Case #90

Case #90

The patient

Patient left profile

Unilateral Asymmetric Keratoconus induced by eye rubbing

Identity : Mr M.Q
First visit : 01/09/2014
Last Visit : 05/22/2018

61
Age (years)
52
Follow-up (months)
JUST DIAGNOSED : WHAT SHOULD YOU DO ?

Mr. M.Q is a 61-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 left eye than the right one.

His refraction at the first visit at the Rothschild foundation (on 01/09th/2014) was : Right Eye (RE) 20/25 with+1.25 (-0.5 x 40 °) and Left Eye (LE) 20/40 with +2.50 (-8.75 x 180 °).

Slit lamp examination revealed a keratoconus pattern with a Fleischer ring in the left eye. The right eye was unremarkable. Fleischer rings are pigmented rings in the peripheral cornea, resulting from iron deposition in basal epithelial cells, in the form of hemosiderin.

When asked about a possible eye rubbing habit, the patient admitted to enjoying rubbing his eyes in the morning when he awakes and at work.

When asked about his working habits, the patient declared that he worked for long hours in front of the computer screen, and had been doing overnight shifts for the last years. He admitted that he rubbed his eyes a lot to relieve visual fatigue

He is right-handed and declared that he used to rub his left eye most of the time, with knuckles.

Also, He used to sleep on left side, with the head buried in the pillow. 

We provided him some explanation about the plausible effect of eye rubbing on the onset of keratoconus. We strongly advised this patient to pay attention to possible subconscious rubbing episodes, and to stop eye rubbing indefinitely

At his subsequent review a month from the first visit, he verbalized that he was rubbing his eyes more often and more vigorously than he had realized at the first visit. He also remembered being allergic during his childhood, with his left eye more often itchy.

Here are pictures of the patient rubbing his eyes and his profiles

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 LEFT PROFILE. This picture shows a change in corneal curvature between the upper and lower parts based on the corneal reflection.
The patient demonstrates how he rubs his eyes. The direct contact of the knuckles on the eyeball (through the closed eyelids) is particularly harmful for the corneal dome. Interestingly, when asked to show how they rubbed their eyes, most patients would spontaneously rub one eye, which is the eye that they rubbed more frequently.
PATIENT DEMONSTRATING HIS SLEEP POSITION (ON HIS LEFT SIDE)

Here are the Orbscan quadmaps

RIGHT EYE ORBSCAN (1st VISIT). There is less 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.

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 52 months after the patient has definitely stopped to rub 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.
RIGHT EYE PENTACAM DIFFERENTIAL MAPS. The difference map reveals the absence of significant change since the patient ceased to rub his eyes.
LEFT EYE PENTACAM DIFFERENTIAL MAPS. 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 allergy, extended computer work and night-time ocular compression from an unhealthy sleeping position.  The asymmetric nature of keratoconus development is related to the sleeping position (left sided) and the habit of preferentially rubbing the left eye because of allergy and usual habit. 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 15 juillet 2018
  • Tags Asymmetric, Bilateral keratoconus, Childhood rubbing, Computer screen, Inferior keratoconus, Knuckles rubbing, Male, Night shift, Oldest, Palm rubbing, Sleep position, Stabilization, Work rubbing