Case #67

Case #67

The patient

Patient left profile

Unilateral corneal ectasia post lasik induced by eye rubbing

Identity : Ms W.W
First visit : 07/11/2017
Last Visit : 12/12/2017

50
Age (years)
5
Follow-up (months)
The crosslinking controversy

Ms. W.W is a 50-year-old female who had bilateral LASIK performed in 1999 for myopia (- 3 D). She was referred to us by an ophthalmologist to evaluate the increasing astigmatism in her left eye since 2014, which was causing a progressive decrease in visual acuity. She had already sought an opinion in another institution, where she was advised to have corneal collagen cross-linking on an urgent basis.

Her refraction at the first visit at the Rothschild Foundation (on 07/11th/2017) was: Right Eye (RE) 20/20 with -1 (-0.5 x 35 °) and Left Eye (LE) 20/25 with -0.75 (-3.75 x 115 °).

Clinical examination with the slit lamp suggested a thin and irregular left cornea. We also found bilateral tarsal papillae (more pronounced in the left eye), and signs of dry eye.

Corneal topography performed at our institution revealed the presence of unilateral post LASIK ectasia in the left eye. 

At the first visit, when asked about the possibility of frequent eye rubbing, the patient admitted to rubbing her eyes when she awoke in the mornings and after removing her eye makeup.

With regards to her sleeping habits, she described sleeping on her left side or stomach, with the head buried in the pillow (pillow hugging). She is allergic to dust mites, and shared how her left eye was more often irritated than the right one.

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 corneal ectasia in her case.

We strongly advised this patient to stop rubbing her eyes and to change her unhealthy sleeping position.

At the subsequent visits, the patient informed us that after being primed about the deleterious effects of eye rubbing, she had come to realize that she was rubbing her eyes more often than she had thought initially. She has also since tried her best to alter her sleeping posture. 

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

photo of the right eye profilePATIENT RIGHT PROFILE. The corneal profile is noticeably flatter than that of the left eye.
profile of an eye with post LASIK corneal ectasiaPATIENT LEFT PROFILE.
patient demonstrating eye rubbing with knucklesPATIENT RUBBING HER EYE WITH HER KNUCKLES. When asked to demonstrate her eye rubbing technique, the patient spontaneously rubbed her left eye with the knuckle of her left index finger, despite being right handed.
patient sleep positionPATIENT DEMONSTRATING HER SLEEPING POSITION (LEFT SIDE). The patient sleeps on her left side with her left eye buried in the pillow.

Here are the Orbscan quadmaps, Pentacam maps OPD scans, Ocular Response Analyzer (ORA) results, Corneal Cross-sectional OCT and epithelial maps of the first visit. Unfortunately, no pre-LASIK topographies or other examinations are available.

post LASIK corneal topographyRIGHT EYE ORBSCAN (1st VISIT). The cornea is thin, and flatter centrally. This topographic pattern corresponds to a normal post-myopic LASIK profile.
topography pattern of post LASIK ectasiaLEFT EYE ORBSCAN (1st VISIT). The cornea is thin centrally, and there is marked asymmetry with an inferior steepening. With a history of prior LASIK, this pattern is strongly suggestive of post-LASIK ectasia.
corneal topography pentacam post myopic LASIKRIGHT EYE PENTACAM (1st VISIT). The central flattening is homogeneous and centered. The corneal profile is regular and compatible with an uneventful post-LASIK course.
pentacam map of a post LASIK ectasiaLEFT EYE PENTACAM (1st VISIT). There is marked inferior steepening and central thinning. This is highly suggestive of post LASIK ectasia.
topographic and aberrometric examination after myopic LASIK, OPDscan IIIRIGHT EYE OPDscan III maps. The combined topography and aberrometry map shows a slight elevation of some higher order aberrations, such as positive spherical aberration (as a result of the positive corneal asphericity and oblate profile)
OPDscan III topography and aberrometry data in an eye with post LASIK ectasia.LEFT EYE OPDscan III map. Topography and aberrometry combined reveal the increase in higher order aberrations such as trefoil and coma. These aberrations are induced by the distortion from the corneal ectasia.
ORA ocular response analysisRIGHT EYE ORA (Ocular Response Analyzer). The reduced hysteresis (CH for Corneal Hysteresis) is commonly observed in eyes following corneal refractive surgery. The height of the peaks are slightly reduced.
ocular response analyzer examination in an eye with post LASIK ectasiaLEFT EYE ORA (Ocular Response Analyzer). The height of the peaks is reduced, and the corneal hysteresis (CH) is low.
High resolution OCT of a corneal with a LASIK flapRIGHT EYE CORNEAL HIGH RESOLUTION OCT (CROSS SECTIONAL). This examination reveals the presence of a LASIK flap interface
high resolution OCT , ectasia, post LASIK,LEFT EYE CORNEAL HIGH RESOLUTION OCT (CROSS SECTIONAL). This examination reveals the presence of a LASIK flap and a residual stromal bed thickness (under the LASIK flap) of close to 300 microns.
high resolution OCT map after LASIK for myopiaRIGHT EYE HIGH RESOLUTION OCT EPITHELIAL THICKNESS AND PACHYMETRY MAP. Note the slight increase in the thickness of the epithelial layer in the center, to partly compensate for the myopic photoablation
high resolution OCT after post LASIK ectasiaLEFT EYE OCT EPITHELIAL MAP. Note the slight irregular distribution of the epithelial layer.

Difference maps were performed at each subsequent visit. No evolution was observed between the first and last visits. The corneal ectasia is stable, more than 5 months after the patient definitively stopped rubbing her eyes .

orbscan mapping after myopic LASIKRIGHT EYE ORBSCAN (2nd VISIT). This map shows stability since the first visit.
post LASIK ectasia Orbscan mapLEFT EYE ORBSCAN (2nd VISIT). The topographic features suggest stability of the ectasia since the first visit
pentacam map, after myopic surgeryRIGHT EYE PENTACAM (2nd VISIT). Stability since the first visit.
pentacam map post LASIK ectasiaLEFT EYE PENTACAM (2nd VISIT). Stability since the first visit.
difference map after LASIKPENTACAM DIFFERENTIAL MAPS : RIGHT EYE. (between first and second visits). This difference map demonstrates stability
pentacam difference map after post LASIK ectasiaPENTACAM DIFFERENTIAL MAPS : LEFT EYE. (between first and second visits). This difference map demonstrates the absence of corneal ectasia progression, coincident with the time at which the patient had stopped rubbing her eyes.
Orbscan right eye post myopic LASIKRIGHT EYE ORBSCAN (3rd VISIT). Stability
Orbscan map post LASIK ectasia stabilityLEFT EYE ORBSCAN (3rd VISIT). Stability.
pentacam map stability after myopic LASIKRIGHT EYE PENTACAM (3rd VISIT). Stability
Pentacam map, post LASIK ectasiaLEFT EYE PENTACAM (3rd VISIT). Stability
PENTACAM DIFFERENTIAL MAPS : RIGHT EYE. (between first and third visits). This difference map demonstrates stability
PENTACAM DIFFERENTIAL MAPS : LEFT EYE. (between first and third visits). This difference map demonstrates stability

In this case we find many triggers for eye rubbing like eye rubbing and an unhealthy sleeping position.  The unilateral or asymmetric nature of corneal ectasia development may be related to the sleeping position (left sided) and the habit of preferentially rubbing the left eye.

  • Date 14 janvier 2018
  • Tags Allergy, Asymmetric, Cross linking, Dry eyes, Ectasia, Eye rubbing, Female, Fleischer ring, Knuckles rubbing, Lasik, Morning rubbing, Oldest, Pillow hugging, Removing makeup rubbing, Sleep position