Case #97

Case #97

The patient

Patient right profile

Unilateral Post LASIK Corneal Ectasia induced by eye rubbing

Identity : Mr P.M
First visit : 09/03/2013
Last Visit : 10/17/2017

39
Age (years)
49
Follow-up (months)
The crosslinking controversy

Mr. P.M is a 39-year-old male administrative agent 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. He had bilateral LASIK performed in 2013 at another institution. Pre-operatively, he had myopia of about -8 D in both eyes. There were no known surgical complications during the procedure.

He complained of a progressive decrease in visual acuity two years after the surgery (2014), greater in the left eye than the right one.

His refraction at the first visit at the Rothschild Foundation (on 09/03th/2017) was : Right Eye (RE) 20/20 with+0.25 (-0.75 x 70 °) and Left Eye (LE) 20/32 with -0.5 (-2.5 x 115 °).

Clinical examination with the slit lamp suggested a thin and irregular right cornea 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 unilateral corneal ectasia in the left eye.

We investigated the risk factors for ectasia at her first visit. When asked about the possibility of frequent eye rubbing, the patient admitted to rubbing his eyes before and after LASIK, especially the left one. After the surgery in particular, he would rub his eyes vigorously because he enjoyed it. The patient admitted that he had rubbed his eyes regularly following the surgery, to soothe his constantly irritated eyes. As he was right-handed, but he would rub his left eye especially and more vigorously than the right eye at work. When he is at work, he used to keep his right hand on the mouse and rubbing his left eye with his left hand (which is free).

About sleep position, he used to sleep on stomach ou sides.

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.

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

PATIENT RIGHT PROFILE
PATIENT LEFT PROFILE
PATIENT RUBBING HIS LEFT EYE WITH HIS FINGER PULP

Here a video of patient rubbing preferably his left eye

Here are the Orbscan quadmaps, Pentacams maps, 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 49 months after the patient has definitely stopped to rub his eyes .

In this case we find many triggers for eye rubbing like extended computer work and an unhealthy sleeping position.  The unilateral or asymmetric nature of keratoconus development may be related to the sleeping position (right sided) and the habit of preferentially rubbing the right eye. .

This case is very informative and demonstrative of the causal effects of eye rubbing in the pathogenesis of keratoconus. Cross-linking is unnecessary in this case, as stabilisation of the corneal deformation was achieved with the simple act of cessation of eye rubbing.

As demonstrated again in this clinical example, the cessation of eye rubbing and patient education are the best tools in the prevention of the genesis and/or evolution of keratoconus.

The patient

Patient right profile

Unilateral Asymmetric Keratoconus induced by eye rubbing

Identity : Mr S.U
First visit : 09/03/2013
Last Visit : 10/17/2017

39
Age (years)
49
Follow-up (months)
The crosslinking controversy

Mr. S.U  is a 39-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 right eye than the left.

His refraction at the first visit at the Rothschild foundation (on 09/03th/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 a thin and irregular right cornea 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 unilateral keratoconus, 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 when working in front of the computer because he enjoyed it.

He is left handed but rubbed his right eye with his right hand. The patient sleeps 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.

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

PATIENT RIGHT PROFILE
PATIENT LEFT PROFILE
PATIENT SLEEP POSITION
PATIENT DEMONSTRATING HIS SLEEPING POSITION

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

RIGHT EYE ORBSCAN (1st VISIT). This examination shows severe deformation with infero-temporal steepening, evocative of frank keratoconus.
LEFT EYE ORBSCAN (1st VISIT). The cornea is thin, and the posterior float is little increased (top right) but no major deformation evocative of keratoconus is perceptible. This indicates a possible forme fruste keratoconus
RIGHT EYE OPDscan. There is marked elevation of the defocus-like aberration, secondary to the severe corneal distortion infero-temporally.
LEFT EYE OPD. The OPD is uremarkable.
ocular response analyserRIGHT EYE ORA. The corneal hysteresis is very low, and the height of the applanation peaks is dramatically reduced.
LEFT EYE ORA. The hysteresis and the peak heights are slightly less than average. This might imply a slight weakening or mild deformation caused by chronic rubbing.

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 49 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).
RIGHT EYE ORBSCAN (3rd VISIT)
LEFT EYE ORBSCAN (3rd VISIT)
RIGHT EYE ORBSCAN DIFFERENTIAL MAPS
LEFT EYE ORBSCAN (4th VISIT)
RIGHT EYE PENTACAM (2nd VISIT)
LEFT EYE PENTACAM (2nd VISIT)
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.
Pentacam difference map of the left eye, showingPENTACAM DIFFERENTIAL MAPS : LEFT EYE. (between first and second visits). This difference map demonstrates the absence of keratoconus progression, coincident with the time the patient stopped rubbing her eyes.

As demonstrated again in this clinical example, the cessation of eye rubbing and patient education are the best tools in the prevention of the genesis and/or evolution of corneal ectasia

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