Patient left profile
Case #57
The patient
Unilateral Asymmetric Keratoconus induced by eye rubbing
Identity : Mr I.O
First visit : 04/11/2014
Last Visit : 05/29/2018
41
Age (years)49
Follow-up (months)Mr. I.O is a 41-year-old male with eczema, and no known family history of keratoconus. He complained of a progressive decrease in visual acuity greater in the left eye than the right. Keratoconus was diagnosed at another institution in 2014.
His refraction at the first visit at the Rothschild foundation (on 04/11th/2014) was : Right Eye (RE) 20/20 with -1 (-0.75 x 75 °) and Left Eye (LE) 20/20 with -0.75 (-2.5 x 135 °).
Clinical examination with the slit lamp suggested a thin and irregular left cornea.
Corneal topography performed showed the presence of a unilateral keratoconus in the left eye
At the first visit, when asked about the possibility of frequent eye rubbing, the patient admitted to rubbing his eyes when he awoke in the mornings or when working in front of the computer because he enjoyed it.
At the subsequent visits, he verbalized remembering rubbing his eyes frequently during childhood, especially the left eye because of itch from eczema and allergic conjunctivitis (see left profile picture).
The patient is right handed but rubs his left eye with his left hand. He sleeps on his left side, with the head buried in the pillow (pillow hugging)
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.
Here are pictures of the patient rubbing his eyes and his profiles
PATIENT LEFT PROFILE. Note the periorbital eczema
PATIENT RIGHT PROFILE. The periorbital skin is healthy here with no eczema
PATIENT RUBBING HIS EYES WITH HIS KNUCKLES
PATIENT DEMONSTRATING HIS SLEEPING POSITION (LEFT SIDE)Here is a video of the patient rubbing his eyes
Here are the Orbscan quadmaps with SCORE Analyser results, Pentacams maps, OPD scans, Ocular Response Analyzer (ORA) results and OCT VISANTE of the first visit .
RIGHT EYE ORBSCAN (1st VISIT). The cornea is thin, and the posterior float is increased (top right) but no major deformation evocative of keratoconus is perceptible. This indicates a possible forme fruste keratoconus.
LEFT EYE ORBSCAN (1st VISIT). This examination shows severe deformation with inferior steepening, evocative of frank keratoconus.
RIGHT EYE SCORE ANALYZER. The SCORE is a composite index, which includes several parameters and allows us to quantify the degree of corneal deformation and thinning The SCORE here is mildly positive at 0.1 indicating the possibility of very early keratoconus.
LEFT EYE SCORE ANALYZER. Here the SCORE is highly positive, which suggests a keratoconus
RIGHT EYE PENTACAM (1st VISIT). The Pentacam map is unremarkable.
LEFT EYE PENTACAM (1st VISIT). This examination confirms the Orbscan data; the cornea is thinned centrally, and shows excessive inferior prolateness.
RIGHT EYE OPDscan. The topographic and aberrometric investigation reveals a slight elevation of higher order aberrations. The corneal navigator, which provides automated diagnosis based on the corneal topography, indicates the possibility of a keratoconus suspect form (KCS).
LEFT EYE OPDscan. There is marked elevation of the coma-like aberration, secondary to the severe corneal distortion.
RIGHT EYE ORA. The hysteresis and the peak heights are slightly less than average. This might imply a slight weakening or mild deformation caused by chronic rubbing.
LEFT EYE ORA. The corneal hysteresis is very low, and the height of the applanation peaks is dramatically reduced.
RIGHT EYE OCT VISANTE AND EPITHELIAL MAP. The epithelium is thinner in the vicinity of the corneal apex.
LEFT EYE OCT WITH EPITHELIAL MAP. There is a marked reduction of the epithelial thickness near the apex of the corneal deformationDifference maps have been performed at each subsequent visit. No evolution has been observed between the first and last visits. The keratoconus is stable, more than 43 months after the patient had definitively stopped rubbing his eyes .
RIGHT EYE ORBSCAN (2nd VISIT). Stable since first visit.
LEFT EYE ORBSCAN (2nd VISIT). Stable since first visit.
RIGHT EYE ORBSCAN (3rd VISIT). Stable since first visit.
LEFT EYE ORBSCAN (3rd VISIT). Stable since first visit.
RIGHT EYE PENTACAM (3rd VISIT). Stable since first visit.
LEFT EYE PENTACAM (3rd VISIT). Stable since first visit.
PENTACAM DIFFERENTIAL MAPS : RIGHT EYE (between 2014 to 2017). 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 2014 to 2017). This difference map is unremarkable; there is no significant change between the two consecutive examinations; the corneal deformation did not progress, thanks to the cessation of the cause of the deformation; eye rubbing.
PENTACAM DIFFERENTIAL MAPS : RIGHT EYE (between 2014 to 2018). 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 2014 to 2018). This difference map is unremarkable; there is no significant change between the two consecutive examinations; the corneal deformation did not progress.In this case we find many triggers for eye rubbing like allergy, unhealthy sleeping position and eczema more marked on the left side. The unilateral or asymmetric nature of keratoconus development may be related to the sleeping position (left sided) and the habit of preferentially rubbing the left eye because of his eczema.
The contralateral eye shows a forme fruste keratoconus. The patient admitted to rubbing both eyes, but the left eye more aggressively (because of the itch caused by eczema). His right cornea has an early form of keratoconus because the rubbing is less frequent and vigorous in this eye. This reinforces the hypothesis that eye rubbing, which preceded the onset of keratoconus in this case, is the root cause of it.
From our clinical experience, we notice the existence of families of » eye rubbers » with keratoconus. Given the environmental and genetic heritage of atopy and thin corneas, there can be many within the same family (parents-children, brothers or sisters) who tend to rub their eyes. Depending on the habits of each individual, and the intensity and duration of eye rubbing, the appearance and evolution of keratoconus can be variable.
This case is very informative and is demonstrative of the causal effects of eye rubbing in the pathogenesis of keratoconus.
As demonstrated again in this clinical example, the cessation of eye rubbing and patient education are the best tools in the prevention of the genesis and/or evolution of the disease.
- Date 3 décembre 2017
- Tags Allergy, Asymmetric, Childhood rubbing, Eczema, Eye rubbing, Knuckles rubbing, Male, Morning rubbing, Sleep position, Unilateral keratoconus, Work rubbing