December 2018

COVER FEATURE

Good habits for healthy eyes
Understanding eye rubbing


by Rich Daly EyeWorld Contributing Writer


Keratoconus with a visible iron line around the base of the cone and a central elevated nodule that was preventing comfortable contact lens wear. This eye was successfully treated with excimer laser phototherapeutic keratectomy.
Source: Christopher Rapuano, MD



 

Surgeons offer insights on ways to detect and address clinically significant eye rubbing in patients

When people rub their eyes they are doing damage to the most important sensory organ in their body.
Hank Perry, MD, chief of the cornea service, Nassau University Medical Center, East Meadow, New York, and senior partner emeritus, Ophthalmic Consultants of Long Island, noted that the skin of the eyelids is the thinnest skin in the body.
“This skin does not do well
with constant trauma,” Dr. Perry said. “Pigmentary changes (darkening of skin) and loss of retro-orbital fat can lead to an unwanted facial appearance.”
Rubbing the eyes fractures mast cells, which resemble tiny raspberries, with each saccule containing the chemicals histamine, heparin, and serotonin. Histamine makes eyes itch, heparin makes the eyes red, and serotonin keeps the inflammation going.
“The actual rubbing puts pressure on the eye sometimes up to 60 mm Hg, which results in an immediate decrease of the itch response,” Dr. Perry said. “But minutes later it returns, often more intensely.”
Additionally, eye rubbing inflames the ocular surface, which can make any inflammatory ocular surface disease, such as dry eye, worse, said Christopher Rapuano, MD, chief of the cornea service, Wills Eye Hospital, and professor of ophthalmology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia.
Although the exact mechanism by which eye rubbing impacts keratoconus specifically is unknown (although increased inflammation may be a component), it is known that eye rubbing is highly associated with keratoconus, Dr. Rapuano said.
“In some patients it may cause keratoconus, while in others it appears to exacerbate the keratoconus,” Dr. Rapuano said.
Dr. Perry has seen eye rubbing in keratoconus as almost always having a cause and effect relationship.
“The basic increased elasticity or decreased scleral rigidity of keratoconus is adversely affected by eye rubbing,” Dr. Perry said.
Also associated with keratoconus is increased allergies and atopic dermatitis.
“Both of these lead to vigorous eye rubbing,” Dr. Perry said. “The result is increased severity of keratoconus in these patients.”
Additionally, the incidence of floppy eyelid syndrome (FES) is approximately 5% of patients in the 45–60 age group, Dr. Perry said. The presence of this condition has several negative effects on the ocular surface including papillary conjunctivitis, dry eye, severe meibomian gland disease, and exposure keratitis.
Dr. Rapuano noted that mild FES is rather common, although severe FES is less common.
“Having said that, if you don’t flip the eyelids, it is very difficult to make the diagnosis of FES,” Dr. Rapuano said.
FES affects the quality of the lid closure and therefore the wetting of the ocular surface. In more severe cases, the eyelids may actually open at nighttime, which leaves the corneal surface very exposed. Other severe cases occur from an override of the upper lid over the lower lid (lid imbrication syndrome), which damages the underside of the upper lid and the corneal surface.

Rubbing diagnosis

Sometimes diagnosis of problematic eye rubbing is obvious, as patients rub their eyes frequently during the eye exam, Dr. Rapuano noted.
“I ask the patients, but always ask family or friends who accompany them to the office about it,” Dr. Rapuano said. “Often the patient denies it but the family or friend claim they do it frequently.”
Identifying clinically significant eye rubbing can also entail observation, including darkening of skin around the eyes, increased erythema, and signs of mucus fishing syndrome, Dr. Perry said.

How to stop rubbing

Effective approaches to arresting eye rubbing are linked to the cause of the behavior.
Sometimes the behavior is caused by allergies, so treatment of the allergies is key. Effective treatments include the use of topical and systemic anti-allergy medications, allergen avoidance, frequent showering and washing of clothes, and cool or cold compresses, Dr. Rapuano said.
“Often it’s from habit, which is a lot harder to treat,” Dr. Rapuano said. “I stress to the patients how eye rubbing can damage their eyes. I aggressively enlist family and friends who accompany them to the office and tell them to watch for eye rubbing and nag the patient to stop doing it.”
Dr. Perry also explains to patients what rubbing does to the eye. He suggests wearing glasses and taking preservative-free tears, mast cell stabilizers, or occasional topical steroids to break up the cycle of itching. Additionally, patients may consider desensitization therapy by an allergist.

Editors’ note: Dr. Rapuano and Dr. Perry have no financial interests related to their comments.

Contact information

Perry: hankcornea@gmail.com
Rapuano: cjrapuano@willseye.org

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