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Case #75
The patient
Bilateral Asymmetric post-lasik Ectasia induced by eye rubbing
Identity : Ms S.G
First visit : 02/07/2017
Last Visit : 02/06/2018
43
Age (years)12
Follow-up (months)Ms. S.G is a 43-year-old female who had bilateral LASIK performed in 2002 for myopia of – 4 DS at another institution. Five years later, she complained of a progressive decrease in visual acuity in both eyes. She had developed astigmatism requiring spectacle correction. As the astigmatism progressively increased, her ophthalmologist diagnosed post-LASIK ectasia and informed her that she required corneal collagen cross-linking.
She was referred to us by another ophthalmologist to evaluate the increasing astigmatism in both eyes, which was causing a progressive decrease in visual acuity. She had already sought an opinion at another institution, where she was again advised to have corneal collagen cross-linking, this time on an urgent basis.
Her refraction at the first visit at the Rothschild Foundation (on 02/07th/2017) was: Right Eye (RE) 20/20 with +1.25 (-4.25 x 70°) and Left Eye (LE) 20/25 with +1 (-3.25 x 105 °).
Clinical examination with the slit lamp suggested thin and irregular corneas. Her eyes were also found to be clinically dry.
Corneal topography performed at our institution revealed the presence of bilateral post LASIK ectasia.
At the first visit, when asked about the possibility of frequent eye rubbing, the patient admitted to rubbing her eyes because they felt dry and uncomfortable. She would rub her eyes very frequently and intensely after the LASIK to relieve this dry eye sensation. She also admitted to rubbing her eyes prior to the LASIK surgery, especially after removal of her eye makeup.
With regards to her sleeping habits, she described sleeping on the side, predominantly on her right side or stomach, with the head buried in the pillow (pillow hugging).
We explained to the patient how vigorous eye rubbing could have induced weakening of her corneas, which were further compromised by the LASIK procedure. Subsequent eye rubbing after the surgery incurred further weakening, culminating in corneal ectasia in both eyes.
We strongly advised this patient to stop rubbing her eyes and to change her unhealthy sleeping position, in order to prevent further aggravation of the post LASIK ectasia.
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 even more often than she had thought initially, sometimes rubbing continuously for several minutes. She has since tried her best to alter her sleeping posture.
Here are pictures of the patient rubbing her eyes and her profiles
PATIENT RIGHT EYE PROFILE. The central flattening (LASIK correction for myopia) is perceptible.
PATIENT LEFT EYE PROFILE. The central flattening and inferior steepening is perceptible
PATIENT RUBBING HER EYES WITH HER KNUCKLES. This gesture is particularly detrimental to the cornea.
PATIENT DEMONSTRATING HER SLEEPING POSITION (on the right side). Note the proximity between the right eye and the surface of the "pillow".Here are the Orbscan quadmaps, Pentacam maps, OPD scans and Ocular Response Analyzer (ORA) results of the first visit. Unfortunately, no pre-LASIK topographies or other examinations are available
RIGHT EYE ORBSCAN (1st VISIT). The cornea is thin centrally, and there is marked asymmetry with an inferior steepening. With a history of LASIK, this pattern is strongly suggestive of post-LASIK ectasia.
LEFT EYE ORBSCAN (1st VISIT). The cornea is not very thin centrally, but there is marked asymmetry with an inferior steepening. With a history of LASIK, this pattern is strongly suggestive of post-LASIK ectasia.
RIGHT EYE PENTACAM (1st VISIT). There is marked inferior steepening and central thinning. This is highly suggestive of post LASIK ectasia.
LEFT EYE PENTACAM (1st VISIT). There is marked inferior steepening and some central thinning. This is highly suggestive of post LASIK ectasia.
RIGHT EYE OPDscan III map (Topography and aberrometry combined). This exam reveals the increase in higher order aberrations such as trefoil and coma. These aberrations are induced by the corneal distortion due to the corneal ectasia. They result in a reduction of the visual quality and can cause ghost images, halos, etc.
LEFT EYE OPDscan III (Topography and aberrometry combined). It reveals the increase in higher order aberrations such as trefoil and coma. These aberrations are induced by the distortion induced by the corneal ectasia.
RIGHT EYE Ocular Response Analyzer. The height of the peaks is slightly reduced and the value of corneal hysteresis is low (CH)
LEFT EYE Ocular Response Analyzer. The height of the peaks is slightly reduced.
OCT: 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) close to 300 microns.
OCT: 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.Difference maps were performed at each subsequent visit. No evolution has been observed between the first and last visits. The keratoconus is stable, more than 12 months after the patient definitively stopped rubbing her eyes .
RIGHT EYE ORBSCAN (2nd VISIT). Stable since first visit.
LEFT EYE ORBSCAN (2nd VISIT). Stable since first visit
RIGHT EYE PENTACAM (2nd VISIT). Stable since first visit.
LEFT EYE PENTACAM (2nd VISIT). Stable since first visit
PENTACAM DIFFERENTIAL MAPS : RIGHT EYE. (between first and second visits). This difference map demonstrates the absence of corneal ectasia progression, coincident with the time the patient stopped rubbing her eyes.
PENTACAM DIFFERENTIAL MAPS : LEFT EYE. (between first and second visits). This difference map demonstrates the absence of corneal ectasia progression, coincident with the time the patient stopped rubbing her eyes.
RIGHT EYE ORBSCAN (3rd VISIT). : The pattern is not significantly different from the first visit at our institution.
LEFT EYE ORBSCAN (3rd VISIT). : The pattern is not significantly different from the first visit at our institution.
OPD DIFFERENTIAL MAPS : RIGHT EYE. This OPD difference map demonstrates the absence of corneal ectasia progression, coincident with the time the patient stopped rubbing her eyes. 
OPD DIFFERENTIAL MAPS : LEFT EYE. This OPD difference map demonstrates the absence of corneal ectasia progression, coincident with the time the patient stopped rubbing her eyes. The pattern even suggests a slight regularization of the corneal surface.Corneal ectasia post refractive surgery is an unusual but potentially severe complication. It corresponds to a biomechanical decompensation of the cornea, which loses its regularity and whose central curvature increases. Consequently, ectasia results in the reappearance of evolutionary myopia and astigmatism. There are several risk factors for post LASIK ectasia. The main risk factor is the presence of an undetected form of sub-clinical keratoconus existing in the unoperated cornea. As with keratoconus, the habit of repeated eye rubbing is also a risk factor, as these frictions have led to the reduction of corneal resistance before surgery, and the cornea is weakened further if rubbing is continued after the operation.
The role of eye rubbing in post LASIK ectasia is probably underestimated. It should be suspected for every case of ectasia, especially in late-onset post-LASIK ectasia. This case is very informative about the risks of eye rubbing before and after LASIK surgery. Unfortuantely, the pre-LASIK topographies were not available in this case.
Following excimer laser ablation in LASIK, the cornea is thinned. The repeated and sustained friction on this thinned cornea afforded by eye rubbing can be particularly detrimental to the biomechanical integrity of the corneal wall and the compressive effect makes it thinner and more irregular. It is interesting to note that the topographic irregularities detected were all more pronounced in the right eye, which was the eye buried in the pillow at night, and the eye that was rubbed more
Finally, post LASIK ectasia can be observed after LASIK in high myopia, when the corneal flap created is too thick and/or the volume of cornea removed too large. Thanks to the femtosecond laser which is used to create the corneal flap in LASIK today, flap thickness predictability is greatly increased and it is now possible to avoid inadvertently cutting an overly thick flap.
You can read about other cases of post LASIK ectasia induced by eye rubbing on this website like : Case 68, Case 67, Case 52, Case 39, Case 27, Case 25 and Case 13.
All these patients have the same story: a history of vigorous and persistent eye rubbing prior to and/or after the surgery.
- Date 15 février 2018
- Tags Allergy, Asymmetric, Childhood rubbing, Computer screen, Cross linking, Dry eyes, Ectasia, Eczema, Enjoyed eye rubbing, Eye shield, Female, Fleischer ring, Knuckles rubbing, Lasik, Morning rubbing, Sleep position, Stabilization, Work rubbing