Case #73

Case #73

The patient

Patient right profile

Bilateral Asymmetric Keratoconus induced by eye rubbing

Identity : Mr H.H
First visit : 04/02/2013
Last Visit : 02/06/2018

41
Age (years)
58
Follow-up (months)
Eye rubbing : keratoconus & sleep position

Mr. H.H is a 39-year-old male who is an electrical engineer. He has no previous medical history or any known family history of keratoconus. The patient had allergies to dust mites, pollen and cat’s hairs. He used to rub a lot his eyes, especially the left one during his childhood. He complained of a progressive decrease in visual acuity greater in the left eye than the right.

His refraction at the first visit at the Rothschild Foundation (on 04/02th/2013) was : Right Eye (RE) 20/20 with -4 (-0.75 x 80 °) and Left Eye (LE) 20/25 with -3.75 (-4.25 x 55 °).

Clinical examination with the slit lamp suggested a thin and irregular left 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 left 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 at work.  Rubbing his eyes at work also provided relief to his tired eyes.

He explained that he had to move due to his work, and that his allergy was exacerbated following a larger exposure (campaign). During all these years he used to rub his eyes vigorously to relieve ocular scratching.

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

We explained to the patient that since vigorous eye 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 corneal profile picturePATIENT RIGHT PROFILE
photo of a right cornea with keratoconusPATIENT LEFT PROFILE. This eye has keratoconus. This profile picture is not particularly suggestive of any "protrusion". Keratoconus is characterized by a corneal deformation, or "warpage".
photo of eye rubbingPATIENT RUBBING HIS EYES WITH HIS KNUCKLES AND BACKHAND
PATIENT DEMONSTRATING HIS SLEEPING POSITION

After stabilization of his keratoconus more than 5 years, we decided to perform a bilateral Topoguided PRK at 03/29/2018

patient showing how he rubs his eyePATIENT SHOWING AGAIN THE WAY HE USED TO RUB HIS LEFT EYE THE DAY OF THE SURFACE LASER ABLATION / PRKSURGERY.
photo of the sleeping position of a patient with left eye keratoconusPATIENT SHOWING HIS SLEEP POSITION THE DAY OF THE SURGERY (ON LEFT SIDE)

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

orbscan quadmapRIGHT EYE ORBSCAN (1st VISIT). The cornea is thin, and there is a slight inferior steepening.
Orbscan map of a left eye with keratoconusLEFT EYE ORBSCAN (1st VISIT). There is marked central thinning and paracentral inferior steepening. Note the increased prolateness of both the anterior and posterior corneal surfaces.
right eye pentacam corneal topography mapRIGHT EYE PENTACAM (1st VISIT). The right cornea is thin, with a subtle inferior steepening. There are no other abnormalities. This map is classified as unremrkable by the topograph software.
left eye pentacam, keratoocnusLEFT EYE PENTACAM (1st VISIT). This map confirms the pattern observed on the Orbscan display. The corneal deformation is obvious. Note the marked central thinning.
opdscan III map, right eyeRIGHT EYE OPDscan III map. The specular topography map displays a pattern of "keratoconus suspicion", raised by the slight inferior steepening.
left eye opdscan III map of a keratoconus eyeOPDscan III LE (OS) map. The corneal deformation is obvious on the axial map. It causes an increase in higher order aberrations. These aberration are impairing the visual quality which cannot be fully restored with spectacles.
ORA biomechanics corneaRIGHT EYE Ocular Response Analyzer (ORA). The corneal hysteresis and peal heights are within normal range.
ocular response analyzer mapLEFT EYE Ocular Response Analyzer map. Note the reduction of the first peak height.

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

BEFORE THE PRK

RIGHT EYE ORBSCAN (2nd VISIT). Stable since first visit.
LEFT EYE ORBSCAN (2nd VISIT).
RIGHT EYE ORBSCAN (3rd VISIT)
LEFT EYE ORBSCAN (3rd VISIT)
RIGHT EYE ORBSCAN (4th VISIT)
LEFT EYE ORBSCAN (4th VISIT)
RIGHT EYE ORBSCAN (5th VISIT)
LEFT EYE ORBSCAN (5th VISIT)
RIGHT EYE ORBSCAN DIFFERENTIAL MAP (between 4th and 5th visits)
LEFT EYE ORBSCAN DIFFERENTIAL MAP (between 4th and 5th visits)
RIGHT EYE ORBSCAN (6th VISIT)
LEFT EYE ORBSCAN (6th VISIT)
RIGHT EYE PENTACAM (6th VISIT)
LEFT EYE PENTACAM (6th VISIT)
pentacam difference mapPENTACAM DIFFERENTIAL MAPS : RIGHT EYE. (between 1st and 6th visits). This difference map demonstrates the absence of progression of the subtle corneal deformation, coincident with the time the patient stopped rubbing his eyes.
pentacam mapPENTACAM DIFFERENTIAL MAPS : LEFT EYE. (between 1st and 6th visits). This difference map demonstrates the absence of keratoconus progression, coincident with the time the patient stopped rubbing his eyes.

AFTER THE PRK

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

The apparition of a left keratoconus in this patient was probably favorized by the presence of a natively thin cornea (as shown by the right eye topography map).

This case is very informative and demonstrative of the causal effects of eye rubbing in the pathogenesis of keratoconus. We can hypothesize that the chronic nighttime compression as caused left eye irritation, triggering some repeated rubbing. A vicious circle ensues, and the left cornea progressively gets thinner and warped.

Cross-linking was unnecessary in this case, as stabilization of the corneal deformation was achieved with the simple act of cessation of eye rubbing. After 5 years of non progression and the abandon of the eye rubbing habit, we considered that it was safe to perform a laser surface ablation to correct the patient’s myopic astigmatism.

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 8 février 2018
  • Tags Allergy, Asymmetric, Bilateral keratoconus, Childhood rubbing, Enjoyed eye rubbing, Eye rubbing, Knuckles rubbing, Male, Pillow hugging, Sleep position, Stabilization