Patient right profile
Mr. LJ is a 24-year-old male with schizoprenia. He has no known family history of keratoconus. He presented to us with a progressive decrease in visual acuity greater in the right eye than the left, as well as frequent redness in both eyes.
His refraction at the first visit at the Rothschild Foundation (on 03/1st/2018) was : Right Eye (RE) 20/32 with -1.25 (-4.25 x 25 °) and Left Eye (LE) 20/32 with +0.50 (-3.00 x 155 °).
Clinical examination with the slit lamp revealed bilateral Vogt’s striae and Fleischer rings (Fleischer rings are pigmented rings in the peripheral cornea, resulting from iron deposition in basal epithelial cells, in the form of hemosiderin. Vogt’s striae are thin vertical streaks located in the posterior corneal stroma (at the level of the Descemet membrane)). We also found superficial punctate keratopathy in the inferior cornea of the right eye, indicating a clinically dry eye.
Corneal topography performed at our institution showed 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 in the mornings or at night while watching television, as rubbing gives him a sense of well-being. He has no known allergies. He used to sleep on his right side with his head on the arm. He often awakes in the mornings with bilateral eye redness, more in the right eye than the left.
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 him to stop rubbing his eyes and to change his unhealthy sleeping position. We also prescribed him an eye shield for the right eye for use during sleep. We treated his dry eyes with artificial tears and vitamin A ointment at night.
At the subsequent visits, the patient informed us that despite being warned of the dangers of eye rubbing, he had difficulty abstaining from rubbing his right eye, as he derived a certain pleasure from rubbing it. He was however able to stop rubbing his left eye on most occasions. He also verbalized having problems keeping the eye shield on at night (it would often come off his face), and he was still sleeping on his right side.
We once again reiterated the dangers of eye rubbing and strongly encouraged this patient to alter his sleep position and to consciously stop rubbing his eyes.
Here are pictures of the patient rubbing his eyes and his profiles
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 were able to refrain from rubbing their eyes, this patient unfortunately, is unable to stop. The pleasurable and relaxing sensations that eye rubbing affords makes it difficult for patients to quell the habit, especially in the context of co-existent dry eye and ocular fatigue from long hours at work in front of the computer. Currently, only several cases in this website have shown progression of keratoconus, and all these have a common denominator: a failure of compliance to stop their persistent eye rubbing habit. (eg Read the story of a patient with Down syndrome)
To quell the urge to rub the eyes, it is necessary to eliminate all the factors that could trigger eye rubbing. This includes eradication of the responsible allergens, changing the sleeping posture and improving work patterns and habits. As long as one of these factors persists, it would be difficult for patients to stop rubbing their eyes, and the progression of keratoconus is inevitable.
Our goal is not to victim-blame those who are progressing, but to inform and educate them to better understand the circumstances surrounding the genesis and evolution of their keratoconus, in order to help them stop their eye rubbing habit and stabilize the disease.
The corneal dome can be likened to a shell whose equilibrium geometry depends on the difference between the intraocular pressure (exerted on its posterior surface) and the atmospheric pressure. Beyond a certain threshold, the mechanical stresses (compression, shear) conveyed by eye rubbing results in a biomechanical embrittlement, due to the rupture of the harmonious arrangement of collagen fibers, which causes an irreversible deformation of the cornea (This mechanism is analogous to the « buckling » in resistance of materials). If a constant pressure is exerted on the cornea, the deformation can only get worse Stabilization of keratoconus is therefore most challenging in cases of persistent and vigorous eye rubbing.
Other cases :
- Date 15 juillet 2018
- Tags Asymmetric, Bilateral keratoconus, Dry eyes, Enjoyed eye rubbing, Eye rubbing, Eye shield, Fleischer ring, Inferior keratoconus, Knuckles rubbing, Male, Progression, Schizophrenia, Sleep position