Case #98

Case #98

The patient

Patient right profile

Bilateral Asymmetric Keratoconus induced by eye rubbing

Identity : Mr L.N
First visit : 06/26/2018
Last Visit : 10/23/2018

57
Age (years)
4
Follow-up (months)
The crosslinking controversy

Mr. L.N is a 57-year-old male computer scientist with asthma and pollen allergy but no 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 06/26th/2018) was : Right Eye (RE) 20/32 with -0.25 (-5.5 x 85 °) and Left Eye (LE) 20/25 with -1.5 (-3.0 x 115 °).

Corneal topography performed at our institution showed the presence of a bilateral keratoconus, more pronounced in the right eye

Clinical examination with the slit lamp suggested thin and irregular corneas with Fleischer rings. 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 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 enjoying rubbing his eyes when working in front of the computer. The many hours spent in front of the computer was associated with frequent dry and tired eyes, and eye rubbing induced a sense of relaxation for this patient. He told us to be overworked at work, and that eye rubbing helps him to relax.

He is right handed and rubs his right eye more forcefully, with the palm of his hand. He used to sleep on his right side, with the head buried in the pillow (pillow hugging).

Therefore, the patient sleeps on either side, but he reported that he used to sleep on the desk at work, using his arm as a pillow, supporting the head directly on the eyes and forehead. He also mentioned that when in bed, he would sometimes contort his body such that one of the eyes was constantly rubbing against the pillow. He prefers to put his head on his right arm, applying direct pressure on the right eye, which is systematically in direct contact with the arm. This may explain the asymmetrical nature of the keratoconus, with the right eye being more severely affected than the left. Over time, the patient became more aware of the importance of  the role played by eye rubbing and an unhealthy sleeping position on his cornea, and thus modified his habits accordingly.

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 referred him to a specialist for management of his allergies and treated his dry eyes with artificial tears,

At subsequent visits, the patient alluded to having allergic rhinitis as well as ocular allergy during childhood, resulting in frequent and intense eye rubbing episodes. He also realized that on the occasions when he was trying to sleep on his back, he would sometimes place his arm over the eyes (i.e. to block any light in the room). He also came with his 8-year-old daughter, who is also allergic to pollen and used to rub her eyes with the knuckles. We recommended her to stop doing this gesture and treat her allergy.

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

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

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

RIGHT EYE PENTACAM (1st VISIT). This is a typical keratoconus pattern.
LEFT EYE PENTACAM (1st VISIT). As for the right eye, the right eye shows marked irregularity and steepening.
RIGHT EYE PENTACAM (1st VISIT). This is a typical keratoconus pattern.
LEFT EYE PENTACAM (1st VISIT). As for the right eye, the right eye shows marked irregularity and steepening.
RIGHT EYE OPDscan. There is marked elevation of the defocus-like aberration, secondary to the severe corneal distortion infero-temporally.
LEFT EYE ORBSCAN (1st VISIT).
High resolution OCT of the right eye cornea, which shows a paracentral temporal inferior thinning. The epithelium is also thinner in the vicinity of the thinnest stromal area. This zone receives the majority of the mechanical energy and shearing forces vehicled by the fingers.
high resolution OCTHR OCT of the left cornea. There is a slight thinning of the epithelium inferiorly.

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 4 months after the patient has definitely stopped to rub his eyes .

RIGHT EYE PENTACAM DIFFERENTIAL MAP (1). This map shows the absence of progression between the two examinations (1st and 2nd columns)
LEFT EYE PENTACAM DIFFERENTIAL MAP (1). This maps demonstrates the absence of progression of the disease.
RIGHT EYE PENTACAM DIFFERENTIAL MAP (2). This maps demonstrates the absence of progression of the disease.
LEFT EYE PENTACAM DIFFERENTIAL MAP (2) : there is no progression of the corneal deformation (stability)

In this case we find many triggers for eye rubbing like extended computer work and an unhealthy sleeping position.  The 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.

  • Date 23 octobre 2018
  • Tags Allergy, Asymmetric, Bilateral keratoconus, Computer screen, Dry eyes, Eye rubbing, Knuckles rubbing, Male, Sleep position, Stabilization