient left profile
Patient rubbing his eyes
Offset glasses sign

Here are the Orbscan quadmaps, Pentacam exams, OPD scans and Ocular Response Analyzer (ORA) results of the first visit

RIGHT EYE ORBSCAN (1st VISIT). The corneal deformation is obvious: it is characterized by an irregular central steepening, with slight against the rule astigmatism. The corneal surfaces are hyerprolate.
LEFT EYE ORBSCAN (1st VISIT). Apart from a slight vertical asymmetry, the map of the left eye is unremarkable.
RIGHT EYE PENTACAM (1st VISIT). The topographic features of the Pentacam examination mirror the abnormalities seen on the Orbscan,: central steepening and thinning.
LEFT EYE PENTACAM (1st VISIT). This examination is unremarkable: there is a slight inferior steepening visible on the axial curvature map (top left).
OPD Scan RIGHT EYE. There is an important increase in higher order aberrations, caused by the corneal distortion.
OPD Scan LEFT EYE. The slight inferior steepening causes the corneal navigator (automated classifier) to classify this cornea as a "keratoconus suspect".
RIGHT EYE ORA. The base of the first applanation peak is enlarged and the signal irregular.
LEFT EYE ORA. The height of the peaks is slightly reduced.

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 11 months after the patient definitely 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 PENTACAM (2nd VISIT). The pattern is not significantly different from the first visit at our institution.
LEFT EYE PENTACAM (2nd VISIT). The pattern is not significantly different from the first visit at our institution.
PENTACAM DIFFERENTIAL MAPS : RIGHT EYE. (between 1st and 2nd VISITS). The third column (difference between the two exams obtained at different time points) demonstrates the perfect stability of the corneal deformation. There is no progression of the keratoconus.
PENTACAM DIFFERENTIAL MAPS : LEFT EYE (between 1st and 2nd visits). As for the right eye, there is no progression.

This case reveals that eye rubbing is often triggered by allergies during childhood and long hours spent in front of the computer screen, which causes visual fatigue associated with dry eye (reduced blinking). These sensations are often relieved (transiently) by eye rubbing, which as described by patients, can be pleasurable and relaxing in such circumstances. These repeated and sustained frictions over the long-term are responsible for a permanent warpage of the cornea, culminating in the condition called « keratoconus ». Rubbing with the knuckles is particularly detrimental to the corneas, because the knuckles are the hardest part of the hands.
Since the cessation of rubbing, there has been no aggravation of the keratoconus in this patient.

  • Date 5 novembre 2017
  • Tags Allergy, Asymmetric, Central keratoconus, Childhood rubbing, Computer screen, Eye rubbing, Eye shield, Fleischer ring, Male, Morning rubbing, Offset glasses, Pillow hugging, Sleep position, Work rubbing