Patient right profile
Ms C.D is a 37-year-old female with no previous medical history or any known family history of keratoconus. She had bilateral LASIK performed in December 2006 at another institution. Pre-operatively, she had myopia of about -4.5 D in both eyes. There were no known surgical complications during the procedure.
She complained of a progressive decrease in visual acuity one year after the surgery (2007), greater in the right eye than the left one.
Her refraction at the first visit at the Rothschild Foundation (on 03/16th/2017) was : Right Eye (RE) 20/20 with -1.50 (-0.5 x 155 °) and Left Eye (LE) 20/20 with -0.75 (-0.5 x 155 °).
Clinical examination with the slit lamp suggested a right thin and irregular cornea. Both eyes were dry with tear film BUT (Break Up Time) < 8 secs.
Corneal topography performed at our institution showed the presence of a unilateral corneal ectasia in the right eye.
The retrospective analysis of the examinations performed before the LASIK revealed no topographic abnormalities in both eyes.
We investigated the risk factors for ectasia at her first visit. When asked about the possibility of frequent eye rubbing, the patient admitted to rubbing her eyes before and after LASIK. After the surgery in particular, she would rub her eyes vigorously at night after eye makeup removal because she enjoyed it. As she was right-handed, she would rub her right eye especially and more vigorously than the left eye.
With regards to her sleeping position, she sleeps on her right side, with the head buried in the pillow (pillow hugging).
At the subsequent visits, she admitted to rubbing her eyes in the mornings as well, and that she was rubbing her eyes more frequently and vigorously than she had initially thought.
We explained to the patient how vigorous eye rubbing could have induced weakening of her corneas, which were further compromised by the LASIK procedure. The corneas were subsequently further weakened by eye rubbing after LASIK, culminating in corneal ectasia in both eyes.
We therefore strongly advised this patient to stop rubbing her eyes and to change her unhealthy sleeping position. She was also prescribed an eye shield to be worn during sleep to prevent ocular compression and rubbing during bedtime.
Here are pictures of the patient rubbing his eyes and his profiles
Induced corneal ectasia (or iatrogenic keratoconus) is a rare but devastating complication of LASIK.
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 cases.
The unilateral corneal ectasia development in this case is related to the sleeping position (right- sided) and the habit of preferentially rubbing the right eye.
In our experience, the cessation of eye rubbing is the most important parameter in the control of progression of the corneal deformation. Cross linking was not necessary to stop the progression of the ectasia in this case. In our opinion, corneal ectasia post refractive surgery, similar to keratoconus, is not an inherited disease, but the consequence of repeated mechanical trauma, especially in cases which were determined to be of low ectasia risk pre-operatively. Logically, the cessation of inflicted trauma leads to the eradication of the inciting cause of deformation and the cessation of eye rubbing thus arrests the evolution of the corneal ectasia. This website provides many other encouraging examples of this.
The monocular diplopia (double vision) in this case is an interesting point and is the consequence of the corneal asymmetry and irregularity induced by the ectasia. The visual symptoms of ghost images are frequently observed not just in post-LASIK ectasia but in the early course of keratoconus as well.
Other cases :
- Date 10 mars 2018
- Tags Asymmetric, Cleansing eye rubbing, Dry eyes, Ectasia, Eye rubbing, Female, Lasik, Nails rubbing, Pillow hugging, Sleep position, Stabilization