Patient right profile
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
After stabilization of his keratoconus more than 5 years, we decided to perform a bilateral Topoguided PRK at 03/29/2018
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.
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- Date 8 février 2018
- Tags Allergy, Asymmetric, Bilateral keratoconus, Childhood rubbing, Enjoyed eye rubbing, Eye rubbing, Knuckles rubbing, Male, Pillow hugging, Sleep position, Stabilization