Case #61

Case #61

The patient

Patient right profile

Bilateral Asymmetric Keratoconus induced by eye rubbing

Identity : Mr I.N
First visit : 11/15/2016
Last Visit : 03/27/2018

Age (years)
Follow-up (months)

Mr. I.N is a 22-year-old male student with no previous medical history or any known family history of keratoconus. He complained of a progressive decrease in visual acuity greater in the right eye than the left. Although he has no allergies of note, he complained of frequent ocular itch and irritation.

His refraction at the first visit at the Rothschild Foundation (on 11/15th/2016) was : Right Eye (RE) 20/40 with -2.25 (-3.5 x 30 °) and Left Eye (LE) 20/32 with -1.5 (-2.25 x 155 °).

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.

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 frequent eye rubbing, the patient admitted to enjoying rubbing his eyes when he awoke in the mornings or when working in front of the computer. The many hours spent in front of the computer was associated with frequent dry and tired eyes, and eye rubbing induced a sense of relaxation for this patient. 

At the subsequent visits, he conveyed that he started rubbing his eyes at the age of 10.

He is right handed and rubs his right eye more forcefully, with the palm of his hand. He 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 this patient to stop rubbing his eyes and to change his unhealthy sleeping position. We also referred him to a specialist for management of his allergies.

Here are pictures of the patient rubbing his eyes and his profiles

patient rubbing his eyes with the knucklesPATIENT RUBBING HIS EYES WITH HIS KNUCKLES. This way of rubbing is very detrimental to the corneas.
patient sleeping on the right side, with the head buried in the pillowPATIENT DEMONSTRATING HIS SLEEPING POSITION (ON HIS RIGHT SIDE). He uses his bag to show how he positions his head in the pillow.
patient showing hand palm eye rubbingPATIENT RUBBING HIS EYES WITH HIS PALMS. This maneuver is often performed by patient who seek for relaxation, and/or to relieve eyestrain.

Here are the Pentacam maps, OPD scans and Ocular Response Analyzer (ORA) results of the first visit .

pentacam map of an advance keratoconusRIGHT EYE PENTACAM (1st VISIT). The deformation of the cornea is characterized by vertical asymmetry and increased prolateness. There is a marked thinning centrally (pachymetry map: bottom left).
pentacam map of a left eye, advanced keratoconusLEFT EYE PENTACAM (1st VISIT). The deformation in the left eye is similar to that of the right eye (vertical asymmetry), although slightly less pronounced than that of the right eye.
OPDscan map of the right eyeRIGHT EYE OPD. The vertical asymmetry at the corneal plane results in the induction of vertical coma. This higher order aberration cannot be corrected by spectacles. It can induce the perception of ghost images.
OPDscan map, left eye with keratoconusLEFT EYE OPD. The vertical coma and coma-like aberrations are the predominant higher order aberrations. These aberrations are induced by the deformation of the cornea. They can cause visual disturbances such as ghost images, "tails" around bright lights, which cannot get corrected by spectacles.
ocular response analyzer map of a keratoconus eyeRIGHT EYE ORA. The height of the peaks is reduced, and the corneal hysteresis (CH) is low. These findings show that the corneal biomechanics are impaired.
corneal biomechanics impaired on a ocular response analyzer instrumentLEFT EYE ORA. The height of the peaks is markedly reduced. The value of the corneal hysteresis (CH) is slightly reduced as well. As for the right eye, the corneal biomechanics are severely affected.

Difference maps were performed at each subsequent visit. No evolution was observed between the first and last visits. The keratoconus is stable, more than 16 months after the patient definitively stopped rubbing his eyes .

RIGHT EYE PENTACAM (2nd VISIT). Stable since first visit.
LEFT EYE PENTACAM (2nd VISIT). Stable since first visit.
difference map of the Pentacam instrument, keratoconusPENTACAM DIFFERENTIAL MAPS : RIGHT EYE. (between first and second visits). This difference map demonstrates the absence of keratoconus progression, after the patient has stopped to rub his eyes.
Difference map, left eye, absence of progression of keratoconusPENTACAM DIFFERENTIAL MAPS : LEFT EYE. (between first and second visits). This difference map demonstrates the absence of keratoconus progression, as for the right eye.

In this case we find many triggers for eye rubbing like extended hours of work on the computer, unhealthy sleeping position and allergy during childhood.  The asymmetric nature of keratoconus development may be related to the sleeping position (right sided) and the more forceful and preferential rubbing of the right eye with the dominant hand (right handed).

This is a classic example of bilateral keratoconus induced by eye rubbing. Eye rubbing preceded the onset of the corneal deformation by several years. Cessation of eye rubbing resulted in the stabilization of the deformation (no keratoconus progression). The patient can next be fitted with rigid gas permeable contact lenses to restore vision.

This case also illustrates the importance of patient education.  Teenagers with allergies and allergic tendencies should be counselled with regards the deleterious effects of eye rubbing before they inflict permanent damage on their corneas. 

  • Date 9 décembre 2017
  • Tags Allergy, Asymmetric, Bilateral keratoconus, Childhood rubbing, Computer screen, Dry eyes, Enjoyed eye rubbing, Eye rubbing, Male, Morning rubbing, Sleep position, Work rubbing