In a 25‑year‑old patient who frequently rubs his or her eyes, what are the risks and recommended management for potential keratoconus or irregular astigmatism?

Management of Eye Rubbing in a 25-Year-Old Patient at Risk for Keratoconus

A 25-year-old patient who frequently rubs their eyes requires immediate cessation of eye rubbing behavior and comprehensive corneal imaging to detect early keratoconus, as this age group is at peak risk for disease progression and vision loss. 1

Critical Age-Related Risk Factors

Your patient falls into the highest-risk category for keratoconus progression:

• Keratoconus typically presents in the second or third decade of life, with peak progression occurring before age 30. 1
• Younger age of onset is directly associated with greater disease progression and more severe vision loss due to irregular astigmatism, thinning, and scarring. 1
• The natural progression of corneal steepening decelerates after age 30, making your 25-year-old patient particularly vulnerable to rapid deterioration. 1
• Overall, keratoconus progresses at a faster rate in younger patients, making early detection and treatment crucial in this age group. 1

Immediate Management Priorities

1. Stop Eye Rubbing Immediately

All patients must be counseled to avoid eye rubbing, which is linked to disease progression. 2

• Eye rubbing is a proven considerable contributing factor in corneal degeneration, and progression can be decreased or halted by stopping eye rubbing at early stages. 3
• Abnormal rubbing may increase the likelihood of developing keratoconus and contributes to progression even after the disease is established. 4
• Adding a mast cell stabilizer to control ocular allergy should be considered to reduce eye rubbing. 1

2. Comprehensive Corneal Evaluation

Early detection requires tomographic evaluation to determine disease extent and establish a baseline. 2

Specific imaging to obtain:

• Corneal topography and tomography are essential for detecting irregular astigmatism or abnormalities of the posterior cornea suggestive of keratoconus. 1
• Corneal pachymetry and higher-order aberration data are now commonly used in addition to corneal topography, as a single parameter is insufficient for diagnosis in incipient cases. 5
• Biomechanical changes in a keratoconus cornea happen before morphological changes, and identification of corneal biomechanical properties may be useful in early diagnosis. 1

3. Establish Baseline for Progression Monitoring

Serial topographic analysis with comparison of at least two pentacam reports taken at different time points is essential to document disease progression. 6

Documented progression requires at least 2 of the following:

• Steepening of the anterior corneal surface
• Steepening of the posterior corneal surface
• Thinning and/or increase in the rate of corneal thickness change from periphery to thinnest point 1, 6

A 1.3 D increase in Kmax over the past year indicates clinically significant progression. 2

Follow-Up Strategy

Closer follow-up is recommended in patients younger than 17 and with steeper than 55 D Kmax, but vigilant monitoring is warranted for all patients under 30. 1

• Schedule follow-up pentacam examination in 3-6 months to compare with current findings and assess for progression. 6
• Regular follow-up with serial corneal tomography is essential to monitor treatment response. 2

Treatment Algorithm Based on Findings

If No Ectasia Detected:

• Chronic eye rubbing may cause reversible corneal epithelial hypertrophy that mimics keratoconus but normalizes after cessation of rubbing behavior. 7
• Continue monitoring every 6 months for at least 2 years given the patient's high-risk age 1

If Early/Subclinical Keratoconus Detected Without Documented Progression:

• Immediate crosslinking without documented progression could expose patients to unnecessary risks. 6
• Establish baseline and monitor for progression over 3-6 months 6
• Eyeglasses can correct 71% of patients to 20/40 vision in early cases. 2

If Progression is Documented:

Corneal cross-linking (CXL) is the first-line treatment for progressive corneal ectasia to halt disease progression. 2

• Once progression is observed, prompt treatment with CXL can reduce or stop keratoconus progression and preserve visual acuity with eyeglasses and/or contact lenses. 1
• CXL works best early in the disease process, and early intervention is crucial to avoid additional loss of best-corrected vision. 1, 2
• The greater the delay of diagnosis, the higher the risk of greater vision loss and of the patient requiring a cornea transplant. 1

Critical Pitfalls to Avoid

Delaying intervention in progressive corneal ectasia can lead to irreversible vision loss. 2

• Underestimating the impact of eye rubbing on corneal ectasia progression can worsen the condition. 2
• Performing crosslinking without documented progression may expose patients to unnecessary risks without clear benefit. 6
• Failing to address underlying allergic triggers that perpetuate eye rubbing behavior 1
• Patients should be promptly referred to an ophthalmologist with expertise in corneal disorders if they experience visual loss, loss of functional vision, acute hydrops, or disease progression. 2