Patient rubbing his left eye
Case #65
The patient
Unilateral Asymmetric Keratoconus induced by eye rubbing
Identity : Mr B.I
First visit : 03/07/2017
Last Visit : 11/27/2017
47
Age (years)8
Follow-up (months)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
At the second visit, the patient spontaneously demonstrated how he rubbed his eyes: using the left hand on the left eye, in grinding movements exerted directly on the eyeball through the eyelids.
Patient showing us at the second visit how he rubbed his eyes with the left hand forming a "claw", placing his thumb on the left eye and his index finger on the right. He would first remove his spectacles with his right hand (he is right handed), before rubbing with his left. He revealed that he was exerting a stronger pressure with the thumb than the index finger. 
The patient demonstrating his favourite sleeping position : on the stomach or left side, with the head turned so that the left eye is buried against the left hand or pillow.
Patient showing another sleeping position: when he sleeps on the stomach, he would put the pillow on his face such that the left eye is in direct contact with the pillow.
Offset glasses sign :
the temple on the left side is shifted; it is an indirect sign that shows the asymmetry of eye rubbing in patients who rub their eye while still wearing spectaclesThe 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.
Here are the Orbscan quadmaps, OPD scans, Ocular Response Analyzer (ORA) results and OCT epithelial maps of the first visit.
RIGHT EYE ORBSCAN (1st VISIT). The topographic pattern is evocative of mild keratoconus: increased negative asphericity, irregular and inferior steepening, central thinning.
LEFT EYE ORBSCAN (1st VISIT). The topographic pattern is evocative of advanced keratoconus: increased negative asphericity, irregular and marked inferior steepening and central thinning.
RIGHT EYE OPD. Topographic and aberrometric examinatin of the right eye reveals an increase in higher order aberrations. These are caused by the corneal irregularity.
LEFT EYE OPDscan map: the higher order wavefront aberrations are increased by the major corneal deformation. Coma-like aberration are markedly elevated, and explain the visual degradation which cannot be fully corrected by spectacles.
RIGHT EYE ORA. The height of the applanation peaks is slightly reduced, and the hysteresis value is low.
LEFT EYE ORA. The height of the peaks is markedly reduced, showing an increased tissue deformability
RIGHT EYE : EPITHELIAL MAPPING The epithelium is thicker in the paracentral nasal area
LEFT EYE : EPITHELIAL MAPPING, showing a marked epithelial thinning towards the corneal apical zone, surrounded by an annular zone of thickeningDifference maps were performed at each subsequent visit. No evolution has been observed between the first and last visits. The keratoconus is stable, more than 8 months after the patient definitively stopped rubbing his eyes .
RIGHT EYE ORBSCAN (2nd VISIT). Stable since first visit.
LEFT EYE ORBSCAN (2nd VISIT). Stable since first visit.
RIGHT EYE PENTACAM (2nd VISIT). Stable since first visit.
LEFT EYE PENTACAM (2nd VISIT). Stable since first visit.
PENTACAM DIFFERENTIAL MAPS : RIGHT EYE. (between 1st and 2nd visits). This difference map demonstrates the absence of KC progression, coincident with the time the patient stopped rubbing his eyes.
PENTACAM DIFFERENTIAL MAPS : LEFT EYE. (between 1st and 2nd visits). This difference map demonstrates the absence of KC progression, coincident with the time the patient stopped rubbing his eyes.
RIGHT EYE ORBSCAN (3rd VISIT). Stable since first visit.
LEFT EYE ORBSCAN (3rd VISIT). Stable since first visit.
RIGHT EYE PENTACAM (3rd VISIT). Stable since first visit.
LEFT EYE PENTACAM (3rd VISIT). Stable since first visit.
PENTACAM DIFFERENTIAL MAPS : RIGHT EYE. (between 1st and 3rd visits). This difference map demonstrates the absence of KC progression, coincident with the time the patient stopped rubbing his eyes.
PENTACAM DIFFERENTIAL MAPS : LEFT EYE. (between 1st and 3rd visits). This difference map demonstrates the absence of KC progression, coincident with the time the patient stopped rubbing his eyes. A slight central flattening is even perceptible. It could correspond to some artefact, or be the consequence of some epithelial regularizationIn 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.
- 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