Patient right profile
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
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.
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- Date 23 octobre 2019
- Tags Allergy, Asymmetric, Bilateral keratoconus, Computer screen, Dry eyes, Eye rubbing, Knuckles rubbing, Male, Sleep position, Stabilization