Case #96

Case #96

The patient

Patient right profile

Bilateral Keratoconus induced by eye rubbing

Identity : Mr E.G
First visit : 06/01/2018
Last Visit : 10/23/2018

29
Age (years)
4
Follow-up (months)
The first and only prospective online study of keratoconus and eye rubbing

Mr. E.G is a 29-year-old male statistician with allergy to dust mites. He has a brother who works as an air traffic controller and he does not have any known allergies or 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 06/1st/2018) was : Right Eye (RE) 20/32 with -0.75 (-4 x 30 °) and Left Eye (LE) 20/20 with +0.25 (-2.5 x 155 °).

Corneal topography performed at our institution showed the presence of bilateral keratoconus.

Clinical examination with the slit lamp revealed a discrete irregular inferior corneal bulge in both eyes. The eyes were clinically dry, with break up time < 8 seconds.

When asked about his work habits, the patient declared that he worked for long hours in front of the computer, and had been doing overnight shifts for the last 4 years. He admitted to rubbing his eyes very frequently to relieve visual fatigue. He described how his vision deteriorated a few years after starting his new job where he was required to spend many hours in front of the computer to conduct market research.

He is right-handed and sleeps preferentially on the right side.

We urged him to stop rubbing his eyes and treated his dry eye with lubricants. 

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.

We once again reiterated the dangers of eye rubbing  and strongly encouraged this patient to consciously stop rubbing his eyes. 

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

PATIENT RIGHT PROFILE
PATIENT LEFT PROFILE
PATIENT SHOWING HIS SLEEP POSITION
PATIENT RUBBING HIS EYES WITH HIS KNUCKLES

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

RIGHT EYE ORBSCAN (1st scan). These maps show a typical mild keratoconus pattern. The cornea is hyperprolate (conical shape). It is also irregular. The repeated trauma has caused the cornea to "buckle" centrally.This explains the steepening of the corneal apex.
LEFT EYE ORBSCAN (1st scan). These maps show a typical mild keratoconus pattern. The cornea is hyperprolate (conical shape). It is also irregular. The repeated trauma has caused the cornea to "buckle" centrally.This explains the steepening of the corneal apex.
RIGHT EYE OPD. The ocular wavefront is distorted by odd aberration terms
LEFT EYE OPD. The ocular wavefront is distorted by odd aberration terms
RIGHT EYE ORA (Ocular Response Analyzer) The height of the applanation peak is reduced. This suggests an increased susceptibility to corneal deformation.
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 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 .

PENTACAM DIFFERENTIAL MAPS : RIGHT EYE (between 1st and 2nd visits). The difference map (third column) and its related indices demonstrate the absence of evolution of the corneal deformation. You can note a "crosslinking-like" effect with flattening of the central cornea.
PENTACAM DIFFERENTIAL MAPS : LEFT EYE (between 1st and 2nd visits). The difference map (third column) and its related indices demonstrate the absence of evolution of the corneal deformation. You can note a "crosslinking-like"effect with flattening of the central cornea.

This case reveals that an eye rubbing habit can often be triggered by long hours of overnight shifts and/or time spent in front of the computer, which induces visual fatigue associated with dry eye (reduced blinking). These sensations are often relieved (transiently) by eye rubbing, which as described by patients, can be pleasurable and relaxing in such circumstances. 

It’s known that digital eye strain from extended computer work can cause ocular fatigue, headaches and difficulty focusing, which may potentially impact our vision over the long-term. Eye rubbing or compression of the globe (eyeball) is often used to relieve the visual fatigue by inducing a reflex tearing that moisturises the eyes. It also helps relieve stress by vagal stimulation that slows the heart rate. 

The repeated and sustained frictions from eye rubbing over the long-term are responsible for the pathological permanent warpage of the cornea, culminating in the condition we call « keratoconus ». Rubbing with the fists and knuckles is particularly detrimental to the cornea, because the knuckles are the hardest part of the hands.

The cessation of eye rubbing and treatment of underlying dry eye are sufficient in such cases.

  • Date 2 novembre 2018
  • Tags Allergy, Asymmetric, Bilateral keratoconus, Eye rubbing, Knuckles rubbing, Male, Sleep position