What is the appropriate management for a patient with frequent eye rubbing leading to retinal nerve‑fiber layer thinning and risk of glaucoma?

Management of Eye Rubbing with RNFL Thinning

Immediately implement aggressive behavioral intervention to eliminate eye rubbing, as chronic eye rubbing can cause glaucomatous optic neuropathy and progressive RNFL thinning even with normal intraocular pressure, and this damage may be irreversible. 1, 2

Primary Management Strategy

Behavioral Modification (Critical First Step)

• Institute intensive patient education and counseling as the foundation of treatment, using take-home educational materials that explain the severe consequences of continued rubbing 3
• Emphasize that eye rubbing can:
  • Raise intraocular pressure to more than 10 times normal levels during the rubbing episode 3
  • Cause progressive glaucomatous optic neuropathy even when measured IOP remains normal 2
  • Lead to irreversible visual field loss and vision decline (documented cases show progression from 12/20 to counting fingers vision) 2
• Extend education to all family members, as this creates beneficial synergy for behavior change 3

Address Underlying Triggers

• Aggressively treat any ocular allergy or atopic conditions, particularly vernal keratoconjunctivitis, as these drive the itching sensation that triggers rubbing 1
• The association between atopy and rubbing-related complications is well-established, making allergy control essential 1

Monitoring Protocol

Structural Assessment

• Perform serial RNFL thickness measurements with spectral-domain OCT every 4-6 months 4
• Use Guided Progression Analysis software to detect progressive thinning, as RNFL thickness changes are detected earlier than retardance changes (mean lag time 13.4 months) 4
• Monitor specifically for disc hemorrhages, which carry a 37-fold increased risk of progressive RNFL thinning (OR 37.529,95% CI 2.915-483.140) even with well-controlled IOP 5

Functional Assessment

• Obtain baseline and serial visual field testing to document any progression 2
• Recognize that visual field damage can occur despite normal IOP measurements during routine examinations 2

Critical Clinical Pitfalls

Recognition Challenges

• Maintain high clinical suspicion in patients with RNFL thinning and normal IOP, as rubbing-induced optic neuropathy mimics advanced glaucoma 2
• Take a detailed history specifically asking about rubbing habits, including duration and frequency (some patients rub >10 hours daily) 2
• Understand that factors other than IOP play significant roles in glaucomatous progression, making IOP control alone insufficient 5

Progression Patterns

• Be aware that 48.8% of glaucoma patients with mean IOP below 15 mmHg still show rapid RNFL progression (≥1.0 µm/year) 5
• The inferotemporal region (223°-260°) shows the most frequent progressive RNFL loss 4
• Recovery from rubbing-related damage appears to be a passive process, while adverse consequences are active—meaning prevention is far superior to attempted reversal 3

When Behavioral Intervention Fails

• Recognize that advice to avoid rubbing may not be successfully followed, necessitating repeated counseling sessions 3
• Consider psychological or psychiatric consultation if compulsive rubbing behavior persists despite education 2
• Document the severity of potential outcomes (including legal blindness) to emphasize urgency 2