Case #93

Case #93

The patient

Patient right profile

Bilateral Asymmetric Keratoconus induced by eye rubbing

Identity : Mr F.X
First visit : 04/10/2018
Last Visit : 10/02/2018

34
Age (years)
6
Follow-up (months)
The crosslinking controversy

Mr. F.X is a 34-year-old male music DJ with no any known family history of keratoconus (he has one brother and one sister without keratoconus). He underwent bilateral ptosis in childhood. He complained of a progressive decrease in visual acuity greater in both eyes.

His refraction at the first visit at the Rothschild Foundation (on 04/10th/2018) was : Right Eye (RE) 20/80 with -2.0 (-1.5 x 0 °) and Left Eye (LE) 20/32 with  +0.5 (-1.75 x 85 °).

Clinical examination with the slit lamp suggested a thin and irregular corneas with Fleischer ring. Fleischer rings are pigmented rings in the peripheral cornea, resulting from iron deposition in basal epithelial cells, in the form of hemosiderin.

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 frequent eye rubbing, the patient admitted to rubbing his eyes when he awoke in the mornings or before sleeping. He used to rub his eyes using his right hand as a forceps, with his thumb rubbing his right eye and his forefinger rubbing his left eye. It gives him a feeling of well being and relieves him of his fatigue. He  also spends many hours in front of the computer to do music and  works till late in the evening and night.

He is right handed and used to sleep on his stomach, 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 also advise him to adapt his lifestyle and avoid the night shifts, often leading to rubbing his eyes.

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

PATIENT RIGHT PROFILE
PATIENT LEFT PROFILE
PATIENT RUBBING HIS EYES WITH KNUCKLES
PATIENT SLEEP POSITION. He sleeps on his right side, with the head buried in the pillow.

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

RIGHT EYE ORBSCAN (1st VISIT). This examination reveals a pronounced keratoconus pattern. The cornea is very aspheric, and the deformation is also asymmetric. There is marked central thinning.
LEFT EYE ORBSCAN (1st VISIT). This maps shows an advanced keratoconus.
RIGHT EYE PENTACAM (1st VISIT). This data parallels that of the Orbscan: the deformation of the cornea is pronounced.
LEFT EYE PENTACAM (1st VISIT). The pattern disclosed here mirrors that of the right eye. The corneal distortion is very pronounced.
ORARIGHT EYE ORA. The biomechanical examination reveals low applanation peaks, indicating a "locally more deformable" cornea.
LEFT EYE ORA (Ocular Response Analyzer). The ORA measurement of the left eye is unremarkable, despite a slight reduction in the height of the peaks.

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 .

RIGHT EYE PENTACAM DIFFERENTIAL MAP (1)
PENTACAM DIFFERENTIAL MAPS : LEFT EYE. (between first and second visits)
RIGHT EYE PENTACAM DIFFERENTIAL MAP (2)
PENTACAM DIFFERENTIAL MAPS : LEFT EYE. (between first and third visits)

In this case, many factors responsible for eye rubbing are present: extended computer workirregular work schedules with frequent night shifts, and finally an unhealthy sleeping position.

Prolonged work in front of the computer is responsible for dry eye caused by a reduced  blinking rate and subsequent increased tear film evaporation. This triggers ocular surface irritation and the desire to rub the eyes.  Rubbing neutralizes the irritation and allows a re-lubrication of the ocular surface.

Night-shift work is also associated with dry eye . The lack of sleep is often relieved by eye rubbing which provides a sense of well-being to the patient.

Finally, we observed that the position of sleep is often related to the side of asymmetric cases. The prolonged compression on the eye and orbit may result in a local increase in temperature, and the lack of oxygenation and prolonged contact with the pillow (& allergens) during the night may be responsible for a desire to rub the eyes upon awakening.

All these factors were explained to the patient during his first visit. He stopped rubbing his eyes and changed his sleeping position.

  • Date 23 octobre 2018
  • Tags Enjoyed eye rubbing, Eye rubbing, Finger pulp rubbing, Knuckles rubbing, Male, Morning rubbing, Sleep position, Stabilization

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