Patient left profile
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
Here is a video of the patient rubbing his eyes
Corneal 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.
Other cases :
- 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