In a child who frequently rubs his/her eyes, how can this cause retinal nerve fiber layer thinning and what examinations and treatments are recommended?

Eye Rubbing and Retinal Nerve Fiber Layer Thinning in Children

Frequent eye rubbing in children does not directly cause retinal nerve fiber layer (RNFL) thinning, but rather causes complications through repeated intraocular pressure (IOP) spikes that can lead to glaucomatous optic neuropathy, which then results in RNFL thinning. 1

Pathophysiologic Mechanism

The connection between chronic eye rubbing and RNFL thinning occurs through several mechanisms:

• Acute IOP elevation during rubbing episodes creates distending forces on the optic nerve head, with repeated trauma leading to glaucomatous optic neuropathy over time 1

• Mechanical stress and inflammation from vigorous rubbing triggers a cascade that can damage posterior segment structures, including the optic nerve 1

• Children with ocular allergies (particularly vernal keratoconjunctivitis) are at highest risk because itching drives the chronic rubbing behavior that perpetuates this cycle 1

Clinical Examination Protocol

When evaluating a child with frequent eye rubbing, perform these specific assessments:

• IOP measurement at every visit, as chronic uveitis and repeated rubbing increase risk of IOP elevation (occurs in 37.9% of affected eyes) 2

• Optical coherence tomography (OCT) to measure RNFL thickness, with particular attention to the inferior quadrant where glaucomatous thinning manifests earliest (mean 121.3 μm in glaucomatous eyes versus 142.1 μm in normotensive eyes) 2

• Optic disc examination to identify glaucomatous changes, as children with raised IOP and disc changes show significant RNFL thinning compared to those with IOP elevation alone 2

• Corneal evaluation for keratoconus, corneal thinning, and ectatic disorders, which are the most common rubbing-related complications 1

• Assessment for underlying atopy or allergic conjunctivitis, as these conditions strongly associate with rubbing behavior 1

Treatment Strategy

The primary intervention is eliminating the eye rubbing behavior itself, as this addresses the root cause:

• Aggressive management of ocular allergy with topical antihistamines, mast cell stabilizers, and corticosteroids (when appropriate) to reduce itching that triggers rubbing 1

• Behavioral modification strategies are vital, particularly in young children who are at highest risk for developing complications 1

• IOP monitoring and treatment if elevated, as chronic uveitis increases risk 9-fold (OR=9.28) for raised IOP 2

• Counseling families about specific complications: keratoconus progression, acute hydrops, iris prolapse, lens dislocation, retinal detachment, and glaucomatous optic neuropathy 1

Critical Risk Factors

Children at highest risk for RNFL thinning from eye rubbing include:

• Younger age patients who are high steroid responders (70% show IOP increases >15 mmHg) if corticosteroids are used for allergy management 2

• Those with chronic versus acute conditions, as chronicity increases glaucoma risk 8.4-fold (OR=8.4) 2

• Children with higher peak IOP readings during follow-up (OR=1.4 per mmHg increase for developing glaucoma) 2

Common Pitfalls

• Do not assume RNFL thinning from rubbing is benign—it indicates glaucomatous damage requiring intervention 2

• Avoid relying solely on IOP measurements; some children develop glaucomatous changes despite modest IOP elevations 2

• Do not overlook the inferior RNFL quadrant on OCT, as this shows the earliest and most significant thinning 2

• Remember that anterior segment complications (keratoconus) are more common than posterior segment damage, but both require surveillance 1