Patient right profile
Case #81
The patient
Bilateral Asymmetric Keratoconus induced by eye rubbing
Identity : Mr T.S
First visit : 10/24/2017
Last Visit : 03/06/2018
21
Age (years)5
Follow-up (months)Mr. T.S is a 21-year-old male mechanic with no previous medical history or any known family history of keratoconus (He has two sisters, both of whom have no keratoconus). He complained of a progressive decrease in visual acuity greater in the right eye than the left. He has allergy to dust mites and cat’s fur.
His refraction at the first visit at the Rothschild Foundation (on 10/24th/2017) was : Right Eye (RE) 20/60 with -1.5 (-4.5 x 180 °) and Left Eye (LE) 20/40 with -5 (-2.75 x 105 °).
Clinical examination with the slit lamp suggested thin and irregular corneas with Fleischer rings in both eyes at the base of the cone (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 in the right eye.
At the first visit, when asked about the possibility of eye rubbing, the patient admitted to rubbing his eyes frequently during childhood, especially during spring. He would rub his eyes continuously for up to an hour because it gave him a sense of well being .
The patient is right handed and rubs his right eye with his right hand. He sleeps on his right side, with the head buried in the pillow (pillow hugging).
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.
We strongly advised this patient to stop rubbing his eyes and to change his unhealthy sleeping position. We then prescribed him an eye shield, lubricants and anti-histamine eye drops for both eyes. Fortunately, all these have curbed his desire to rub his eyes.
For visual rehabilation, he was fitted with scleral contact lenses
Here are pictures of the patient rubbing his eyes and his profiles
PATIENT RIGHT PROFILE.
The corneal irregularity is prominent, with a bulge seen in the inferior cornea
PATIENT LEFT PROFILE.
The irregularity is more difficult to perceive here, but a change of corneal curvature from the upper to lower aspects of the cornea can be observed
PATIENT RUBBING HIS RIGHT EYE WITH THE KNUCKLES
PATIENT RUBBING HIS RIGHT EYE WITH HIS RIGHT PALM
SLIT LAMP PHOTOGRAPH OF THE RIGHT EYE: Note the iridoschisis inferiorly, with depigmentation. So such changes are observed in the left eye.
PATIENT SHOWING HIS SLEEP POSITION (RIGHT SIDE)Here is a video of the patient rubbing his right eye vigorously with the knuckles.
Here are the Pentacam maps, OPD scans, Ocular Response Analyzer (ORA) and OCT Epithelial maps of the first visit .
RIGHT EYE PENTACAM (1st VISIT). The corneal surface is highly prolate and irregular. This association with a marked central thinning is typical in advanced keratoconus.
LEFT EYE PENTACAM (1st VISIT). The deformation of the left eye is less pronounced: the corneal surface is highly prolate and irregular. This association with a marked central thinning is also typical in advanced keratoconus.
RIGHT EYE OPD
LEFT EYE OPD
RIGHT EYE ORA. The height of the peaks is slightly reduced. The reduction is more marked in this eye.
LEFT EYE ORA. The height of the peaks is slightly reduced.
OCT: There is a marked and irregular reduction of the epithelial thickness near the apex of the corneal deformation
OCT: There is a less marked reduction of the epithelial thickness near the apex of the corneal deformationDifference maps were performed at each subsequent visit. No evolution has been observed between the first and last visits. The keratoconus is stable, more than 5 months after the patient definitively stopped rubbing his eyes .
RIGHT EYE PENTACAM (2nd VISIT). Stable since first visit.
LEFT EYE PENTACAM (2nd VISIT). Stable since first visit.
PENTACAM DIFFERENTIAL MAPS : RIGHT EYE (1st and 2nd VISITS). The subtraction map reveals the absence of progression between the 1st and second visits.
PENTACAM DIFFERENTIAL MAPS : LEFT EYE (1st and 2nd VISITS). The keratoconus in the left eye is stable between the 1st and 2nd visits.
RIGHT EYE PENTACAM (3rd VISIT). Stable since first visit.
LEFT EYE PENTACAM (3rd VISIT). Stable since first visit.
PENTACAM DIFFERENTIAL MAPS : (1ST AND 3RD VISITS) RIGHT EYE. The difference map demonstrates objectively the absence of keratoconus progression (3rd column).
PENTACAM DIFFERENTIAL MAPS : LEFT EYE (1ST AND 3RD VISITS) The difference map demonstrates objectively the absence of keratoconus progression (3rd column).This is a classic example of bilateral keratoconus induced by allergy-triggered eye rubbing. Eye rubbing preceded the onset of the corneal deformation by several years. Cessation of eye rubbing resulted in the stabilization of the deformation (no keratoconus progression).
It is important to explain to patients, especially teenagers with allergies and allergic tendencies, the importance of refraining from eye rubbing, to prevent them from continuing with the habit into adulthood, whereby permanent and severe damage to their corneas would have been inflicted.
Allergy has been described as a classic « risk factor » for keratoconus, but this association might be because allergic patients rub their itchy eyes more frequently and firmly than non-allergic patients. Indeed, children and adolescents who rub their eyes vigorously because of itch and inflammation caused by the phenomena of allergic conjunctivitis have found to have keratoconus. The forces exerted on the corneal dome by the fingers and particularly the bones of the knuckles during eye rubbing are sufficiently intense to cause a rupture of the junctions connecting the collagen fibers of the anterior corneal stroma, causing focal weakening and a cascade of changes culminating in the abnormalities seen in what we call « keratoconus ».
Most medical text books would attribute keratoconus to an unknown genetic factor. Genetics alone would not explain the unilateral occurrence of keraotconus in many cases, while eye rubbing does very well (unilateral rubbing causes unilateral keratoconus). Genetics however, may account for increased ocular sensitivity, atopy, and reduced corneal resistance to repeated trauma.
- Date 10 mars 2018
- Tags Allergy, Asymmetric, Bilateral keratoconus, Central keratoconus, Childhood rubbing, Enjoyed eye rubbing, Eye rubbing, Knuckles rubbing, Male, Palm rubbing, Pillow hugging, Sleep position