Patient right profile
Case #74
The patient
Unilateral Asymmetric Keratoconus induced by eye rubbing
Identity : Mr S.U
First visit : 06/06/2017
Last Visit : 02/06/2018
37
Age (years)8
Follow-up (months)Mr.H.I is a 37-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 left eye than the right.
His refraction at the first visit at the Rothschild Foundation (on 06/06th/2017) was : Right Eye (RE) 20/20 with+0.25 (-1.5 x 70 °) and Left Eye (LE) 20/25 with -0.5 (-2.75 x 115 °). The patient told that his vision was perfect until the early 2000 ( he was then in his early twenties). At that time, he started to work in the construction field, where he was exposed to dust and dry air.
Clinical examination with the slit lamp suggested a thin and irregular left cornea with a 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 bilateral keratoconus, more pronounced on the left eye.
At the first visit, when asked about the possibility of frequent eye rubbing, the patient admitted to rubbing his eyes (left more than the right).
At a subsequent visit, the patient admitted that he realized that he was rubbing his eyes quite vigorously when he awoke in the mornings or when working for long hours in front of the computer.
He is left-handed and sleeps on his left side, with the head buried in the pillow (pillow hugging). He realized after receiving that information that his left eye was somehow « crushed » in that particular sleeping position.
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.
This patient has a young son who rubs his eyes quite often because of pollen allergies. He explained to his child that this was a bad habit which should be abandoned.
Here are pictures of the patient rubbing his eyes and his profiles
PATIENT RIGHT PROFILE
PATIENT LEFT PROFILE.
PATIENT RUBBING HIS EYES WITH HIS KNUCKLES. Using knuckles is particularly detrimental as this is the most rigid part of the fingers.
PATIENT DEMONSTRATING HIS SLEEPING POSITION (LEFT SIDE)Here are the Orbscan quadmaps, OPD scans and Ocular Response Analyzer (ORA) results of the first visit .
RIGHT EYE ORBSCAN (1st VISIT). The cornea is thinned centrally, The prolateness of both surfaces is considerably increased.
LEFT EYE ORBSCAN (1st VISIT). The corneal deformation and thinning is obvious, and slightly more pronounced than on the right eye.
RIGHT EYE OPD
LEFT EYE OPD
RIGHT EYE ORA/ The corneal hysteresis value is reduced.
LEFT EYE ORA. The corneal hysteresis value is reduced. Note the reduction of the height of the peaks.Difference maps have been performed at each subsequent visit. No evolution has been observed between the first and last visit. The keratoconus is still stable, more than 8 months after the patient has definitely stopped to rub his eyes .
RIGHT EYE ORBSCAN (2nd VISIT). Stable since first visit.
LEFT EYE ORBSCAN (2nd VISIT). Stable since first visit.
RIGHT EYE PENTACAM (2nd VISIT). 
LEFT EYE PENTACAM (2nd VISIT). 
RIGHT EYE ORBSCAN (3rd VISIT). 
LEFT EYE ORBSCAN (3rd VISIT). 
RIGHT EYE ORBSCAN (3rd VISIT). 
LEFT EYE PENTACAM (3rd VISIT). 
PENTACAM DIFFERENTIAL MAPS : RIGHT EYE. (between 2nd and 3rd visits). This difference map demonstrates the absence of keratoconus progression, coincident with the time the patient stopped rubbing his eyes.
PENTACAM DIFFERENTIAL MAPS : LEFT EYE. (between 2nd and 3rd visits). This difference map demonstrates the absence of keratoconus progression, coincident with the time the patient stopped rubbing his eyes.
RIGHT EYE ORBSCAN (4th VISIT). 
LEFT EYE ORBSCAN (4th VISIT). 
OPD DIFFERENTIAL MAPS : RIGHT EYE. (between 2nd and 4th visits). This difference map demonstrates the absence of keratoconus progression, coincident with the time the patient stopped rubbing his eyes.
OPD DIFFERENTIAL MAPS : LEFT EYE. (between 2nd and 4th visits). This difference map demonstrates the absence of keratoconus progression, coincident with the time the patient stopped rubbing his eyes.In this case we find many triggers for eye rubbing like extended computer work and an unhealthy sleeping position. The slight asymmetric nature of keratoconus development may be related to the sleeping position (left-sided) and the habit of preferentially rubbing the left eye with the dominant hand (the patient is left-handed).
This case is very informative and demonstrative of the causal effects of eye rubbing in the pathogenesis of keratoconus. Cross-linking was unnecessary in this case, as stabilization 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 for the prevention of the genesis and/or evolution of keratoconus.
- Date 12 février 2018
- Tags Bilateral keratoconus, Central keratoconus, Eye rubbing, Fleischer ring, Knuckles rubbing, Male, Morning rubbing, Sleep position, Work rubbing