Patient right profile
Case #82
The patient
Bilateral Asymmetric Keratoconus induced by eye rubbing
Identity : Mr X.F
First visit : 01/05/2018
Last Visit : 03/23/2018
20
Age (years)2
Follow-up (months)Mr. X.F is a 20-year-old male with no previous medical history or any known family history of keratoconus. He complained of a progressive decrease in visual acuity greater in the right eye than the left.
His refraction at the first visit at the Rothschild Foundation (on 01/05th/2018) was : Right Eye (RE) 20/32 with +0.25 (-3.50 x 70 °) and Left Eye (LE) 20/25 with -0.5 (-2.75 x 115 °).
Clinical examination with the slit lamp suggested thin and irregular corneas, especially in the right eye.
Corneal topography performed at our institution showed the presence of bilateral keratoconus, more pronounced in the right eye.
During the first visit, the patient denied rubbing his eyes. We advised him to be more aware of his habits, as eye rubbing is a subconscious activity in many individuals.
At his next visit, he was accompanied by his mother, who revealed to us that her son was a habitual eye rubber. The patient, having been primed to the fact that he was subconsciously rubbing his eyes, spontaneously demonstrated how he would rub his eyes, especially the right, just before sleep to relax himself. He shared with us that having changed jobs, where the environment was very dusty, he found himself rubbing his eye very frequently at work as well.
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 him that since vigorous eye 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 him to avoid rubbing his eyes and to change his unhealthy sleeping position. We also prescribed him an eye shield to be worn at night, and artificial tears to relieve dry eye symptoms which could trigger the pruritus (itch).
Fortunately, the patient complied with our instructions. To relieve ocular itch, he describes how he modified his eye rubbing technique, by avoiding direct contact and force on the cornea (watch the video below).
Here are pictures of the patient rubbing his eyes and his profiles
PATIENT LEFT PROFILE.
This picture shows a change in corneal curvature between the upper and lower parts based on the corneal reflection.
PATIENT RIGHT PROFILE. It is difficult to appreciate a change of corneal curvature on this profile. Nevertheless we can perceive a slight corneal bulge.
PATIENT RUBBING HIS RIGHT EYE WITH THE KNUCKLES
PATIENT DEMONSTRATING HIS SLEEP POSITION (ON HIS RIGHT SIDE)
THE PATIENT'S MOTHER POINTING OUT TO US A PATIENT PROFILE SIMILAR TO HER SON'S CASE ON THIS WEBSITE
HER MOM SHOWING HOW HER SON USED TO RUB HIS EYES WITH KNUCKLESPatient showing how he rubs his eyes
Patient demonstrating his new technique to avoid eye rubbing
Here are the Orbscan quadmaps with SCORE ANALYZER, OPD scans, Ocular Response Analyzer (ORA) and Corneal OCT maps (epithelial and cross-sectional) of the first visit .
RIGHT EYE ORBSCAN (1st VISIT). There is marked central thinning and paracentral inferior steepening. Note the increased prolateness of both the anterior and posterior corneal surfaces.
LEFT EYE ORBSCAN (1st VISIT). There is marked central thinning and paracentral inferior steepening. Note the increased prolateness of both the anterior and posterior corneal surfaces.
RIGHT EYE SCORE.
The positive SCORE (generated from a set of criteria) strongly suggests the presence of keratoconus.
LEFT EYE SCORE. The positive SCORE (generated from a set of criteria) strongly suggests the presence of keratoconus.
RIGHT EYE OPDscan III map (corneal topography and aberrometry). The corneal deformation causes the optical quality of the eye to decrease dramatically. There is a marked increase in coma-like aberrations. These aberrations cannot be corrected by spectacles.
LEFT EYE OPDscan III map (corneal topography and aberrometry). The slight corneal distortion induces some coma and trefoil-like aberrations. The automated classification (neural network, Corneal Navigator, Nidek) suggests the presence of keratoconus.
RIGHT EYE ORA. (Ocular Response Analyzer). The ORA measurement of the left eye is unremarkable, despite a slight reduction in the height of the peaks.
LEFT EYE ORA. The hysteresis and the peak heights are slightly less than average. This might imply a slight weakening or mild deformation caused by chronic rubbing.
RIGHT EYE HIGH RESOLUTION OCT EPITHELIAL THICKNESS AND PACHYMETRY MAP. Note the slight increase in the thickness of the epithelium, to partly compensate for the corneal deformation.
LEFT EYE HIGH RESOLUTION OCT EPITHELIAL THICKNESS AND PACHYMETRY MAP. Note the slight increase in the thickness of the epithelium, to partly compensate for the corneal deformation.
RIGHT EYE CROSS-SECTIONAL OCT
LEFT EYE CROSS- SECTIONAL OCTDifference maps were performed at each subsequent visit. No evolution has been observed between the first and last visits. The keratoconus is stable, more than 2 months after the patient definitively stopped rubbing his 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 ORBSCAN (2nd VISIT). Stable since first visit.
ORBSCAN DIFFERENTIAL MAPS : RIGHT EYE (between 1st and 2nd visits) This map reveals the stability of the corneal deformation. There is no progression.
ORBSCAN DIFFERENTIAL MAPS : LEFT EYE (between 1st and 2nd visits). This map reveals the stability of the corneal deformation. There is no progression.
RIGHT EYE ORBSCAN (3rd VISIT)
LEFT EYE ORBSCAN (3rd VISIT)
RIGHT EYE PENTACAM (3rd VISIT)
LEFT EYE PENTACAM (3rd VISIT)
RIGHT EYE PENTACAM DIFFERENTIAL MAPS (between 2nd and 3rd visits). The difference map reveals the absence of significant change since the patient ceased to rub his eyes.
LEFT EYE PENTACAM DIFFERENTIAL MAPS (between 2nd and 3rd visits). The difference map reveals the absence of significant change since the patient ceased to rub his eyes.In this case, we find many triggers for eye rubbing like exposure to dust and night-time ocular compression from an unhealthy sleeping position. The asymmetric nature of keratoconus development is related to the sleeping position (right sided) and the habit of preferentially rubbing the right eye. Once again, the technique of eye rubbing is directly related to the severity of keratoconus. Rubbing with the knuckles, the hardest part of the hands, is particularly detrimental, as it inflicts severe biomechanical stress on the cornea.
An interesting point of note is that through numerous patient testimonials on this site, initiation of the eye rubbing habit often begins shortly after a change of profession, especially when the environment concerned is filled with dust and irritants, or if the job requires long periods of intensive work. In the younger patients, long hours preparing for exams can be a triggering factor.
It is very important to spend time with the patient to elucidate the need for eye rubbing. Often the answers are not apparent at the first consultation, because the patient is not always conscious of the habit. Hence the importance of re-interrogating the patient at each consultation to make him aware of his rubbing habits.
The presence of relatives is often useful because it allows the patient to better realize at which moments he rubs his eyes.
Fortunately, the cessation of eye rubbing resulted in a stabilization of the corneal deformation in this patient’s case, with no progression of the keratoconus.
- Date 1 avril 2018
- Tags Asymmetric, Bilateral keratoconus, Dry eyes, Eye rubbing, Inferior keratoconus, Knuckles rubbing, Male, Night shift, Pillow hugging, Sleep position, Stabilization, Witness, Work rubbing