Case #89

Case #89

The patient

Patient right profile

Bilateral Asymmetric Keratoconus induced by eye rubbing

Identity : Mr C.I
First visit : 12/21/2017
Last Visit : 06/25/2018

Age (years)
Follow-up (months)
The crosslinking controversy

Mr. C.J is a 39-year-old male with no previous medical history or any known family history of keratoconus (he has one brother, without any allergy and keratoconus). He complained of a progressive decrease in visual acuity greater in the right eye than the left. He has allergy to dust mites, with eczema since his childhood and he rubbed his eyes very frequently during childhood because of this allergy.

His refraction at the first visit at the Rothschild foundation (on 12/21th/2017) was : Right Eye (RE) 20/25 with+0.25 (-2.5 x 70 °) and Left Eye (LE) 20/20 with -0.5 (-0.75 x 115 °).

Clinical examination with the slit lamp suggested thin and irregular corneas  with 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) and Vogt’s striae (vertical fine, whitish lines in the deep/posterior stroma and Descemet’s membrane commonly found in patients with keratoconus) in the right eye, with eczema on eyelid in both eyes. There is also coexistent ocular rosacea with blepharitis (common inflammation of the eyelid margins caused by abnormal secretion of Meibomian glands).

Corneal topography performed at our institution showed the presence of a 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 used to sleep 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 initially 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 from his 4th visit.

For visual rehabilation, he was fitted with scleral contact lenses

At the subsequent visithis mother iterated that his son would often rub his right eye with his right hand (see picture below).

After that, he became more conscious of his eye rubbing habit and the importance of the role played by eye rubbing and an unhealthy sleeping position on his cornea, and thus modified his habits accordingly.

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

Here are the Orbscan quadmaps, OPD scans and Ocular Response Analyzer (ORA) results of the first visit .

Difference maps have been performed at each subsequent visit. No evolution has been observed between the first and last visit. The keratoconus is still stable, more than 6 months after the patient has definitely stopped to rub his eyes .

This interesting case illustrates that the progression of keratoconus is directly related to the persistence of eye rubbing. Unlike the other cases in this website where the patients are able to refrain from rubbing their eyes, this patient unfortunately, is unable to stop. The responsible allergen (his cat’s hairs) is persistently in the environment, triggering an allergic cascade and the need to rub his eyes constantly to relieve the itch. Long hours spent in front of the computer screen, which causes visual fatigue associated with dry eye (reduced blinking), and an unhealthy sleeping position are also factors. The ocular discomfort in such instances is often relieved (transiently) by eye rubbing, which as described by patients, can be pleasurable and relaxing in such circumstances

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 becauseallergic 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 ».

When keratoconus patients stop rubbing their eyes definitively, the keratoconus no longer progresses. This renders obsolete the concept and therapeutic aims of cross-linking, whose effectiveness when measured objectively is doubtful, and is unfortunately being performed even in cases with no documented progression.

The cessation of eye rubbing and  proper allergy therapy are the best tools in preventing the onset and/or evolution of keratoconus.

  • Date 15 juillet 2018
  • Tags Allergy, Asymmetric, Bilateral keratoconus, Childhood rubbing, Eczema, Enjoyed eye rubbing, Eye rubbing, Fists rubbing, Knuckles rubbing, Male, Progression, Sleep position, Vogt's striae