Various experts in the field of keratoconus share clinical pearls for managing and comanaging the condition as well as the latest diagnostic and treatment options, including corneal cross-linking. Image: John D. Gelles, OD, FIAO, FCLSA, FSLS, and CLEI Center for Keratoconus

BLOG: Why do patients rub?

Mitch Ibach

by Mitch Ibach, OD, FAAO

In clinic when I am evaluating a patient for suspected keratoconus or corneal ectasia, within the first 3 minutes of our time together I ask the question, “Do you rub, touch or press on your eyes?”

I will often follow up the first question with, “Do you sleep on your stomach, back or side?” to assess nocturnal rubbing in stomach or side sleepers.

Keratoconus is a noninflammatory corneal degeneration with asymmetric weakening to corneal biomechanics. The single exact cause of keratoconus is unknown, and while the corneal degeneration is likely multifactorial there is strong anecdotal and research-based evidence correlating mechanical eye rubbing to the diagnosis and progression.

The Collaborative Longitudinal Evaluation of Keratoconus Study enrolled more than 1,000 patients with KCN, and when asked about eye rubbing nearly 50% admitted to vigorous eye rubbing (Wagner et al.). In surveying other published data, common admittance to eye rubbing ranges from 50% to 70% of diagnosed patients and up to 90% in the pediatric population (Hawkes et al, Shneor et al, Leoni-Mesplie et al). With this known risk for mechanical ectasia, why do patients rub, and how do we as the primary diagnosticians for KCN help disconnect the eye rubbing link?

The phrase, “The first step is realizing you have a problem,” holds true for many eye rubbers. Touching and pressing on the eyes becomes habitual, and on many instances in the exam room when I ask a patient about eye-rubbing he or she will deny it. If I then ask the family member or friend accompanying our patient if he/she rubs his/her eyes, the story reverses.

This patient has acute hydrops secondary to aggressive eye rubbing and keratoconus.
Source: Mitch Ibach, OD, FAAO

When reviewing ocular conditions that drive eye-rubbing, atopy, inflammation and loose/excess eyelid skin are three big culprits. First, allergic conjunctivitis (atopy) commonly leads to chronic itching and ocular pressure. Treating ocular allergies with a myriad of topical and/or oral allergy medications can lessen the urge to itch.

Second, ocular surface disease (OSD) (inflammation) and external blepharitis induces uncomfortable and often watery eyes. We’re well equipped to treat OSD/blepharitis with artificial tears, anti-inflammatories, steroids, autologous tears, eyelid hygiene, thermal pulsation treatments, oral antibiotics and many more.

Finally, floppy eyelid syndrome (FES) leads to excessive lid laxity and chronic papillary conjunctivitis. These patients are prone to eye-rubbing and dry eye with a high correlation to chronic sleep apnea and CPAP machines. Aggressively treating the ocular surface in FES patients can help cut down on eye rubbing.

Corneal cross-linking (CXL) provides an exceptional treatment for progressive keratoconus and corneal ectasia patients. In our practice, after the diagnosis of keratoconus is made, two staples in our management plan include halting all eye rubbing and recommending CXL to freeze progression. Providing patients with effective treatments to decrease the eye-rubbing urges is paramount to their efforts. After they leave our office, building a team approach to boost awareness is a helpful tool for ceasing mechanical grinding.


References:

Hawkes E, et al. Int J Kerat Ect Cor Dis. 2014;3(3):118-121.

Leoni-Mesplie S, et al. J Fr Ophtalmol. 2012;doi:10.1016/j.jfo.2011.12.012.

Shneor E, et al. Clin Exp Optom. 2013;doi:10.1111/cxo.12005.

Wagner H, et al. Cont Lens Anterior Eye. 2007;doi:10.1016/j.clae.2007.03.001.


For more information:

Mitch Ibach, OD, FAAO, is a residency-trained optometrist at Vance Thompson Vision in Sioux Falls, S.D., who specializes in anterior segment surgical care including cataracts, corneal diseases, glaucoma and refractive surgeries. He can be reached at: mitch.ibach@vancethompsonvision.com.


Disclosure: Ibach reports he is a consultant/lecturer for Aerie, Avedro and Glaukos; a speaker for Alcon; an investor in Equinox; and a consultant for Ocular Therapeutix.