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In this case report, it is aimed to present the clinical findings and treatment of a 9-year-old girl who developed bilateral acute corneal hydrops (ACH) at short intervals. Our patient first presented with ACH findings first the right eye and then 1 month later in her left eye. At first admission, both visual acuities were at very low levels and she had advanced stage keratoconus. The patient had a history of eye rubbing accompanied by mild to moderate allergic conjunctivitis. Corneal cross-linking treatment was planned for the left eye, but it could not be performed due to the rapid development of ACH in the left eye within 1 month. In cases of advanced keratoconus accompanied by eye rubbing in young children, caution should be exercised in case it progresses to bilateral ACH. [ABSTRACT FROM AUTHOR]

Abstract Background Although body mass index (BMI) and eye rubbing are linked to an increased risk of keratoconus (KC), the interactive effect of eye rubbing and BMI on KC is largely unknown. This study aimed to evaluate the independent and interactive effects of BMI and eye rubbing on KC and to further explore the role of environmental factors on the occurrence of KC. Methods A total of 621 individuals (291 KC patients and 330 control individuals) were enrolled in this hospital‑based study on KC patients in Central China after individuals missing BMI data were excluded. BMI was calculated as weight in kilograms divided by the square of height in meters. Data on eye rubbing was recorded through face-to-face interviews. Generalized linear regression models were used to analyze associations among BMI, eye rubbing and KC. Interaction plots were used to describe the interactive effects of BMI and eye rubbing on KC. Results The β and 95% confidence interval (CI) were 0.923 (0.112, 1.733) (p = 0.026) and 3.356 (1.953, 4.759) (p

Background: Although body mass index (BMI) and eye rubbing are linked to an increased risk of keratoconus (KC), the interactive effect of eye rubbing and BMI on KC is largely unknown. This study aimed to evaluate the independent and interactive effects of BMI and eye rubbing on KC and to further explore the role of environmental factors on the occurrence of KC. Methods: A total of 621 individuals (291 KC patients and 330 control individuals) were enrolled in this hospital‑based study on KC patients in Central China after individuals missing BMI data were excluded. BMI was calculated as weight in kilograms divided by the square of height in meters. Data on eye rubbing was recorded through face-to-face interviews. Generalized linear regression models were used to analyze associations among BMI, eye rubbing and KC. Interaction plots were used to describe the interactive effects of BMI and eye rubbing on KC. Results: The β and 95% confidence interval (CI) were 0.923 (0.112, 1.733) (p = 0.026) and 3.356 (1.953, 4.759) (p < 0.001), respectively, for the effect of each 10 kg/m2 increase in BMI and each 1 min increase in eye rubbing on KC. The interaction of BMI and eye rubbing were positively correlated with KC (p < 0.001). Conclusion: These findings suggested that a high BMI aggravated the negative effect of eye rubbing on KC, implying that individuals with a high BMI may be more susceptible to exposure to eye rubbing, which is related to an increased risk of KC. [ABSTRACT FROM AUTHOR]

Background: To investigate the association between keratoconus (KC) and allergic eye diseases, eye rubbing, and atopy. Methods: PubMed, Web of Science, Scopus, and Cochrane databases were searched for studies investigating eye allergy, atopy, and eye rubbing as risk factors for KC up to April 2021. Two authors independently screened all titles and abstracts against the predefined inclusion and exclusion criteria. The study analysed the prevalence of KC and its risk factors, including eye rubbing, family history of KC, atopy, and allergic eye diseases. The National Institutes of Health Study Quality Assessment Tool was used. Pooled data are presented as odds ratios (OR) and 95% confidence intervals (CI). The analysis was conducted using RevMan version 5.4 software. Results: The initial search yielded 573 articles. After screening, 21 studies were identified for qualitative analysis and 15 for quantitative synthesis. A significant association was found between KC and eye rubbing (OR = 5.22, 95% CI [2.80, 9.75], p < 0.00001), family history of KC (OR = 6.67, 95% CI [4.77, 9.33], p < 0.00001), and allergies (OR = 2.21, 95% CI [1.57, 3.13], p < 0.00001). However, no significant association was found between KC and allergic eye disease (OR = 1.82, 95% CI [0.37, 8.97], p = 0.46), atopy (OR = 1.54, 95% CI [0.58, 4.09], p = 0.39), allergic rhinitis (OR = 0.85, 95% CI [0.54, 1.33], p = 0.47), smoking (OR = 0.96, 95% CI [0.76, 1.21], p = 0.73), and asthma (OR = 1.58, 95% CI [0.99, 2.53], p = 0.05). Conclusion: Significant associations were observed between KC and eye rubbing, family history, and allergy, but not with allergic eye disease, atopy, asthma, and allergic rhinitis. This article can be found online at https://onlinelibrary.wiley.com/doi/10.1111/ceo.14215 [ABSTRACT FROM AUTHOR]

Tomás Loureiro,1 Sandra Rodrigues-Barros,1 Ana Rita Carreira,1 Filipe Gouveia-Moraes,1 Pedro Carreira,1 Ana Vide Escada,1 Paul Campos,1 Inês Machado,1 Nuno Campos,1 Timothy J Archer,2 Dan Z Reinstein,2 Renato Ambrósio Jr3 1Ophthalmology Department, Hospital Garcia de Orta, Almada, Portugal; 2London Vision Clinic, London, UK; 3Federal University of the State of Rio de Janeiro, Rio de Janeiro, BrazilCorrespondence: Tomás Loureiro, Ophthalmology Department, Hospital Garcia de Orta, Avenida Torrado da Silva, Almada, 2805-267, Portugal, Tel +35 1 913 513 175, Email loureiro.tomas@gmail.comPurpose: To evaluate the effect of eye rubbing on the epithelial thickness profile in tomographically normal corneas by AS-OCT and to compare right and left eyes in right-handed children.Methods: Thirty right-handed boys (mean age 11.2 years) with ocular allergy and history of eye rubbing were evaluated using Scheimpflug (Pentacam HR, Oculus Wetzlar, Germany) and anterior segment optical coherence tomography. Epithelial thickness (ET) and full corneal thickness (CT) parameters were compared between right and left eyes with a non-parametric Mann–Whitney test. A p-value lower than 0.05 was considered for statistical significance.Results: No eyes had topometric nor tomographic criteria for keratoconus. The min-max ET was lower in right eyes (− 2.8 μm vs − 3.5; p = 0.02). The difference between inferior and superior (I-S) octants was lower in right eyes (1.1 μm vs 1.9 μm; p = 0.03) as a result of inferotemporal thinning. The highest ET difference was registered between nasal and temporal octants and was more pronounced in the right eyes (2 μm vs 3.1 μm; p < 0.001).Conclusion: AS-OCT analyses reveal different epithelial thickness patterns between the eyes in young atopic patients, likely eye rubbers. Inferior and temporal epithelial thickness seem to be more affected by thinning in the eye on the side of the dominant hand.Keywords: eye rubbing, keratoconus, epithelial thickness, AS-OCT, pediatrics

Purpose: Describe the cognitive and behavioral symptomatology of patients with chronic ocular rubbing in keratoconus (KC) and Ocular Surface Disease (OSD) using a self-questionnaire. Methods: A prospective study was conducted in a tertiary ophthalmology center between May and July 2021. We consecutively included all patients presenting with one of the following conditions: KC and OSD. A questionnaire including the evaluation of Goodman and CAGE-modified criteria for eye rubbing was given to patients in consultation to evaluate their ocular symptoms and medical background. Results: We included 153 patients in the study. Of these, 125 (81.7%) patients reported eye rubbing. The average Goodman score was 5.8 ± 3.1 and was ≥ 5 in 63.2% of cases. The CAGE score was ≥ 2 in 74.4% of patients. Addiction (p = 0.045) and psychiatric family history (p = 0.03) were more frequent in patients with higher scores. Ocular symptoms and eye rubbing were significantly more frequent and intense in patients with higher scores; Conclusion: Eye rubbing presents addictive-like cognitive and behavioral characteristics in patients with KC or OSD. The eye rubbing cycle could play an essential role in the onset and progression of keratoconus and could be a factor in the maintenance of dry eye. [ABSTRACT FROM AUTHOR]

Purpose: To investigate short-term changes in corneal biomechanical properties caused by eye rubbing in myopia and emmetropia and compare the different responses between the two groups.Methods: This was a prospective observational study of 57 eyes of 57 healthy subjects aged 45 years and younger. The participants were divided into myopia and emmetropia groups. All the subjects underwent eye rubbing by the same investigator using the same technique. Biomechanical parameters were recorded using the Corvis ST device before and after 1 min of eye rubbing. One week later, all the participants underwent the test again. Statistical methods were employed to compare the differences between the data from before and after the 1 min of eye rubbing and demonstrate the different responses of the two groups.Results: After 1 min of eye rubbing, smaller SP-A1 (p < 0.001), higher deformation and deflection amplitudes (p < 0.001, p = 0.012), higher peak distances (p < 0.001), earlier A1 times (p < 0.001), faster velocities (p < 0.001), and lower maximum inverse radii (p = 0.004) were observed. According to the automatic linear modeling analysis, the refractive states (B = −5.236, p = 0.010) and biomechanically corrected intraocular pressure (bIOP) (B = 0.196, p = 0.016) had influenced a decrease in the stiffness parameter at the first applanation (SP-A1). The central corneal thickness (CCT) had decreased only in the myopia group (p = 0.039). The change of SP-A1 in amplitude was larger in the myopia group than in the emmetropia group (p < 0.001). All the parameters returned to the baseline level 1 week later.Conclusion: Eye rubbing appears to alter corneal biomechanical properties temporarily and make the cornea softer, especially for myopic young patients.

Keratoconus is a corneal ectatic disease characterized by progressive corneal thinning and protrusion. Its pathogenesis remains unclear. In vitro experiments have shown that mechanical stimulation may damage corneal stromal cells by increasing oxidative stress level and inflammatory factor concentration, resulting in a series of changes such as degradation of corneal extracellular matrix. Numerous clinical studies have confirmed that mechanical factors, including eye rubbing and eyeball compression caused by sleeping position, may play an important role in the process of keratoconus occurrence and development. They may affect the cornea by increasing the level of inflammatory factors in tear, causing changes in intraocular pressure, changing the biomechanical properties of the cornea, directly damaging corneal tissue by mechanical friction, and increasing the temperature of corneal epithelium. The main aim of this review was to describe the efforts of mechanical factors on corneal stromal cells, corneal tissue, and the possible role of mechanical factors in the pathogenesis of keratoconus, so as to provide a reference for the prevention and management of keratoconus.

The potential for eye rubbing to contribute to keratoconus development and progression is well established, but the mechanisms of that association have not been fully elucidated. This review examines mechanisms for rubbing-related corneal trauma from both anterior and posterior surface responses to elevated intraocular pressure. Apart from rubbing-related intraocular pressure elevation, consideration is given to other sources of elevation which may contribute to corneal bulging and cone formation. Mechanisms whereby intraocular pressure-related increased posterior corneal surface distending stress and stromal hydrostatic pressure may alter keratocyte functions and increase susceptibility to such stress are examined. Elevated intraocular pressure (IOP) that is associated with a chronic habit of abnormal rubbing (CHAR) can be a major contributor of keratoconus (KC) development and progression. Anterior corneal surface protection during rubbing due to Bell's reflex in most patients, at least for the central and para-central cornea, increases the likelihood that IOP distending stress can be an important source of KC pathogenesis, perhaps even in patients who do not have abnormal rubbing habits. That the earliest pathological changes in KC occur at the posterior corneal surface is consistent with the significance of an IOP-related distending force mechanism for KC pathogenesis. [ABSTRACT FROM AUTHOR]

We report a case of discordant keratoconus (KC) in a set of monozygotic twins with contrasting environmental risk factors. Twin one had bilateral, asymmetrical KC. He reported significant eye rubbing using his knuckles during his night-shift work as an emergency doctor. His usual sleeping position on the left side corresponded to the most affected eye. Twin two had normal corneas, with no evidence of KC. He reported mild infrequent eye rubbing, daytime work pattern, and a supine sleeping position. This case report highlights the influence of environmental and behavioural factors in the development of KC, in particular eye rubbing, night work, and sleeping position, in two individuals sharing identical genetic inheritance.

The aim of this study was to investigate the corneal microstructure and Langerhans cells using in vivo confocal microscopy in keratoconus patients before and after cross-linking, and to correlate the morphologic findings with clinical and patient-reported outcomes, including eye rubbing (ER) behavior. Patients with progressive keratoconus undergoing iontophoresis-assisted epithelium-on cross-linking (I-CXL) were consecutively enrolled. In vivo confocal microscopy was performed before and 6 months after treatment. Patients were asked to quantify their ER behavior on a Visual Analogue Scale (VAS) and completed the Keratoconus Outcomes Research Questionnaire and the Ocular Surface Disease Index questionnaires at the same time points. Visual acuity, tear osmolarity, topography, aberrometry, and pachymetry of both eyes were assessed. Thirteen patients were included in this pilot study. Preoperatively, the mean Langerhans cells density was 35,615 cells per mm2, and the median morphology was 3. The mean ER VAS before treatment was 7,077 out of 10. The ER VAS showed significant positive correlations with both Langerhans cells density and morphology of the study eye. After treatment, a statistically significant reduction in ER VAS and in Langerhans cells variables was observed. The mean sub-basal plexus nerve density was comparable to pre-operative values 6 months after I-CXL. Based on this preliminary evidence, the presence of high density of mature Langerhans cells in the central cornea of keratoconus patients and its correlation with eye rubbing support the role of inflammation in keratoconus. The reduction in these markers after treatment may suggest a potential of CXL in moderating immune-related inflammation and eye rubbing in the medium term. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the independent and interactive effects of eye rubbing and atopy on keratoconus (KC) in central China. Methods: A total of 330 KC patients and 330 controls were recruited in the case-control study. Eye rubbing and history of atopy were recorded through face-to-face interviews. The association between KC and eye rubbing, atopy, interactive effects of eye rubbing and atopy were analyzed by logistic regression, and the odds ratios (OR), relative excess risk due to interaction (RERI), attributable proportion (AP), synergy (S) index, and 95% confidence intervals (95% CI) were calculated. Results: A total of 228 patients (69.09%) had an eye rubbing history, and 53 (16.06%) had an atopy history in the KC group, which were both higher than that in the control group (p<0.001). Eye rubbing and atopy were positively associated with KC in multivariate analysis, with ORs (95% CIs) of 15.11 (10.02, 22.80) and 5.30 (2.59, 10.84), respectively. Compared to non-eye rubbing and non-atopy eyes, the risk for eye rubbing coexisted with atopy was 52.31 (12.25, 223.35). No significant associations were found between KC and multiplicative interaction (p=0.608). The RERI, AP, and S values were 32.89 (-43.35, 109.14), 0.63 (0.05, 1.21), and 2.79 (0.56, 13.96), respectively, with no significant association between additive interaction and KC. No significant associations were found between eye rubbing, atopy and the severity of KC (p>0.05). Conclusion: Eye rubbing and atopy were separately positively associated with KC, and there was a strong impact of coexistent eye rubbing and atopy on KC in China. Further multi-center and cohort study need to be conducted to explore the role of eye rubbing and atopy in the occurrence and development of KC. [ABSTRACT FROM AUTHOR]

Purpose: We present the case of a 71-year-old male who developed decreased visual acuity eleven years after uncomplicated bilateral cataract extraction and in-the-bag IOL implantation following recent bouts of vigorous eye rubbing. Observations: On examination, the posterior capsules were ruptured centrally in both eyes, and there was anterior vitreous prolapse bilaterally. While both IOLs remained in the visual axis, there was mild bilateral decentration and resultant decreased vision. Conclusion and importance: To the authors’ knowledge, this is the first reported case of bilateral simultaneous posterior capsule rupture with anterior vitreous prolapse due to eye rubbing. Contrasting to previous case reports, this scenario demonstrates that severe eye rubbing can have variable severity and complications. Frequent and vigorous eye rubbing can be a precipitating cause of late postoperative posterior capsule rupture and should be avoided in pseudophakic patients, especially those with older IOL models.

Background: To investigate association between keratoconus and allergic eye diseases, eye rubbing, and atopy. Methods: PubMed, Web of Science, Scopus, and Cochrane were searched for relevant published studies from inception to April 2021 without restrictions or filters. We included case–control, cohort, and cross‐sectional studies that investigated eye allergy, atopy, or eye rubbing as possible risk factors for KC. Two authors independently screened all titles and abstracts against predefined inclusion and exclusion criteria. This study analysed keratoconus prevalence and risk factors including eye rubbing, family history of keratoconus, atopy, and allergic eye diseases. The National Institute of Health Study Quality Assessment tool was utilised. Pooled data were presented as odds ratio (OR) and 95% confidence intervals (CI). Analysis was conducted using RevMan version 5.3 software. Results: Out of 573 articles, we excluded 161 duplicates than 361 articles by title and abstract screening. The remaining 51 articles underwent full‐text screening, and 29 articles were excluded. Twenty‐one studies were included in the qualitative synthesis and fifteen for quantitative synthesis. There was no significant association found between KC and allergic eye diseases (OR = 1.03, 95% CI [0.96, 1.11], p = 0.45), eye rubbing (OR = 1.59, 95% CI [0.70, 3.63], p = 0.27), or atopy (OR = 1.08, 95% CI [0.80, 1.44], p = 0.62). Conclusion: No significant association was observed between KC and allergic eye disease, eye rubbing, or atopy. Further prospective studies are needed to clarify and validate these findings. [ABSTRACT FROM AUTHOR]

We report a case of discordant keratoconus (KC) in a set of monozygotic twins with contrasting environmental risk factors. Twin one had bilateral, asymmetrical KC. He reported significant eye rubbing using his knuckles during his night-shift work as an emergency doctor. His usual sleeping position on the left side corresponded to the most affected eye. Twin two had normal corneas, with no evidence of KC. He reported mild infrequent eye rubbing, daytime work pattern, and a supine sleeping position. This case report highlights the influence of environmental and behavioural factors in the development of KC, in particular eye rubbing, night work, and sleeping position, in two individuals sharing identical genetic inheritance. [ABSTRACT FROM AUTHOR]

Abstract Background To determine the average amount of mechanical forces applied to the lids of keratoconus patients during eye rubbing. Methods Fifty-seven patients (41 male, 16 female, average age 34.8 years) with a clinically and topographically diagnosed keratoconus and a history of eye rubbing were prospectively asked to perform their individual eye rubbing movement on a high-precision balance. The type of eye-rubbing movement and the force applied, represented in newtons (N), were recorded and analyzed. Results We detected three different types of eye rubbing. Rubbing with the fingertip was most frequent (51%), followed by rubbing with the knuckle (44%) and rubbing with the fingernail (6%). Each type of eye rubbing showed different average forces, with knuckle type eye rubbing applying significantly more force (9.6 ± 6.3 N) on the lids than fingertip (4.3 ± 3.1 N) and fingernail (2.6 ± 3.3 N) types (p

Abstract Introduction Keratoconus usually presents during puberty and is considered rare in young children. Methods Case report with clinical findings and computerized corneal tomography. Results We report the case of an 8-year-old girl with early bilateral keratoconus who presented with allergic conjunctivitis and persistent eye rubbing. Although our patient did not exhibit steep keratometry, early cones and inferotemporal thinnest corneal thicknesses were detected in both eyes using Scheimpflug imaging (Oculus GmbH Pentacam, Wetzlar, Germany). Belin/Ambrósio total D values were 1.85 on the right and 2.11 on the left. Improvement in best-corrected visual acuity was noted after treatment of allergic eye disease, and corneal tomographic findings remained stable 4 months after initial consult. Conclusion This is a case of early diagnosed keratoconus in a young patient. Diagnosis of this condition in young children is challenging, as these patients are less likely to report visual complaints, and clinical examination is usually unremarkable. Keratoconus screening should be considered in children with atopy and eye rubbing behavior regardless of age, even in those with no other associated pathology and with negative family history.

The dislocation of a posterior chamber intraocular lens (PC IOL) because of constant eye rubbing is unusual and has never been reported in a child with Leber’s congenital amaurosis (LCA). A 4-year-old full-term girl with an ocular history of LCA presented to the emergency room with a single-piece PC IOL dislocated into the anterior chamber (AC) of the left eye. There was no history of trauma or any other surgical intervention. A specific behavior known as Franceschetti’s oculo-digital sign is a characteristic feature of LCA; this sign consists of repeated pressing, poking, and rubbing of the eyes with knuckles and fingers to stimulate the photoreceptors. This behavior caused the dislocation of the PC IOL into the AC. The dislocated IOL was explanted, and the patient was provided with aphakic glasses.

Mohammed Iqbal,1 Ahmed Elmassry,2 Amani E Badawi,3 Hesham M Gharieb,4 Omar M Said5 1Department of Ophthalmology, Faculty of Medicine, Sohag University, Sohag, Egypt; 2Department of Ophthalmology, Faculty of Medicine, Alexandria University, Alexandria, Egypt; 3Department of Ophthalmology, Faculty of Medicine, Mansoura University, Mansoura, Egypt; 4Department of Ophthalmology, Faculty of Medicine, Ain Shams University, Cairo, Egypt; 5Department of Ophthalmology, Faculty of Medicine, Fayoum University, Fayoum, EgyptCorrespondence: Omar M SaidDepartment of Ophthalmology, Faculty of Medicine, Fayoum University, Fayoum, EgyptTel +20 100 350 8051Email oms01@fayoum.edu.egPurpose: To analyze the effectiveness and stability of the refractive, topographic and visual outcomes of the standard cross-linking (SCXL) in keratoconus (KC) management.Patients and methods: This study was designed as a retrospective non-comparative study that included 28 KC patients (n=49 eyes) who performed SCXL as a single procedure to treat KC and completed five-year follow-up period. The topographic, refractive and visual data were recorded preoperatively and at 12, 24, 36 and 60 months postoperatively.Results: Forty eyes (81.6%) showed achieved postoperative spherical equivalent (SE) refraction better than the attempted refraction. Ten eyes (20.4%) improved by

Keratoconus is a non-inflammatory disorder which is gradual in development; corneal thinning and ectatic protrusion characterizes it. Keratoconus prevalence varies between different regions depending on several factors that affecting its prevalence. There are risk factors for developing keratoconus such as demographic and environmental factors. It was suggested that eye rubbing was associated with the development of keratoconus. The main aim of this review was to summarize the literature data about keratoconus and to identify the role of eye-rubbing in the aetiology of the disease. A number of 24 articles was reviewed through the PubMed, Google Scholar and Research Gates. There are many keywords used such as keratoconus, aetiology of keratoconus, eye rubbing, keratoconus prevalence, keratoconus and eye rubbing correlation. We concluded that eye rubbing causes the thinning of keratocyte, and the degree of effect of eye rubbing depends on the period and force of performing eye rubbing. It is recommended to avoid eye rubbing to prevent keratoconus, this can be achieved by avoiding itching and treating dryness of the eye and avoiding wearing eye lenses.

Purpose: To explore the effect of mechanical compression (similar to that induced by eye rubbing) on cell morphology, proliferation, apoptosis, and extracellular matrix synthesis and degradation in human corneal fibroblasts. Materials and methods: Human corneal fibroblasts were isolated from corneal lenticule tissue of 10 patients after small incision lenticule extraction surgery. A system was established to mechanically compress corneal fibroblasts with pressure ranging from 0 to 524 Pa. Morphological changes, cell proliferation, apoptosis, and corneal matrix synthesis and degradation were examined using microscopy imaging, bromodeoxyuridine staining, flow cytometry, and qPCR analysis in human corneal fibroblasts after mechanical compression. Results: Human corneal fibroblasts showed short and thick cytoplasmic extensions, as well as a relatively low aspect ratio, suggesting significant morphological alterations caused by high levels of compressive stress. Mechanical compression inhibited cell proliferation and promoted cell apoptosis. Furthermore, compressive stress led to significant elevation in the expression of genes related to extracellular matrix degradation (matrix metalloproteinases MMP1 and MMP9) as early as 6 h after compression and moderate changes in the expression of tissue inhibitors of metalloproteinases. In addition, the mRNA expression levels of COL1A1, lumican, and vimentin were reduced 24 and 48 h after mechanical compression. Conclusions: Mechanical compression alters cell morphology, inhibits proliferation, induces apoptosis, upregulates genes related to extracellular matrix degradation, and downregulates corneal structural genes in human corneal fibroblasts. This study provides evidence that compressive stress significantly influences corneal keratocytes. Our findings suggest that this mechanical effect may be related to keratoconus associated with chronic eye rubbing. [ABSTRACT FROM AUTHOR]

Purpose: Keratoconus is a potentially blinding condition that slowly deforms the cornea in young people. Despite the increasing prevalence of keratoconus, the exact aetiology of the condition is unknown. This first systematic review examines the evidence of eye rubbing and its association with keratoconus and presents the findings of the meta-analysis. Methods: Two independent reviewers searched the electronic databases for all potential articles published from 1st of January 1900 to 31st of July 2020 on eye rubbing and keratoconus. The researchers assessed the methodological quality of the studies using the Newcastle-Ottawa scale for observational studies. The assessment for statistical heterogeneity was estimated using chi-square and I-square (I2) tests. A p value of < 0.05 was considered as statistically significant and I2 < 30% as homogenous. Begg funnel plot was used to interpret the asymmetry or small study effects. Results: Eight case-control studies were included in this systematic review. Two studies assessed eye rubbing without odds ratios and thus were excluded. The pooled odds ratios for the six remaining studies included in the meta-analysis was 6.46 (95% CI 4.12–10.1). The study results were heterogenous (I2 = 71.69 [95% CI 35.14–87.88]). All the studies scored moderate quality methodology on the Newcastle-Ottawa scale. Begg funnel plot showed asymmetry supporting heterogeneity. Conclusion: Eye rubbing showed consistent association with keratoconus. However, the current evidence is limited to only a small number of case-control studies which present as heterogeneous and of sub-optimal methodological quality. Additionally, the cause-effect temporal relationship cannot be determined. Further studies are needed to address this intricate relationship of eye rubbing and its induction, ongoing progression, and severity of keratoconus. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate eye rubbing and sleeping position in patients with Unilateral or Highly Asymmetric Keratoconus (UHAKC). Methods: Case-control study of consecutive UHAKC patients diagnosed at the Rothschild Foundation. Controls were age- and sex-matched, randomly selected refractive surgery clinic patients. Patients self-administered questionnaires regarding their family history of keratoconus, eye rubbing, and sleeping habits. All the eyes underwent a comprehensive ocular examination. Logistic regression was used to analyze univariate and multivariate data to identify risk factors for keratoconus. Results: Thirty-three UHAKC patients and 64 controls were included. Univariate analyses showed that daytime eye rubbing [OR = 172.78], in the morning [OR = 24.3], or in eyes with the steepest keratometry [OR = 21.7] were significantly different between groups. Allergy [OR = 2.94], red eyes in the morning [OR = 6.36], and sleeping on stomach/sides [OR = 14.31] or on the same side as the steepest keratometry [OR = 94.72] were also significantly different. The multivariate model also showed statistical significance for most factors including daytime eye rubbing [OR = 134.96], in the morning [OR = 24.86], in the steepest eye [OR = 27.56], and sleeping on stomach/sides [OR = 65.02] or on the steepest side [OR = 144.02]. A univariate analysis in UHAKC group, comparing the worse and better eye, showed that eye rubbing [OR = 162.14] and sleeping position [OR = 99.74] were significantly (p < 0.001) associated with the worse eye. Conclusion: Our data suggests that vigorous eye rubbing and incorrect sleeping position are associated with UHAKC. This is especially true in rubbing the most afflicted eye, and contributory sleep position, including positions placing pressure on the eye with the steepest keratometry. [ABSTRACT FROM AUTHOR]

PurposeTo determine whether corneal biomechanical properties and intraocular pressure (IOP) are affected by eye rubbing and breath holding.MethodsCorneal hysteresis, corneal resistance factor, corneal compensated IOP (IOPcc), and Goldmann equivalent IOP (IOPg) were measured on both eyes of 40 subjects. Measurements were taken at baseline before eye rubbing (ER(0)) and before breath holding (BH(0)), immediately after 2 episodes of eye rubbing (ER(1) and ER(2)), and during 2 episodes of breath holding (BH(1) and BH(2)).ResultsCorneal hysteresis, corneal resistance factor, and IOPg were significantly lower after ER(1) compared with ER(0) and were significantly lower after ER(2) compared with ER(1). In contrast, IOPcc did not decrease significantly. There were no significant differences among BH(0), BH(1), and BH(2) in any of the 4 outcomes.ConclusionsEye rubbing should be avoided before measurements of corneal biomechanical properties and IOPg. In contrast, breath holding during measurements is not likely to cause a significant change in IOPg and IOPcc or corneal biomechanical properties.

Purpose: To report an unusual case of ectopia lentis and angle closure in a patient with chronic eye rubbing. Methods: A 57-year-old male with a history of poorly controlled atopic dermatitis presented with right eye pain, decreased vision, and an intraocular pressure (IOP) of 55 mm Hg. He had no past history of ocular disease and no reported history of trauma. He did report a history of chronic eye rubbing. Results: Best corrected visual acuity was hand motions. The examination revealed severe atopic keratoconjunctivitis in both eyes, microcystic corneal edema of the right eye, and 2+ nuclear sclerosis in both eyes. Gonioscopy showed no visible angle structures OD and an open angle OS. Topical and oral IOP-lowering medications and a laser iridotomy were unsuccessful at lowering IOP. He was taken to the operating room for a lensectomy and was found to have 9 clock hours of zonular dehiscence and a dislocated lens. After lensectomy, the IOP improved to 9 mm Hg on postoperative day 1. A follow-up examination at 2 weeks showed improved acuity to 20/150 with a pinhole and an IOP of 10 mm Hg. A dilated examination OS did not reveal significant phacodonesis, and the patient was referred for a possible sutured sulcus lens or anterior chamber intraocular lens. Conclusions: It is important for the provider to consider ectopia lentis in the differential for patients with pupillary block angle closure. For patients with atopic disease, one should be aware that eye rubbing may be a cause of zonular dehiscence, even in the absence of reported trauma or prior intraocular surgery.

Keratoconus (KC) is an ectatic disease of the cornea characterized by localized thinning and protrusion causing irregular astigmatism, which can lead to significant visual impairment. KC has often been associated with allergy and/or atopy, which are immune-mediated inflammatory reactions primarily driven by IgE. A higher proportion of KC patients were reported to have history or suffer from systemic and/or ocular allergy with elevated allergen-specific IgE and/or total serum IgE. Eye rubbing, one of the risk factors for worsening of the disease and developing related complications in KC, is associated with IgE driven conditions. The current review enumerates and contextualizes the evidence related to IgE in mediating KC pathogenesis, including aberrant extra-cellular matrix remodeling. This review also discusses clinical strategies directed at modulating IgE-mediated responses in the management of KC, and the emerging academic and plausible clinical relevance of assessing serum and tear IgE (allergen-specific and total) status in improving the understanding of disease pathobiology, treatment planning, and prognosis. [ABSTRACT FROM AUTHOR]

Introduction: Keratoconus usually presents during puberty and is considered rare in young children. Methods: Case report with clinical findings and computerized corneal tomography. Results: We report the case of an 8-year-old girl with early bilateral keratoconus who presented with allergic conjunctivitis and persistent eye rubbing. Although our patient did not exhibit steep keratometry, early cones and inferotemporal thinnest corneal thicknesses were detected in both eyes using Scheimpflug imaging (Oculus GmbH Pentacam, Wetzlar, Germany). Belin/Ambrósio total D values were 1.85 on the right and 2.11 on the left. Improvement in best-corrected visual acuity was noted after treatment of allergic eye disease, and corneal tomographic findings remained stable 4 months after initial consult. Conclusion: This is a case of early diagnosed keratoconus in a young patient. Diagnosis of this condition in young children is challenging, as these patients are less likely to report visual complaints, and clinical examination is usually unremarkable. Keratoconus screening should be considered in children with atopy and eye rubbing behavior regardless of age, even in those with no other associated pathology and with negative family history. [ABSTRACT FROM AUTHOR]

Background: To determine the average amount of mechanical forces applied to the lids of keratoconus patients during eye rubbing.Methods: Fifty-seven patients (41 male, 16 female, average age 34.8 years) with a clinically and topographically diagnosed keratoconus and a history of eye rubbing were prospectively asked to perform their individual eye rubbing movement on a high-precision balance. The type of eye-rubbing movement and the force applied, represented in newtons (N), were recorded and analyzed.Results: We detected three different types of eye rubbing. Rubbing with the fingertip was most frequent (51%), followed by rubbing with the knuckle (44%) and rubbing with the fingernail (6%). Each type of eye rubbing showed different average forces, with knuckle type eye rubbing applying significantly more force (9.6 ± 6.3 N) on the lids than fingertip (4.3 ± 3.1 N) and fingernail (2.6 ± 3.3 N) types (p < 0,001 and p = 0,016, respectively).Conclusions: There were major variations in the force exerted on the lids, depending on the type of eye rubbing employed. This data will help determine the forces that need to be applied in future experimental eye rubbing models. [ABSTRACT FROM AUTHOR]

Purpose: To demonstrate the correlation between excessive eye rubbing and corneal degeneration for Keratoconus patients. Materials and methods: Keratoconus (KC) patients who regularly rub their eyes had shown a rapid degeneration rate of their affected corneas. This observation is experimentally and numerical discussed and developed based on clinical data of 8 of KC Patients with a mean age of 26.5 ± 9.4 years old, and four healthy individuals with a mean age of 24.33 ± 5 years old at the baseline. Corneal topography was used to measure both central corneal thickness (CCT) and its total refractive power. The registered data had been exploited to assess the progression of the disease, and the final results were embedded in a finite element model of human corneas to simulate their response to eye rubbing at different stages of the pathology. Corneal lifetime prognosis using multi-layer perceptron was then established to estimate the number of eye rubbing cycles for each stage of KC. Results: The survey of KC patients who declared stopping eye rubbing had shown a decrease in CCT loss rate, followed by a durable stability. Mechanical stresses numerical simulations had shown different corneal behaviours in term of shape deformity, apical raise and corneal applanation between healthy and KC stages models. Apical rise ranged from 0.122 to 0.389 mm for an applied intraocular pressure that equals to 15 mmHg. A normal stress of 5 kPa provoked a corneal applanation that ranged from 0.27 mm in healthy cases to 1.173 mm in severe stages of the disease. The application of 2.5 kPa biaxial stress had resulted normal and tangential applanations that successively ranged from 0.152 and 0.173 mm in healthy corneas to 0.446 mm and 0.458 mm in severe KC stages. An adopted prognosis algorithm was able to predict the current stage of the disease and to estimate the remaining number of eye rubbing cycles before failure. Conclusion: Eye rubbing was proven to be a considerable contributing factor in KC patient's corneal degeneration. The progression of this pathology could be decreased or halted by stopping eye rubbing at early stages. [ABSTRACT FROM AUTHOR]

Atopic dermatitis is a chronic condition of complex etiology, whose clinical course involves remission and recurrence. It is not an isolated disease entity affecting only the skin, but one that co-occurs with disorders of other organs. Numerous literature reports have long confirmed the relationship between the disorder and a growing number of ophthalmic manifestations such as keratoconus and retinal detachment. Further studies are required to establish the cause of correlations and to allow for implementation of appropriate prophylaxis and treatment. The aim of the present paper is to review published literature regarding the correlation between atopic dermatitis and ophthalmic manifestations in adults and children. [ABSTRACT FROM AUTHOR]

The dislocation of a posterior chamber intraocular lens (PC IOL) because of constant eye rubbing is unusual and has never been reported in a child with Leber's congenital amaurosis (LCA). A 4-year-old full-term girl with an ocular history of LCA presented to the emergency room with a single-piece PC IOL dislocated into the anterior chamber (AC) of the left eye. There was no history of trauma or any other surgical intervention. A specific behavior known as Franceschetti's oculo-digital sign is a characteristic feature of LCA; this sign consists of repeated pressing, poking, and rubbing of the eyes with knuckles and fingers to stimulate the photoreceptors. This behavior caused the dislocation of the PC IOL into the AC. The dislocated IOL was explanted, and the patient was provided with aphakic glasses. [ABSTRACT FROM AUTHOR]

Introduction: To report the development of unilateral keratoconus in a healthy male after persistent unilateral eye rubbing by the nondominant hand which was not needed for professional activities. Methods: Observational case report. Results: A 60-year-old male was first seen in our clinic due to decreased vision in his left eye. Slit-lamp biomicroscopy of the left eye revealed Vogt’s striae, stromal thinning, and a stromal scar. Corneal topography showed a stage 4 keratoconus. Clinical examination and corneal topography of the right eye were normal. Medical history revealed a habit of chronic eye rubbing only in the left eye because of the right hand being occupied for professional needs. During follow-up of 5 years, Scheimpflug images of the right eye stayed normal while the left eye showed a stable cone. Discussion: This case report supports the hypothesis of mechanical fatigue of the cornea due to repetitive shear stress on the surface caused by eye-rubbing.

Abstract Background To investigate the effect of eye rubbing on keratometry (K), aberrometry, tear film break-up-time (TFBUT) and anterior chamber depth (ACD). Methods Volunteers without any corneal pathology or dry eyes were randomised to rubbing in one eye and the fellow-eye was control. Eye rubbing was performed for 2 min. Primary outcomes studied were anterior and posterior K changes. Secondary outcomes were changes in TFBUT, axial length (AL) & ACD, K changes in various zones, asphericity and aberrometry. Pre and post rubbing K, aberrometry, ACD and TFBUT were assessed in a predetermined sequence. The relationship of the above parameters to axial length (AL) was also assessed. Astigmatism was analysed using vector analysis. Results Pre versus post rubbing, anterior flatter K further flattened (42.51 ± 1.52 D vs. 42.36 ± 1.53 D, p = 0.003) and the changes to J0 vector in central cornea (−0.16 ± 0.26 D vs. -0.27 ± 0.33 D, p = 0.038) suggested change to against-the-rule (ATR) astigmatism. There was significant change in Z2 +2 polynomial following rubbing. We found a positive correlation between axial length and change in posterior K (r = 0.335, p = 0.020). The TFBUT reduced following eye rubbing (15.3 s vs. 13.9 s, p = 0.0001). There was a positive correlation between AL and increase in ACD post rubbing (r = 0.300, p = 0.038). There was a positive correlation between ACD and change in mean posterior K (r = 0.305, p = 0.035). Conclusions In healthy eyes, following eye rubbing, there is a significant change in TFBUT and central anterior K changes towards ATR astigmatism. Longer eyes had more changes in posterior K and ACD. Whereas, eyes with deeper ACD showed more steepness of posterior K. Trial registration ClinicalTrials.gov ID: NCT02131740 .

We report two male children with persistent allergic eye disease (AED) and keratoconus (KC). Both presented with symptoms of vernal keratoconjunctivitis and decreased vision. In view of unrelenting AED, serum immunoglobulin E (IgE) quantification and identification of specific allergens were advised. Increased serum IgE levels were observed in both cases. Sunflower and sheep wool were identified as specific allergens for the first and second patient respectively by skin patch test. There was complete resolution of symptoms of AED in both patients following avoidance of causative allergens. However, the progression of KC in both eyes of the first patient and one eye of the second patient was observed. They were advised collagen cross-linking. Elevated serum IgE indicates the presence of systemic allergy. Avoiding implicated allergens help alleviate ocular symptoms. Using serum IgE and identifying specific allergen can guide in the treatment of AED and thus prevent progressive KC due to eye rubbing and resulting inflammation.

Background: Keratoconus is an eye condition where the cornea, the clear, dome-shaped front part of the eye, becomes thinner and gradually bulges outward into a cone shape. Keratoconus usually affects both eyes. The exact cause of keratoconus is unknown, but it is believed to involve a combination of genetic and environmental factors., Aim: This study aims to assess the awareness level of keratoconus and its relation to eye rubbing among the population in the Eastern Province of Saudi Arabia., Methods: A cross-sectional study was conducted in the Eastern Province of Saudi Arabia, involving all eligible participants via an online pre-designed questionnaire from March to June 2023. The data were collected through social media., Results: A total of 388 eligible participants completed the study questionnaire. Participants' ages ranged from 19 to 60 years, with a mean age of 26.2 ± 13.9 years. There were 265 (68.3%) female participants. Regarding public awareness about keratoconus among participants in the Eastern Province of Saudi Arabia, our research revealed a total of 101 (26%) participants had an overall good awareness of keratoconus, while 287 (74%) had a poor awareness level. The most reported source of information included scientific lectures (21.6%). Precisely, 316 (81.4%) of the research subjects rub their eyes primarily because of allergies (7%), strain headaches (25%), and itching (66.5%)., Conclusion: Most of the study participants have poor awareness about keratoconus and its relation to eye rubbing. Health education programs for the population should be conducted to enhance public awareness about keratoconus., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2024, AlSomali et al.)

An 18-year-old boy with an obsessive-compulsive disorder of eye rubbing presented with forme fruste keratoconus (KC) and posterior subcapsular cataracts. After evaluation, he underwent phacoemulsification in his left eye with intraocular lens implantation. The aggressive eye rubbing, however, aggravated the rapid progression to established KC, and further acute corneal hydrops within 3 months. Within the next 3 months, the eye rubbing precipitated rhegmatogenous retinal detachments (RDs) in both eyes. Furthermore, after undergoing a combined cataract and RD surgery with belt buckling and silicone oil endotamponade in his right eye, the repeated eye rubbing caused extrusion of the implanted silicone oil into the subconjunctival space and within the corneal stroma. This is the first report to our knowledge describing this unique complication associated with eye rubbing. It also highlights the need for increased vigilance and care that needs to be directed toward patients predisposed to such complications.

In this report, we describe a particular condition of a 52-year-old man who showed advanced bilateral glaucomatous-like optic disc damage, even though the intraocular pressure resulted normal during all examinations performed. Visual field test, steady-state pattern electroretinogram, retinal nerve fiber layer and retinal tomographic evaluations were performed to evaluate the optic disc damage. Over a 4-year observational period, his visual acuity decreased to 12/20 in the right eye and counting fingers in the left eye. Visual fields were severely compromised, and intraocular pressure values were not superior to 14 mm Hg during routine examinations. An accurate anamnesis and the suspicion of this disease represent a crucial aspect to establish the correct diagnosis. In fact, our patient strongly rubbed his eyes for more than 10 h per day. Recurrent and continuous eye rubbing can induce progressive optic neuropathy, causing severe visual field damage similar to the pathology of advanced glaucoma.

AIM: To assess the effects of eye rubbing on corneal thickness (CT) and intraocular pressure (IOP) measurements obtained 0-30min after habitual eye rubbing in symptomatic patients. METHODS: Measurements of IOP and CT were obtained at five locations (central, temporal, superior, nasal and inferior) before, and every 5min for 30min interval after 30s of eye rubbing, for 25 randomly selected eyes of 14 subjects with ocular allergy and 11 age-matched normals. Differences in measurements were calculated in each group [Baseline measurements minus measurements recorded at each time interval after eye rubbing (for IOP), and for each corneal location (for CT)] and comparison were then made between groups (allergic versus control) for differences in any observed effects. RESULTS: Within groups, baseline mean IOPs in the allergic patient-group (14.2±3.0 mm Hg) and in the control group (13.1±1.9 mm Hg) were similar at all times, after eye rubbing (P >0.05, for all). The maximum reduction in IOP was 0.8 mm Hg in the control subjects and the maximum increase was also 0.8 mm Hg in the allergic subjects. Between groups (allergic versus control), the changes in IOP remained under 1 mm Hg at all times (P=0.2) after 30min of eye rubbing. Between 0 and 30min of CT measurements after eye rubbing, the mean central CT (CCT), inferior CT (ICT), superior CT (SCT), temporal CT (TCT) and nasal CT (NCT) did not vary significantly from baseline values in the control and allergic-subject groups (P>0.05, for both). Between both groups, changes in CT were similar at all locations (P>0.05) except for the TC which was minimally thinner by about 4.4 µm (P=0.001) in the allergic subjects than in the control subjects, 30min following 30s of eye rubbing. CONCLUSION: IOP measured in allergic subjects after 30s of habitual eye rubbing was comparable with that obtained in normal subjects at all times between 0 and 30min. Although, CT in the allergic subjects were similar to those of the control subjects at all times, it varied between +10 and -7.5 µm following eye rubbing, with the temporal cornea showing consistent reductions in thickness in the subjects with allergy. However, this reduction was minimal and was considered to not be clinically relevant.

Purpose: To report an unusual case of ectopia lentis and angle closure in a patient with chronic eye rubbing. Methods: A 57-year-old male with a history of poorly controlled atopic dermatitis presented with right eye pain, decreased vision, and an intraocular pressure (IOP) of 55 mm Hg. He had no past history of ocular disease and no reported history of trauma. He did report a history of chronic eye rubbing. Results: Best corrected visual acuity was hand motions. The examination revealed severe atopic keratoconjunctivitis in both eyes, microcystic corneal edema of the right eye, and 2+ nuclear sclerosis in both eyes. Gonioscopy showed no visible angle structures OD and an open angle OS. Topical and oral IOP-lowering medications and a laser iridotomy were unsuccessful at lowering IOP. He was taken to the operating room for a lensectomy and was found to have 9 clock hours of zonular dehiscence and a dislocated lens. After lensectomy, the IOP improved to 9 mm Hg on postoperative day 1. A follow-up examination at 2 weeks showed improved acuity to 20/150 with a pinhole and an IOP of 10 mm Hg. A dilated examination OS did not reveal significant phacodonesis, and the patient was referred for a possible sutured sulcus lens or anterior chamber intraocular lens. Conclusions: It is important for the provider to consider ectopia lentis in the differential for patients with pupillary block angle closure. For patients with atopic disease, one should be aware that eye rubbing may be a cause of zonular dehiscence, even in the absence of reported trauma or prior intraocular surgery. [ABSTRACT FROM AUTHOR]

Objectives: To determine whether corneal biomechanical properties and intraocular pressure (IOP) are affected by eye rubbing. Materials and Methods: Healthy individuals, aged between 15 and 50 years, without any ocular pathological signs were included. Corneal biomechanical parameters, Goldmann-equivalent intraocular pressure (IOPg), corneal-compensated intraocular pressure (IOPcc), corneal resistance factor (CRF), and corneal hysteresis (CH) values were measured using an ocular response analyzer (ORA). Measurements were taken at baseline and immediately after 30 seconds of eye rubbing. ORA parameters before and after eye rubbing were analyzed using student’s t test. A p-value less than 0.05 was considered statistically significant. Results: We included eighty-one eyes of 53 individuals with a mean age of 32±10.11(15-50) years. Before eye rubbing, the mean measurement values were as follows: CH 10.93±1.69 mmHg, CRF 10.82±1.78 mmHg, IOPg 15.76±3.18 mmHg, and IOPcc 15.74±2.69 mmHg. The mean values after eye rubbing were: CH 11.11±1.52 mmHg, CRF 10.54±1.56 mmHg, IOPg 14.32±3.10 mmHg, and IOPcc 14.20±2.77 mmHg. The decrease in CRF, IOPg, and IOPcc was statistically significant, while the change in CH was found to be statistically insignificant. Conclusion: CRF, IOPg, and IOPcc decreased significantly after eye rubbing and this should be considered before taking any ORA measurements and interpreting the results. (Turk J Ophthalmol 2014; 44: 268-71)

Purpose: To report a young child with bilateral keratoconus in the context of vernal keratoconjunctivitis (VKC) who developed bilateral corneal hydrops associated with eye rubbing, and to discuss the pathogenesis and review the pertinent literature. Case Report: A seven-year-old girl with VKC and asymmetric keratoconus developed corneal hydrops due to habitual eye rubbing. Corneal edema subsided within 16 weeks in her right eye and 9 weeks in the left eye with subsequent corneal scarring. Conclusion: Continuous mechanical trauma, such as eye rubbing, plays a significant role in the pathogenesis of keratoconus and subsequent hydrops even in childhood.