A case of bilateral self-induced keratoconus in a patient with tourette syndrome associated with compulsive eye rubbing: case report

Abstract

BackgroundTourette syndrome is a neurologic disorder that is characterized by repetitive muscle contractions that produce stereotyped movements or sounds. Approximately 50% of individuals with TS also exhibit obsessive-compulsive behaviors including eye rubbing. We report a case of bilateral self-induced keratoconus in a patient with TS, associated with compulsive eye rubbing.Case presentationA 35-year-old man was first seen in our clinic as an outpatient due to rapid deterioration of vision in his right eye associated with pain and tearing, over a period of one month. Slit lamp biomicroscopy of the right eye showed a central stromal scar due to corneal hydrops. Clinical examination and corneal topography of the left eye were normal. Six months later the patient developed corneal hydrops of his left eye. During the following examinations his vision continued to deteriorate in both eyes, while a central stromal scar was forming in his left cornea. Four years after the initial examination the patient's visual acuity was no light perception in the right eye and counting fingers at 33 cm in the left eye. His right eye was phthisic.ConclusionsOur patient developed a rapidly progressing bilateral corneal ectasia and phthisis of his right eye during a time period of 4 years. This unusual pattern suggests that the patient's compulsive behavior compromised both of his corneas and led to bilateral keratoconus.

The Epidemiology and Etiology of Keratoconus

“…In fact, a recent case report described bilateral self-induced keratoconus in a patient with Tourette syndrome associated with compulsive eye rubbing. 76 Coyle 77 reported the case of an 11-year-old boy who, at age 5, discovered he could stop his paroxysmal atrial tachycardia by vigorously massaging his left eye (up to 20 times per day). At age 7, his ocular examination was normal.…”

Effects of eye rubbing on the levels of protease, protease activity and cytokines in tears: relevance in keratoconus

“…Various case reports have examined the involvement of eye rubbing in keratoconus . Other case studies have linked eye rubbing in keratoconus to nasolacrimal duct obstruction, punctual agenesis and Tourette's syndrome . These associations between eye rubbing and keratoconus have meant that clinicians often advise people of the risk of progression of keratoconus, if they indulge in eye rubbing.…”

“…[38][39][40][41] Other case studies have linked eye rubbing in keratoconus to nasolacrimal duct obstruction, 42 punctual agenesis 43 and Tourette's syndrome. 44 These associations between eye rubbing and keratoconus have meant that clinicians often advise people of the risk of progression of keratoconus, if they indulge in eye rubbing. Although many patients with keratoconus do not report or acknowledge abnormal eye rubbing, it is not uncommon for parents or family members to contradict a patient's statement about rubbing history.…”

Self Mutilation with Bilateral Rhegmatogenous Retinal Detachment in Tourette’s Syndorme Treated with Pars Plana Vitrectomy

“…Tics like head banging, punching and striking of the face or periorbital region can lead to direct coup injury to eye resulting in breakdown of formed vitreous. Rapid movement of the vitreous body due to repeated self inflicted trauma caused tensile stress on the vitreous base and peripheral retina leading to formation of giant retinal tears and dialysis [12]. Eye rubbing, jabbing of fingers into the eye contribute to axial myopia that may increase the traction at vitreous base in presence of partial posterior vitreous detachment.…”