Patient rubbing his left eye
Mr. B.I is a 47-year-old male with no previous medical history or any known family history of keratoconus (He has a brother without KC). He complained of a progressive decrease in visual acuity greater in the left eye than the right. He is a movie critic and his job entails working long hours in front of the computer watching movies.
His refraction at the first visit at the Rothschild Foundation (on 11/27th/2017) was : Right Eye (RE) 20/20 with -0.75 (-2.5 x 85 °) and Left Eye (LE) 20/80 with -7.25 (-3 x 150 °).
Clinical examination with the slit lamp suggested a thin and irregular left 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 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 claimed that he was unaware of any eye rubbing habits. When asked about his sleeping posture, the patient alluded to sleeping on his left side or stomach, with the head buried in the pillow (pillow hugging).
We advised this patient to be conscious of any eye rubbing habits, and instructed him to prime his family members and colleagues to keep a watch for such episodes. We also strongly encouraged him to change his unhealthy sleeping position and prescribed him an eye shield to be worn over his left eye at night.
At the one month visit, the patient informed us that he was indeed rubbing his eyes very often, in particular in the mornings after awaking. He is right-handed but would mostly rub his left eye with his left hand, either with the knuckles or finger pulps. He also described that he was often using his left thumb and forefingers as a claw to rub both eyes, after removing his spectacle with his right hand. He also revealed that his family members have noticed that he has been rubbing his eyes intensely and frequently for many years!
This realization convinced the patient of the responsibility of eye rubbing in the genesis of keratoconus in his case. He ceased to rub his eyes with immediate effect. However, he had problems using the eye shield on his left eye at night, as he would often awake from the discomfort of the compression of the eye shield on his orbit. We encouraged him to continue wearing the eye shield, and explained to him that the compression on the bones surrounding the orbit was less problematic than the soft tissue compression of his left eye by pillow hugging, as this would lead to irritation and contamination, and more eye rubbing upon awakening.
Here are pictures of the patient rubbing his eyes and demonstrating his sleeping posture
The patient’s testimony caught on video : He realized that he was rubbing his eyes particularly when he was fatigued, and is now consciously trying to avoid the habit.
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 (left sided) and the habit of preferentially rubbing the left eye. We also noticed that when the patient rubs both eyes with the thumb on one side and the index on the other, the eye rubbed with the thumb (the left one in this case) is the most deformed.
At the first visit, the patient was not conscious of his rubbing habit. He could have been wrongly considered as a « non eye-rubber » if we had not given him proper information and asked him to come back a month later for a second review.
This case is very informative and demonstrative of the causal effects of eye rubbing in the pathogenesis of keratoconus. Cross-linking was unnecessary in this case, as the stabilization of the corneal deformation was achieved with the simple act of cessation of eye rubbing, and the protection of the left eye at night.
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.
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- Date 14 janvier 2018
- Tags Asymmetric, Computer screen, Enjoyed eye rubbing, Eye rubbing, Eye shield, Inferior keratoconus, Male, Offset glasses, Palm rubbing, Pillow hugging, Sleep position, Unilateral keratoconus, Work rubbing