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Case #78
The patient
Bilateral Asymmetric Post PRK Corneal Ectasia Induced By Eye Rubbing
Identity : Mr T.D
First visit : 02/20/2018
Last Visit : 06/26/2018
31
Age (years)4
Follow-up (months)Mr. T.D is a 31-year-old male with no previous medical history or any known family history of keratoconus. He has a history of atopy since childhood, with allergy to mites and allergic rhinitis. He complained of a progressive decrease in visual acuity greater in the left eye than the right one, following bilateral Photorefractive Keratectomy (PRK) in September 2013 in an another institution. Pre-operatively, he had myopia of about -2D in both eyes. The surgery was uneventful, and mild bilateral haze was noted postoperatively.
His refraction before the surgery in an another institution (09/2013) was : Right Eye (RE) 20/20 with -1.75 and Left Eye (LE) 20/20 with -2 (-0.5 x 60 °).
His refraction at the first visit at the Rothschild Foundation (on 02/20th/2018) was : Right Eye (RE) 20/25 with -0.75 (-0.75 x 5 °) and Left Eye (LE) 20/25 with -1.25 (-0.75 x 85 °).
Clinical examination with the slit lamp revealed thin and irregular corneas, and the suggestion of a presence of a slight irregular inferior corneal bulge with a discrete Fleischer ring. (Fleischer rings are pigmented rings in the peripheral cornea, resulting from iron deposition in basal epithelial cells, in the form of hemosiderin). Both eyes were dry with tear film BUT (Break Up Time) < 8 secs.
Corneal topography performed at our institution showed the presence of a bilateral corneal ectasia, more pronounced in the left eye.
The retrospective analysis of the examinations performed before the PRK revealed that both eyes presented topographic and aberrometric abnormalities, which were more pronounced in the left eye. We believe that these irregularities were caused by chronic eye rubbing which began in childhood.
At the first visit, when asked about the possibility of frequent eye rubbing, the patient admitted to rubbing his eyes especially at work. After the surgery, he changed jobs and started work at an oil port. Since this career change, the patient worked often at night (night shift). At his workplace where he was often exposed to dust and other allergens, he often had dry and irritated eyes, which triggered an eye rubbing habit using the knuckles. Rubbing his eyes gave the patient a sense of relief from the constant irritation with dust.
He is right-handed, and uses his left hand to rub his left eye.
He also admitted to rubbing his eyes very frequently and intensely during childhood because of allergy. His left eye was always itchier than the right one.
He sleeps on his left side, with the head buried in the pillow (pillow hugging).
We explained to the patient how vigorous eye rubbing could have induced weakening of his corneas, which were further compromised by the PRK 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 his eyes and to change his unhealthy sleeping position and to seek the opinion of a doctor specialising in allergies. An eye shield to be worn at night was prescribed in order to prevent compression and subsequent eye rubbing during bedtime. His dry eyes was also treated with artificial tears.
We have given him an appointment for a follow-up visit a month later. A topography difference map will be performed and the impact of cessation of eye rubbing evaluated.
Here are pictures of the patient rubbing his eyes and his profiles
PATIENT RIGHT PROFILE. The central flattening induced by the PRK sugery is difficult to perceive at this scale.
PATIENT LEFT PROFILE. You can note a little change of curvature between the central and inferior area of the cornea in this profile. 
PATIENT RUBBING HIS EYES WITH HIS KNUCKLES. This maneuver is particularly detrimental to the corneal structure, as the pressure exerted against the eyes by the most rigid portion of the fingers can be quite strong.
PATIENT DEMONSTRATING HIS SLEEPING POSITION. At night, he presses a pillow against the left side. 
We asked the patient to draw the appearance of a white disk with each eye.
The patient is asked to draw what he perceives when shown a white disk on a dark background. With the right eye, the patient describes a slight blur with several circles. But with the left eye, the doubling is much more marked and he sees several circles extending above the target disk.
Right eye slit lamp photography : note the central haze 
Left eye slit lamp photography : note the central haze. Here is a video of the patient rubbing his eyes
Here are the pre-operative examinations before the bilateral PRK (performed in another institution) with Pentacam maps, and laser treatment reports.
PRE-OPERATIVE RIGHT EYE PENTACAM : This examination reveals the presence of a central thinning zone (477 µm) with vertical astigmatism. Note also the asymmetry on the anterior and posterior elevation maps. We believe that these irregularities were caused by chronic eye rubbing which began in childhood.
PRE-OPERATIVE LEFT EYE PENTACAM : This examination reveals the presence of a central thinning zone (489 µm) with more pronounced oblique astigmatism. Note also the asymmetry on the anterior and posterior elevation maps. We believe that these irregularities were caused by chronic eye rubbing which began in childhood. 
RIGHT EYE LASER TREATMENT REPORT.
LEFT EYE LASER TREATMENT REPORT.
RIGHT EYE SURGICAL TREATMENT REPORT.
LEFT EYE SURGICAL TREATMENT REPORT.Here are the Orbscan quadmaps, Pentacam maps, OPD scans, High resolution cross-sectional OCT and OCT Epithelial maps
RIGHT EYE ORBSCAN (1st VISIT). The topography reveals the presence of a flattened superior area (following myopic PRK). The post PRK ectasia pattern is characterized by the asymmetry (inferior steepening) on the axial curvature map (bottom left). The posterior surface is highly prolate (top right) The pachymetry is also thin. 
LEFT EYE ORBSCAN (1st VISIT). The topography reveals the presence of a flattened superior area (following myopic PRK). The post PRK ectasia pattern is characterized by the asymmetry (inferior steepening) on the axial curvature map (bottom left). The posterior surface is highly prolate (top right). The pachymetry is also very thin. The deformation is more pronounced than in the right eye.
RIGHT EYE PENTACAM (FIRST VISIT). Same pattern as shown by Orbscan mapping, There is marked inferior steepening and central thinning. This is highly suggestive of post PRK ectasia.
LEFT EYE PENTACAM (FIRST VISIT). Similar pattern as with the Orbscan, There is marked inferior steepening and central thinning. This marked asymmetry is highly suggestive of post PRK ectasia.
RIGHT EYE OPDscan III examination (combined topography and aberrometry). The irregularity of the corneal surface results in moderate induction of coma and positive spherical aberration. These aberration explain the visual symptoms of the patient (perception of ghosts and multiple images)
LEFT EYE OPDscan III examination (combined topography and aberrometry). The slight irregularity of the corneal surface results in moderate induction of coma and positive spherical aberration.
RIGHT EYE CORNEAL HIGH RESOLUTION OCT (CROSS SECTIONAL). This examination reveals the presence of a hypersignal in the anterior subepithelial stromal layer.
LEFT EYE CORNEAL HIGH RESOLUTION OCT (CROSS SECTIONAL). This examination reveals the presence of haze. 
RIGHT EYE HIGH RESOLUTION OCT EPITHELIAL THICKNESS AND PACHYMETRY MAP.
Note the slight increase in the thickness of the epithelial layer in the center, to partly compensate for the myopic photoablation and corneal deformation.
LEFT EYE HIGH RESOLUTION OCT EPITHELIAL THICKNESS AND PACHYMETRY MAP.
Note the slight increase in the thickness of the epithelial layer in the paracentral area, to partly compensate for the myopic photoablation and ectasia induced stromal deformationThe follow-up is in progress and we will communicate to you soon the results of his next visit .
RIGHT EYE ORBSCAN (2nd VISIT)
LEFT EYE ORBSCAN (2nd VISIT)
RIGHT EYE PENTACAM (2nd VISIT)
LEFT EYE PENTACAM (2nd VISIT)
PENTACAMS DIFFERENTIAL MAPS : RIGHT EYE . This map reveals the stability of the corneal deformation. There is no progression.
PENTACAMS DIFFERENTIAL MAPS : LEFT EYE. This map demonstrates the stability of the corneal deformation (post PRK ectasia)
PENTACAMS DIFFERENTIAL MAPS : RIGHT EYE (between 1st and 3rd visit) . This map reveals the stability of the corneal deformation. There is no progression
PENTACAMS DIFFERENTIAL MAPS : LEFT EYE (between 1st and 3rd visit) . This map reveals the stability of the corneal deformation. There is no progressionCorneal ectasia post-refractive surgery is a rare 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. Corneal ectasia post-PRK is rarer than post-LASIK ectasia. There are several risk factors for 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 lead to the reduction of corneal resistance before surgery, and the cornea is weakened further if rubbing is continued after the surgery.
Following refractive surgery (LASIK more than PRK), patients often have dry eye, and this gives them a sensation of visual fatigue which is relieved by eye rubbing. This explains why it is not uncommon for patients to describe an intense desire to rub their eyes after corneal refractive surgery.
In this particular patient, we find many triggers for eye rubbing like allergy and an unhealthy sleeping position which correspond to the side of rubbing.
In our experience, the cessation of eye rubbing is the most important parameter in the control of progression of corneal deformation. In our opinion, corneal ectasia post refractive surgery, similar to keratoconus, is not an inherited disease, but the consequence of repeated mechanical trauma. Logically, the cessation of inflicted trauma leads to the eradication of the cause of deformation and thus like many cases described in this site, the cessation of eye rubbing is able to arrest the evolution of the corneal ectasia. This website provides many other encouraging examples of this.
- Date 4 mars 2018
- Tags Allergy, Asymmetric, Childhood rubbing, Dry eyes, Ectasia, Enjoyed eye rubbing, Eye rubbing, Fleischer ring, Knuckles rubbing, Lasik, Male, Night shift, PRK, Sleep position