Eyeworld

APRIL 2022 | EYEWORLD | 75 R ening in the wall of the ball, such that the wall then develops that 'lump' irregularity. Every time they rub their eye, it's like bouncing that basketball, and their cornea may develop that same irregularity over time." Patients to specifically counsel against eye rubbing include keratoconus patients, refractive surgery patients, patients with phakic IOLs, dry eye and allergy patients, and patients with Down syndrome. For keratoconus patients, Dr. Greenwood said, it's important to explain to them that the goal of crosslinking is to halt progression. If they continue to rub their eyes, they might need another procedure. Refractive surgery patients need to understand that they're making a lifelong commitment to avoid eye rubbing postop. If a patient has a phakic IOL, Dr. Greenwood explained that pushing on the anterior surface of the eye could cause the IOL to touch the iris or natural lens, causing dam- age. Patients with allergies and/or dry eye often have low-level inflammation, and eye rubbing can continue the inflammation cascade. Hands aren't the only culprit putting pres- sure on the eye. "Face planting into a pillow is also suspected to produce similar mechanical strain to the cornea as an eye rub, and I will most commonly question my grossly asymmet- ric keratoconus patients about sleeping position. Not infrequently, they admit to sleeping on the side of the more advanced keratoconus eye," Dr. Baartman said. T o patients, eye rubbing might seem innocuous, but to the ophthalmol- ogist, it's an action that can have sight-threatening consequences and is something that patients should be warned against. Eye rubbing has been associated with ker- atoconus most commonly 1 but also retinal de- tachments 2 and dislocated implants. 3 It's also ex- perimentally been shown to significantly cause a rise in IOP. 4 Sometimes, when patients rub their eyes hard enough, they see lights, flashes, or dots. Brandon Baartman, MD, described this as not actually light but mechanical traction put on the retina by the vitreous. "The retina then communicates any stimulus, be it mechanical traction during a retinal tear or eye rubbing, as 'light' to the brain," he said. Dr. Baartman said he'll often ask patients to think about what structures they're rubbing or pressing on. "Rubbing over the inner corner and pressing on bone is very different than the rubbing of the actual vulnerable structure of the eye itself," he said. Michael Greenwood, MD, said he also tells people that rubbing the bridge of the nose or close to the temple is OK. "Just don't put your fingers on the soft part of the eye," he said. Dr. Greenwood added later that sometimes what the physician might think of as eye rub- bing is not what the patient thinks of. Having the patient demonstrate how they rub their eyes can be helpful, as can having a family member in the room. Dr. Greenwood said when he asks a patient if they rub their eyes, they'll say no, but the other person in the room with them is nodding their head yes. "People who rub their eyes aren't always aware that they're doing it," he said. Dr. Baartman also said he asks a loved one, if present, if the patient says they don't rub their eyes. "I then usually describe the type of eye rubbing that can be harmful to an eye and explain that it will lead to new or continued 'warping' of the ocular structures," he said. "Par- ticularly useful is the old basketball analogy; nearly everyone in their school-aged days has been to a gym with that old basketball that has been bounced repeatedly and develops weak- Greater awareness needed about impact of eye rubbing by Liz Hillman Editorial Co-Director About the physicians Brandon Baartman, MD Vance Thompson Vision Omaha, Nebraska Michael Greenwood, MD Vance Thompson Vision Fargo, North Dakota References 1. Sahebjada S, et al. Eye rubbing in the aetiology of keratoco- nus: a systematic review and meta-analysis. Graefes Arch Clin Exp Ophthalmol. 2021;259:2057– 2067. 2. Panikkar K, et al. Progressive keratoconus, retinal detach- ment, and intracorneal silicone oil with obsessive-compulsive eye rubbing. Oman J Ophthal- mol. 2016;9:170–173. 3. Bassily R, et al. Bilateral rup- ture of the posterior capsule and intraocular lens dislocation from excessive eye rubbing. J Cataract Refract Surg. 2016;42:329–331. 4. Turner DC, et al. The mag- nitude of intraocular pressure elevation associated with eye rubbing. Ophthalmology. 2019;126:171–172. Relevant disclosures Baartman: None Greenwood: None continued on page 76

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