Case #72

Case #72

The patient

Patient right profile

Bilateral Asymmetric Keratoconus induced by eye rubbing

Identity : Mr N.W
First visit : 09/12/2017
Last Visit : 01/23/2018

27
Age (years)
4
Follow-up (months)
The crosslinking controversy

Mr. N.W  is a 27-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.

His refraction at the first visit at the Rothschild Foundation (on 09/03th/2017) was : Right Eye (RE) 20/25 with+0.25 (-2.5 x 70 °) and Left Eye (LE) 20/20 with -0.5 (-0.75 x 115 °).

Clinical examination with the slit lamp suggested a thin and irregular right cornea with 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 a unilateral keratoconus in the right eye.

At the first visit, when asked about the possibility of frequent eye rubbing, the patient admitted to rubbing his eyes when he awoke in the mornings or when working in front of the computer. Rubbing his eyes at work brought relief to his tired eyes and also evoked pleasurable sensations.

He is left handed but rubbed his right eye with his right hand. The patient sleeps on his right side, with the head buried in the pillow (pillow hugging).

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 keratoconus in his case.

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

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

right eye corneal profilePATIENT RIGHT EYE AND CORNEAL PROFILE
photo of the left profile of a patientPATIENT LEFT EYE AND CORNEAL PROFILE
patient rubbing his left eye with the hand palmPATIENT RUBBING HIS EYE WITH HIS PALM. When the eye is rubbed with the palm, a strong pressure is usually exerted on the eyeball.
patient showing his sleep positionPATIENT DEMONSTRATING HIS SLEEPING POSITION. This patient sleeps predominantly on the left side, with the head buried in the pillow. Note the close contact of the left orbit with the "pillow".

Here are the Orbscan quadmaps, Pentacam maps OPD scans and Ocular Response Analyzer (ORA) results of the first visit.

RIGHT EYE ORBSCAN (1st VISIT).
LEFT EYE ORBSCAN (1st VISIT).
RIGHT EYE PENTACAM (1st VISIT)
LEFT EYE PENTACAM (1st VISIT)
RIGHT EYE OPD
LEFT EYE OPD
RIGHT EYE ORA
LEFT EYE ORA.
RIGHT EYE OCT EPITHELIAL MAP
LEFT EYE OCT EPITHELIAL MAP

Difference maps were performed at each subsequent visit. No evolution was observed between the first and last visits. The keratoconus is stable, more than 4 months after the patient definitively stopped rubbing his eyes .

RIGHT EYE ORBSCAN (2nd VISIT). Stable since first visit.
LEFT EYE ORBSCAN (2nd VISIT).
RIGHT EYE PENTACAM (2nd VISIT).
LEFT EYE PENTACAM (2nd VISIT).
PENTACAM DIFFERENTIAL MAPS : RIGHT EYE (between 1st and 2nd visits)
PENTACAM DIFFERENTIAL MAPS : LEFT EYE (between 1st and 2nd visits)
RIGHT EYE PENTACAM (3rd VISIT)
LEFT EYE PENTACAM (3rd VISIT)
PENTACAM DIFFERENTIAL MAPS : RIGHT EYE (between 1st and 3rd visits)
PENTACAM DIFFERENTIAL MAPS : LEFT EYE (between 1st and 3rd visits)

In this case we find many triggers for eye rubbing like extended computer work and an unhealthy sleeping position (« pillow hugging »). The unilateral or asymmetric nature of keratoconus development may be related to the sleeping position (right sided) and the habit of preferentially rubbing the right eye. 

This case is very informative and demonstrative of the causal effects of eye rubbing in the pathogenesis of keratoconus. Cross-linking is unnecessary in this case, as stabilisation of the corneal deformation was achieved with the simple act of cessation of eye rubbing.

As demonstrated again in this clinical example, the cessation of eye rubbing and patient education are the best tools in the prevention of the genesis and/or evolution of keratoconus.

  • Date 28 janvier 2018
  • Tags Allergy, Asymmetric, Bilateral keratoconus, Computer screen, Enjoyed eye rubbing, Eye rubbing, Inferior keratoconus, Knuckles rubbing, Male, Sleep position, Stabilization