Patient right profile
Case #64
The patient
Bilateral Asymmetric Keratoconus induced by eye rubbing
Identity : Mr G.T
First visit : 04/18/2017
Last Visit : 01/02/2018
34
Age (years)9
Follow-up (months)Mr. G.T is a 34-year-old male 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 since 2006.
His refraction at the first visit at the Rothschild Foundation (on 04/18th/2017) was : Right Eye (RE) 20/32 with -3.0 (-2.5 x 10 °) and Left Eye (LE) 20/20 with -2 (-0.75 x 180 °).
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 rubbing his eyes with his knuckles while at work in front of the computer. His eyes often felt dry then and he explained that the desire to rub the eyes was strongly correlated to the intensity and duration of computer work during his past studying period. In fact, the practice of eye rubbing commenced when he began preparing for his Masters degree and had to spend long hours in front of the computer. (Watch the video below)
The patient sleeps on either side, but he reported that he used to sleep on the desk at work, using his arm as a pillow, supporting the head directly on the eyes and forehead. He also mentioned that when in bed, he would sometimes contort his body such that one of the eyes was constantly rubbing against the pillow. He prefers to put his head on his right arm, applying direct pressure on the right eye, which is systematically in direct contact with the arm. This may explain the asymmetrical nature of the keratoconus, with the right eye being more severely affected than the left. Over time, the patient became more aware of the importance of the role played by eye rubbing and an unhealthy sleeping position on his cornea, and thus modified his habits accordingly.
At subsequent visits, the patient alluded to having allergic rhinitis as well as ocular allergy during childhood, resulting in frequent and intense eye rubbing episodes. He also realized that on the occasions when he was trying to sleep on his back, he would sometimes place his arm over the eyes (i.e. to block any light in the room).
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 his case.
We strongly advised him to continue to avoid rubbing his eyes and to change his unhealthy sleeping position. We also treated his dry eye with artificial tears, and referred him for hybrid contact lens fitting to restore his vision.
To relieve ocular itch, he described how he altered his technique of eye rubbing, by avoiding direct contact and force on the cornea (watch the videos). He also stopped sleeping with the head on his right arm.
This case, together with a compelling list of other cases stresses the importance of avoiding prolonged compression on the eye during sleep, as this has been shown to play a major role in keratoconus genesis and progression (click here for a compilation of striking examples).
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. This gesture is particularly detrimental to the cornea, because the knuckles are the hardest part of the fingers. The pressure applied on the corneas in this manner can be considerable in some cases.
PATIENT DEMONSTRATING HIS SLEEPING POSITION ON HIS RIGHT SIDE WITH THE HEAD ON HIS RIGHT ARM). As the right eye and orbit are in direct contact with the arm, the weight of the head exerts a constant pressure on the cornea. This patient alludes to this sleeping habit in more detail in one of the videos below.Here are videos of the patient sharing his story with us
The patient relating candidly in his own words how studying for his Masters and PhD influenced his sleeping posture, and how he found himself rubbing the eye that he slept on vigorously whenever he spent extended hours working in front of the computer.
The patient describing his history of atopy during childhood with allergic rhinitis and conjunctivitis, which triggered intensive eye rubbing at an early age
The patient alluding to his heightened awareness of the deleterious effects of eye rubbing and how he modified his technique to avoid compression on the cornea
The proposal for hybrid lens fitting for visual rehabilitation.
EXAMINATIONS PERFORMED IN BRAZIL
Here are his follow-up examinations performed in an institution in Brazil, before his first visit to the Rothschild Foundation in Paris.
OPDscan corneal topography DIFFERENCE MAP : Showing progression of the keratoconus on the right eye between 2015 and 2016. At that time, while the patient was being followed at the institution in Brazil, he was not educated on the risks of intensive and persistent eye rubbing.
OPDscan corneal topography DIFFERENCE MAP : Showing no progression of the keratoconus in the left eye. 
RIGHT EYE PENTACAM : The deformation is marked by an inferior steepening associated with a peripheral flattening and marked central thinning. 
LEFT EYE PENTACAM : The deformation is less marked than in the right eye, with an inferior steepening associated with a peripheral flattening and central thinning.
RIGHT EYE : Belin/Ambrósio Enhanced Ectasia display from the Pentacam instrument.This display is commonly used to help to diagnose the earliest forms of keratoconus (subclinical keratoconus, forme fruste keratoconus)
LEFT EYE : Belin/Ambrósio Enhanced Ectasia display from the Pentacam instrument (Oculus, Germany). This display reveals the presence of increased elevation against the best fit surfaces.
RIGHT EYE : Wavefront analysis and Zernike polynomial decomposition of the anterior corneal surface. The increase of higher order aberration such as coma, trefoil, secondary astigmatism and spherical aberration reflects the corneal deformation.
LEFT EYE : Wavefront analysis and Zernike polynomial decomposition. The increase of higher order aberrations reflects the distortion of the corneal surface.EXAMINATIONS PERFORMED IN FRANCE – ROTHSCHILD FOUNDATION – PARIS
Here are the OPD scans, Orbscan quadmaps, Pentcam maps and Ocular Response Analyzer (ORA) results of the first visit.
RIGHT EYE OPDscan map. 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.
LEFT EYE OPD. 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 and "tails" around bright lights and are not correctable with spectacles. The corneal distortion is slightly less pronounced than in the right eye.
RIGHT EYE ORBSCAN (1st VISIT). The corneal distortion is severe and more pronounced than in the left eye. The central thinning is more pronounced, and associated with increased negative asphericity (inferior and central steepness with peripheral flattening) and irregularity.
LEFT EYE ORBSCAN (1st VISIT). The deformation in the left eye is similar to that of the right eye, but less pronounced than that of the right eye. Note the vertical asymmetry (inferior steepening), and the increased negative asphericity of the corneal surface. The cornea is thinned toward a paracentral inferotemporal location.
RIGHT EYE PENTACAM (1st VISIT). As for the Orbscan, the elevation and curvature maps confirm the presence of an advanced keratoconus.
LEFT EYE PENTACAM (1st VISIT). The corneal distortion is slightly less pronounced than that of the right eye.
RIGHT EYE ORA (Ocular Response Analyzer). The height of the peaks is reduced, and the corneal hysteresis (CH) is low. These findings suggest that the corneal biomechanics are impaired.
LEFT EYE ORA (Ocular Response Analyzer). The height of the peaks is reduced, and the corneal hysteresis (CH) is low. These findings show that the corneal biomechanics are impaired (increased local deformation)Difference maps were performed at each subsequent visit. No evolution was observed between the first and last visits. The keratoconus is stable, more than 9 months after the patient definitively stopped rubbing his eyes .
RIGHT EYE ORBSCAN (2nd VISIT). This examination suggests the absence of progression.
LEFT EYE ORBSCAN (2nd VISIT). These maps reveal the stability of the corneal deformation.
PENTACAM DIFFERENTIAL MAPS : RIGHT EYE. (between first and second visits). This difference map demonstrates the absence of keratoconus progression, coincident with the time the patient stopped rubbing his eyes.
PENTACAM DIFFERENTIAL MAPS : LEFT EYE. (between first and second visits). This difference map demonstrates the absence of keratoconus progression, coincident with the time the patient stopped rubbing his eyes.
RIGHT EYE PENTACAM (2nd VISIT). There are no significant changes since the first visit.
LEFT EYE PENTACAM (2nd VISIT). This examination reveals the absence of progression since the first visit.
RIGHT EYE ORBSCAN (3rd VISIT).; This suggests topographic stability since the first visit.
LEFT EYE ORBSCAN (3rd VISIT). As for the right eye, there is topographic stability since the first visit.
RIGHT EYE PENTACAM (3rd VISIT). This exam suggests topographic stability since the first visit.
LEFT EYE PENTACAM (3rd VISIT). There is no evidence of progression since the first visit.
PENTACAM DIFFERENTIAL MAPS : RIGHT EYE. (between first and last examinations performed at the Rothschild Foundation). This difference map demonstrates the absence of keratoconus progression, coincident with the time the patient stopped rubbing his eyes.
PENTACAM DIFFERENTIAL MAPS : LEFT EYE. (between the first and the last examinations performed at the Rothschild Foundation). This difference map demonstrates the absence of keratoconus progression, coincident with the time the patient stopped rubbing his eyes.In this case, we find many triggers for eye rubbing like extended computer work and an unhealthy sleeping position. The asymmetric nature of keratoconus development may be related to the sleeping position (right sided with the head on arm) and the habit of preferentially rubbing the right eye during prolonged usage of the computer. This striking correlation between the severity of keratoconus and the eye which is rubbed more has been described in many other keratoconus patients in this website (see other cases). These cases are very demonstrative of the causal effects of eye rubbing in the pathogenesis of the disease.
In our experience, the progression of keratoconus is also strongly correlated to the persistence of eye rubbing. A progression of keratoconus could be documented in the right eye of this patient when he was first managed in Brazil (refer to the corneal topography difference map between 2015 and 2016). At that time the patient was not informed of the deleterious effects of eye rubbing and not instructed to refrain from rubbing his eyes. Subsequently, after being advised to stop rubbing, keratoconus progression was arrested. Cross-linking was unnecessary in this case, as stabilization of the corneal deformation was achieved with the simple act of cessation of eye rubbing. Similar scenarios have been documented in many other cases in this website.
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 could itself cause a direct deformation of the cornea (by extended pressure, friction or palpebral malposition). It could also cause chronic ocular irritation and contamination by foreign molecules and irritants, 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.
We therefore advise that 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 patients to the dangers of an unhealthy sleeping position and encourage them to modify their habits, so as to prevent through the cessation of eye rubbing, the evolution of keratoconus.
As demonstrated again in this clinical example, the cessation of eye rubbing and patient education are the best tools for the prevention of the genesis and/or evolution of keratoconus.
- Date 7 janvier 2018
- Tags Allergy, Asymmetric, Bilateral keratoconus, Childhood rubbing, Computer screen, Dry eyes, Enjoyed eye rubbing, Eye rubbing, Inferior keratoconus, Knuckles rubbing, Male, Morning rubbing, Night shift, Rigid lens, Sleep position, Work rubbing