Patient right profile
Case #56
The patient
Bilateral Asymmetric Keratoconus induced by eye rubbing
Identity : Mr B.E
First visit : 05/30/2017
Last Visit : 10/17/2017
25
Age (years)5
Follow-up (months)Mr. B.E is a 25-year-old male with no family history of keratoconus. He gave a birth history of prematurity but with no consequent medical or surgical issues. He consulted us because of a progressive decrease in visual acuity greater in the left eye than the right, and frequent redness of the left eye.
His refraction at the first visit at the Rothschild Foundation (on 05/30th/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)). We also found superficial punctate keratopathy in the inferior cornea of the left eye.
Corneal topography performed at our institution showed the presence of bilateral keratoconus more pronounced in the left eye.
When asked about the possibility of frequent eye rubbing, the patient admitted to rubbing his eyes while watching television, as it gives him a sense of well-being. He has no known allergis. He sleeps on his left side with his head on the arm. He often awakes with bilateral eye redness, left eye more than the right.
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 him to stop rubbing his eyes and to change his unhealthy sleeping position. We also prescribed him an eye shield for the left eye for use during sleep. We treated his dry eyes with artificial tears and vitamin A ointment at night.
Here are pictures of the patient rubbing his eyes and his profiles
Patient right profile
Patient left profile. Note the position of the eyelashes (pointing downwards due to chronic eye rubbing)
Patient sleeping position (on left side)
Note the conjunctival hyperaemia in the left eyeHere are the Orbscan quadmaps, Pentacam exams, OPD scans and Ocular Response Analyzer (ORA) results of the first visit .
RIGHT EYE ORBSCAN (1st VISIT). The cornea exhibits severe distortion: there is a marked increase in negative asphericity, and inferior steepening. The cornea is thinned centrally (bottom left).
LEFT EYE ORBSCAN (1st VISIT). The corneal distortion is severe and more pronounced than in the right eye. The central thinning is very pronounced, and associated with increased negative asphericity (central steepness and peripheral flattening) and irregularity.
RIGHT EYE PENTACAM (1st VISIT). The Pentacam examination confirms the presence of marked central thinning associated with a parallel deformation of both the anterior and posterior surfaces of the cornea.
LEFT EYE PENTACAM (1st VISIT). The corneal severe deformation is obvious, with marked irregularity and thinning.
RIGHT EYE OPD. The corneal distortion results in an increased of wavefront higher order aberrations, dominated by coma-like Zernike modes.
LEFT EYE OPD. There is a significant increase in higher order aberrations, caused by the corneal distortion. Note local inferior high myopia due to the inferior steepening
RIGHT EYE ORA. The hysteresis value is low, and the height of the aplanation peaks is reduced: this is the consequence of altered biomechanics of the cornea consecutive to repeated rubbing.
LEFT EYE ORA. The height of the peaks is dramatically reduced, and the hysteresis value is low.Difference maps were performed at each subsequent visit. No evolution was observed between the first and last visits. The keratoconus is stable, more than 5 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. (Unfortunately this is a poor quality examination due to the high astigmatism)
RIGHT EYE PENTACAM (2nd 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.
PENTACAM DIFFERENTIAL MAPS : RIGHT EYE. (between 1st and 2nd VISITS). This examination objectively demonstrates the non progression of the corneal deformation, coincident with the cessation of eye rubbing.
PENTACAM DIFFERENTIAL MAPS : LEFT EYE (between 1st and 2nd visits). This examination objectively demonstrates the non-progression of the corneal deformation, coincident with the cessation of eye rubbing.
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 examination objectively demonstrates the non-progression of the corneal deformation, coincident with the cessation of eye rubbing.
PENTACAM DIFFERENTIAL MAPS : LEFT EYE (between 1st and 3rd VISITS). The third column (difference map) does not show any significant change: the corneal deformation remains severe, but unchanged, due to the cessation of eye rubbing.It is of paramount importance to determine the triggers for eye rubbing in every case. In this case it was severe dry eye inducing ocular surface changes with inferior punctate keratopathy. Treatment of the ocular surface with copious lubricants addresses the ocular discomfort and the need to rub the eyes. This, together with sensitization of the patient to the deleterious effects of eye rubbing, and the actual act of cessation of rubbing was enough to arrest the progression of keratoconus in his case.
This case also reveals the relevance of the sleeping posture in the genesis and evolution of keratoconus.
Indeed, some sleep positions are more detrimental to the cornea(s) than others. The association between such sleeping positions with keratoconus (on the eye that is compressed) is striking and often underestimated. An unhealthy sleeping posture can itself cause a direct deformation of the cornea (by pressure, friction or palpebral malposition during night time). It could also cause eye irritation, inducing itch and hence the need for rubbing in the mornings. In the long term, weakening of corneal biomechanics leads to corneal thinning and curvature changes, culminating in the picture of keratoconus.
At the time of diagnosis, every patient with known or suspected keratoconus should be questioned about his sleeping habits and postures. It is important to sensitize the patient to the dangers of an unhealthy sleeping position, to modify his habits, so as to prevent through the cessation of eye rubbing, the evolution of keratoconus.
- Date 5 novembre 2017
- Tags Asymmetric, Bilateral keratoconus, Dry eyes, Enjoyed eye rubbing, Eye rubbing, Eye shield, Fleischer ring, Male, Sleep position, Vogt's striae