Patient right profile
Case #83
The patient
Bilateral Asymmetric Keratoconus induced by eye rubbing
Identity : Mr H.B
First visit : 11/07/2017
Last Visit : 03/06/2018
36
Age (years)4
Follow-up (months)Mr. H.B is a 36-year-old sports coach 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 11/07th/2017) was : Right Eye (RE) 20/32 with -1 (-3.25 x 80 °) and Left Eye (LE) 20/25 with -0.75 (-2.75 x 125°).
Clinical examination with the slit lamp suggested a slight paracentral thinning and an inferior bulge more pronounced in the right eye .
There were Vogt’s striae and a Fleischer ring (Fleischer rings are pigmented rings in the peripheral cornea, resulting from iron deposition in basal epithelial cells, in the form of hemosiderin) in the right eye. He also had signs of dry eye, with a pathological tear film break up time of less than 8s.
Corneal topography revealed the presence of bilateral keratoconus more pronounced in the right eye.
When asked about the possibility of frequent eye rubbing, the patient admitted to rubbing his eyes at work and after a shower.
He sleeps on his stomach at night, with his head positioned on either side against the pillow.
The patient is right-handed.
At the subsequent visits, he conveyed to us that he became aware that he was rubbing his right eye more frequently and vigorously than his left, especially with his palms, as it brought a sense of relief to his dry and tired eyes. He also described a previous habit of rubbing his eyes after removal of his contact lenses, which he had been wearing for 10 years, but stopped after becoming contact lens intolerant.
We explained to the patient that since vigorous eye rubbing had preceded the drop in visual acuity, this habit may have caused the cornea to deform in his case. We strongly advised him to stop rubbing his eyes and to change his unhealthy sleeping position.
Here are pictures of the patient rubbing his eyes and his profiles
PATIENT RIGHT PROFILE.
It is difficult to perceive any corneal curvature changes on this scale, but there is a hint of a slight protrusion inferiorly. 
PATIENT RUBBING HIS EYES WITH HIS KNUCKLES. 
PATIENT DEMONSTRATING HIS SLEEP POSITION (ON HIS SIDES)Patient rubbing his eyes with the knuckles (more vigorously on the right side with his dominant hand)
Patient rubbing his eyes with his palms
Here are the Orbscan quadmaps with SCORE ANALYZER, Pentacam maps, OPD scans, Ocular Response Analyzer (ORA) and Corneal OCT epithelial maps of the first visit
RIGHT EYE ORBSCAN (1st VISIT). The corneal deformation is obvious: it is characterized by a thin cornea with an irregular inferior steepening. The corneal surfaces are hyerprolate. The keratoconus is more pronounced ain the right eye.
LEFT EYE ORBSCAN (1st VISIT). The corneal deformation is obvious: it is characterized by an irregular inferior steepening. The corneal surfaces are hyerprolate. 
RIGHT EYE SCORE ANALYZER. The highly positive SCORE number strongly suggests the presence of a frank keratoconus
LEFT EYE SCORE ANALYZER. The highly positive SCORE number strongly suggests the presence of a frank keratoconus. 
RIGHT EYE PENTACAM (1st VISIT). The topographic features of the Pentacam examination mirror the abnormalities seen on the Orbscan,: infero-central steepening and central thinning.
LEFT EYE PENTACAM (1st VISIT). The topographic features of the Pentacam examination mirror the abnormalities seen on the Orbscan,: infero-central steepening and central thinning.
RIGHT EYE OPD SCAN. There is an important increase in higher order aberrations, caused by the corneal distortion. The corneal inferior steepening has induced an inferior local myopia.
LEFT EYE OPD SCAN. There is an important increase in higher order aberrations, caused by the corneal distortion. The corneal inferior steepening has induced an inferior local myopia.
RIGHT EYE ORA (Ocular Respolnse Analyzer). The height of the applanation peaks is reduced. This suggests an increased susceptibility to corneal deformation. 
LEFT EYE ORA (Ocular Respolnse Analyzer). The height of the applanation peaks is reduced. This suggests an increased susceptibility to corneal deformation.
CORNEAL OCT (Optical Coherence Tomography) TOTAL AND EPITHELIAL MAP : RIGHT EYE. There is a marked reduction of the epithelial thickness near the apex of the corneal deformation.
CORNEAL OCT (Optical Coherence Tomography) TOTAL AND EPITHELIAL MAP : LEFT EYE. There is a marked reduction of the epithelial thickness near the apex of the corneal deformation.Difference maps were performed at each subsequent visit. No evolution has been observed between the first and last visits. The keratoconus is stable, more than 4 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 PENTACAM (2nd VISIT). Stable since first visit.
PENTACAM DIFFERENTIAL MAPS : RIGHT EYE. There are no significant changes between these examinations.
PENTACAM DIFFERENTIAL MAPS : LEFT EYE. There are no significant changes between these examinations.
RIGHT EYE ORBSCAN (3RD VISIT). Stable since first visit.
LEFT EYE ORBSCAN (3RD VISIT). Stable since first visit.
RIGHT EYE PENTACAM (3RD VISIT). Stable since first visit.
LEFT EYE PENTACAM (3RD VISIT). Stable since first visit.
PENTACAM DIFFERENTIAL MAPS : RIGHT EYE. There are no significant changes between these examinations.
PENTACAM DIFFERENTIAL MAPS : LEFT EYE. There are no significant changes between these examinations.This case demonstrates that the cessation of eye rubbing is the key factor in the stabilisation of keratoconus.
Through this case, we can observe several important elements: the asymmetrical character of the keratoconus on the one hand linked to the differential force exerted by the dominant hand during eye rubbing and also to the unhealthy position of sleep causing compression on the orbit and globe. We note through all cases published on this website that eye rubbing occurs frequently at work (in front of the computer screen mainly), after a shower (possibly from limescale in the water irritating the eyes) or just after removal of contact lenses.
It is important to take the time to interrogate patients on their eye rubbing habits and to educate and counsel them on the dangers of eye rubbing. .
In our opinion, keratoconus is primarily caused by vigorous eye rubbing. The fact that keratoconus progression is invariably arrested when patients stop rubbing their eyes is a strong argument in favour of the theory of eye rubbing being the root cause of keratoconus.
- Date 2 avril 2018
- Tags Asymmetric, Bilateral keratoconus, Dry eyes, Enjoyed eye rubbing, Eye rubbing, Inferior keratoconus, Knuckles rubbing, Male, Palm rubbing, Post shower rubbing, Sleep position, Stabilization, Work rubbing