Patient right profile
Ms. C.T is a 27-year-old female with no known family history of keratoconus. She complained of a progressive decrease in visual acuity greater in the left eye than the right over the past 2 years. She has a history of allergies from the age of 18, with the development of asthma at age 20.
Keratoconus was diagnosed in another institution in 2015, where she was offered a rigid gas permeable contact lens correction for the right eye and a corneal collagen cross-linking for the left eye.
Her refraction at the first visit at the Rothschild Foundation (on 03/22th/2016) was : Right Eye (RE) 20/25 with -1 (-1 x 170 °) and Left Eye (LE) 20/32 with -1.5 (-1.75 x 165 °).
Clinical examination with the slit lamp suggested thin and irregular corneas with Fleischer rings. (Fleischer rings are pigmented rings in the peripheral cornea, resulting from iron deposition in basal epithelial cells, in the form of hemosiderin). Dry eye was noted with pathological tear break up time of < 8 secs.
Corneal topography performed at our institution showed the presence of bilateral keratoconus, more pronounced in the left eye.
At the first visit, when asked about the possibility of frequent eye rubbing, the patient admitted to enjoying rubbing her eyes when she awoke in the mornings or when working in front of the computer. She complained of dry eye symptoms especially at night. While in front of the computer screen, she would use her left hand to rub her left eye, as the right hand would be on the computer mouse and thus unavailable for rubbing.
She sleeps on her stomach or with the head on her left arm.
At the subsequent visits, she verbalized remembering that her vision started deteriorating 3 years prior, coincident with the time when she began to prepare for her doctorate and thus had to work for long hours at the computer.
We explained to the patient that since vigorous eye 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 her case.
We strongly advised this patient to stop rubbing her eyes and to change her unhealthy sleeping position.
Here are pictures of the patient rubbing her eyes and her profiles
Patient rubbing her eyes
In this case we find many triggers for eye rubbing like extended hours of computer use and an unhealthy sleeping position. The asymmetric nature of keratoconus development may be related to the sleeping position (left sided) and the habit of preferentially rubbing the left eye. .
Most medical text books would attribute keratoconus to an unknown genetic factor. Genetics alone would not explain the unilateral occurrence of keraotconus in many cases, while eye rubbing does very well (unilateral rubbing causes unilateral keratoconus). Genetics however, may account for increased ocular sensitivity, atopy, and reduced corneal resistance to repeated trauma.
This case is very informative and demonstrative of the causal effects of eye rubbing in the pathogenesis of keratoconus. Cross-linking is 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.
Autres cas :
- Date 7 décembre 2017
- Tags Allergy, Asymmetric, Bilateral keratoconus, Computer screen, Dry eyes, Enjoyed eye rubbing, Eye rubbing, Female, Inferior keratoconus, Knuckles rubbing, Night shift, Rigid lens, Sleep position, Work rubbing