Patient right profile
Case #58
The patient
Unilateral Asymmetric Keratoconus induced by eye rubbing
Identity : Mr E.N
First visit : 10/13/2015
Last Visit : 11/17/2017
32
Age (years)25
Follow-up (months)Mr. E.N is a 32-year-old male who complained of a progressive decrease in visual acuity greater in the right eye than the left. He has two brothers, one with keratoconus and one without. According to the patient, the brother with keratoconus is a frequent eye rubber, while the brother without keratoconus does not rub his eyes.
The patient’s refraction at the first visit at the Rothschild Foundation (on 10/13th/2015) was : Right Eye (RE) 20/32 with -0.5 (-4 x 70 °) and Left Eye (LE) 20/20 with -1 (-0.5 x 175 °).
Clinical examination with the slit lamp suggested a thin and irregular right cornea with a Fleischer ring. Fleischer rings are pigmented rings in the peripheral cornea, resulting from iron deposition in basal epithelial cells, in the form of hemosiderin.
Corneal topography performed showed the presence of a unilateral keratoconus in the right 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 morning. He also admitted to frequent eye rubbing during childhood.
He is right handed and rubs his eyes with his right hand. His technique of eye rubbing is demonstrated in the video below, with the thumb rubbing the right eye and the index finger rubbing the left eye.
The patient sleeps on his right 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 him 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 RIGHT PROFILE
PATIENT LEFT PROFILE
PATIENT RUBBING HIS EYES WITH HIS KNUCKLES. The patient declares that he rubs more often and more vigorously his right eye, which feel constantly more itchy than his left one.
PATIENT DEMONSTRATING HIS SLEEPING POSITION (ON HIS RIGHT SIDE). This sleeping position may play a key role in the keratoconus genesis. Chronic nighttime ocular compression and irritation may result in chronic inflammation and itch.Here are the Orbscan quadmaps with SCORE Analyzer, OPD scans, OQAS HD Analyzer, Ocular Response Analyzer (ORA) and OCT VISANTE results of the first visit .
RIGHT EYE ORBSCAN (1st VISIT). The keratoconus is located inferiorly on the curvature map. Note the increased prolateness (negative asphericity) and toricity (astigmatism) of the anterior (top right) and posterior (top left) corneal surfaces (marked ridge- island pattern). On the curvature map (bottom left), irregular astigmatism is characterized by a marked inferior steepening . The thickness map (bottom right) shows central thinning with slight vertical displacement of the thinnest point.
LEFT EYE ORBSCAN (1st VISIT). At first glance, this map looks normal. However, the prolateness (negative asphericity) is slightly increased, and the corneal thinning appears slightly accentuated centrally.
RIGHT EYE SCORE RESULT. The SCORE is a composite index, which incorporates several parameters and quantifies the degree of corneal deformation and thinning. In this case, the SCORE is strongly positive, indicating the presence of significant corneal deformation and keratoconus
LEFT EYE SCORE RESULT. The score is at zero (which indicates the possibility of a very early keratoconus) from an increased pachymetry thinning rate and thin cornea. 
RIGHT EYE OPD. The corneal deformation induces a marked elevation of high order aberration (coma, trefoil).
LEFT EYE OPD. This examination shows moderate amounts of irregular astigmatism. The automated diagnosis based on anterior corneal topography is negative for keratoconus.
RIGHT EYE ORA. The corneal hysteresis is low, and the height of the applanation peaks is reduced.
LEFT 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.
RIGHT EYE OCT. This Optical Coherence Tomography cross sectional representation reveals a central steepening and peripheral flattening (increased prolateness). Repeated trauma (rubbing) has caused these flexural changes in the cornea
LEFT EYE OCT. In comparison to the right eye, this cross sectional representation of the left cornea discloses a more regular curvature.Difference maps were performed at each subsequent visit. No evolution was observed between the first and last visits. The keratoconus is stable, more than 25 months after the patient 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 ORBSCAN (4th VISIT). Stable since first visit. 
LEFT EYE ORBSCAN (4th VISIT). Stable since first visit. 
RIGHT EYE ORBSCAN (5th VISIT). Stable since first visit. 
LEFT EYE ORBSCAN (5th VISIT). Stable since first visit. 
RIGHT EYE ORBSCAN (6th VISIT). Stable since first visit. 
LEFT EYE ORBSCAN (6th VISIT). Stable since first visit. 
RIGHT EYE ORBSCAN (7th VISIT). Stable since first visit. 
LEFT EYE ORBSCAN (7th VISIT). Stable since first visit. 
RIGHT EYE PENTACAM (7th VISIT)
LEFT EYE PENTACAM (7th VISIT)
PENTACAM DIFFERENTIAL MAPS : RIGHE EYE. This difference map demonstrates the absence of keratoconus progression, coincident with the time the patient stopped rubbing his eyes.
PENTACAM DIFFERENTIAL MAPS : LEFT EYE. This difference map demonstrates the absence of keratoconus progression, coincident with the time the patient stopped rubbing his eyes.
PENTACAM DIFFERENTIAL MAPS : RIGHE EYE. This difference map demonstrates the absence of keratoconus progression, coincident with the time the patient stopped rubbing his eyes.
PENTACAM DIFFERENTIAL MAPS : LEFT EYE. This difference map demonstrates the absence of topographic change, expected as the patient has stopped rubbing his eyes.In this case we find many triggers for eye rubbing like allergy during childhood and unhealthy sleeping position. The unilateral or asymmetric nature of keratoconus development is related to the sleeping position (right sided) and the habit of preferentially rubbing the right eye, especially with the thumb (the force applied is higher).
Many cases presented on this site show that the genesis of keratoconus often begins during childhood, at the time when allergy commences, and this is the dominant factor responsible for inciting eye rubbing .
It is critical to identify children who rub their eyes, because by doing so the occurrence of keratoconus can be prevented. Once keratoconus develops, the deformation is permanent, and the cessation of eye rubbing can only prevent the evolution.
This case is very informative and demonstrative of the causal effects of eye rubbing on the pathogenesis of keratoconus. Cross-linking was unnecessary in this case, as stabilisation of the corneal deformation was achieved with the simple act of cessation of eye rubbing.
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 keratoconus.
- Date 3 décembre 2017
- Tags Asymmetric, Childhood rubbing, Enjoyed eye rubbing, Inferior keratoconus, Male, Morning rubbing, Sleep position, Unilateral keratoconus