Clinical Assessment of Eye-Rubbing Behavior
Assess eye-rubbing behavior using validated addiction-based screening tools, specifically the Goodman criteria and modified CAGE questionnaire, as eye rubbing demonstrates addictive-like cognitive and behavioral characteristics that require systematic evaluation.1
Structured Assessment Approach
Primary Screening Tools
Goodman Score Assessment: Apply the Goodman criteria for behavioral addiction to quantify eye-rubbing severity, with scores ≥5 indicating clinically significant rubbing behavior that warrants intervention 1
Modified CAGE Questionnaire: Utilize the CAGE-modified criteria specifically adapted for eye rubbing, with scores ≥2 identifying patients at high risk for rubbing-related complications 1
Essential History Components
Rubbing Characteristics:
- Frequency, duration, and intensity of rubbing episodes 1
- Specific triggers including itching, watery eyes, contact lens removal, and insertion 2
- Type of rubbing: gentle versus forceful with tight eye closure (the latter can elevate intraocular pressure to >10 times normal) 3
- "Removal-relief" rubbing: Specifically assess for rubbing immediately after contact lens removal, which is significantly more prevalent in keratoconus patients and represents higher-risk behavior 2
Associated Risk Factors:
- Personal or family history of atopy, allergic conjunctivitis, or vernal keratoconjunctivitis 4
- Psychiatric history (personal and family), as addiction and psychiatric family history correlate with higher rubbing scores 1
- History of ocular surface disease or dry eye symptoms 1
Clinical Examination Priorities
Corneal Assessment:
- Screen for keratoconus or corneal ectasia using topography/tomography, as chronic rubbing causes mechanical corneal thinning, loss of rigidity, elevated epithelial temperature, and inflammatory-mediated remodeling 4
- Evaluate for acute hydrops, corneal perforation risk, or post-surgical wound complications 4
Intraocular Pressure:
- Document baseline IOP and assess for pressure spikes, as rubbing can cause distending forces and IOP elevation 4
- Screen for glaucomatous optic neuropathy in chronic rubbers 4
Additional Complications:
- Anterior segment: iris prolapse, iridoschisis, lens capsule rupture, IOL dislocation 4
- Posterior segment: retinal detachment, silicone oil extrusion in previously operated eyes 4
Critical Clinical Pitfalls
Contact Lens Wearers: Both keratoconic and non-keratoconic contact lens wearers demonstrate significantly more rubbing before lens insertion compared to non-wearers, creating a cycle where pre-insertion trauma predisposes to wound healing responses and greater adverse effects from subsequent rubbing 2
Inadequacy of Simple Counseling: Verbal advice alone to "stop rubbing" fails in a significant proportion of patients, with evidence of frequent relapses requiring structured education programs and repeated counseling sessions 3, 2
Management Framework
- Provide take-home educational materials specifically designed for eye-rubbing cessation that can be shared with family members, as the behavior often has familial patterns 3
- Implement regular follow-up counseling rather than single-session advice 2
- Address underlying triggers aggressively, particularly allergic eye disease and ocular surface disease 4
- Consider the addictive nature of the behavior when designing intervention strategies, similar to substance abuse counseling approaches 1