Patient right profile
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
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.
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.
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.
Autres cas :
- 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