Patient left profile
Case #67
The patient
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)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
PATIENT RIGHT PROFILE. The corneal profile is noticeably flatter than that of the left eye.
PATIENT LEFT PROFILE. 
PATIENT 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 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.
RIGHT EYE ORBSCAN (1st VISIT). The cornea is thin, and flatter centrally. This topographic pattern corresponds to a normal post-myopic LASIK profile. 
LEFT 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.
RIGHT EYE PENTACAM (1st VISIT). The central flattening is homogeneous and centered. The corneal profile is regular and compatible with an uneventful post-LASIK course.
LEFT EYE PENTACAM (1st VISIT). There is marked inferior steepening and central thinning. This is highly suggestive of post LASIK ectasia.
RIGHT 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)
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.
RIGHT 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.
LEFT EYE ORA (Ocular Response Analyzer). The height of the peaks is reduced, and the corneal hysteresis (CH) is low.
RIGHT EYE CORNEAL HIGH RESOLUTION OCT (CROSS SECTIONAL). This examination reveals the presence of a LASIK flap interface
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.
RIGHT 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
LEFT 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 .
RIGHT EYE ORBSCAN (2nd VISIT). This map shows stability since the first visit.
LEFT EYE ORBSCAN (2nd VISIT). The topographic features suggest stability of the ectasia since the first visit
RIGHT EYE PENTACAM (2nd VISIT). Stability since the first visit.
LEFT EYE PENTACAM (2nd VISIT). Stability since the first visit.
PENTACAM DIFFERENTIAL MAPS : RIGHT EYE. (between first and second visits). This difference map demonstrates stability
PENTACAM 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.
RIGHT EYE ORBSCAN (3rd VISIT). Stability
LEFT EYE ORBSCAN (3rd VISIT). Stability.
RIGHT EYE PENTACAM (3rd VISIT). Stability
LEFT 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 stabilityIn 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