How do I use the Goodman Score to quantify eye‑rubbing severity and frequency in a patient suspected of contributing to ocular surface disease, allergic conjunctivitis, or keratoconus, and what management is recommended for moderate or high scores?

Goodman Score Assessment for Eye Rubbing

The Goodman score quantifies eye-rubbing severity on a scale where scores ≥5 indicate clinically significant rubbing behavior that requires intervention, and you should implement aggressive behavioral modification plus topical therapy to break the eye-rubbing cycle in these patients.

Understanding the Goodman Score

The Goodman score is a validated assessment tool that evaluates both frequency and intensity of eye rubbing behavior 1. In a prospective study of 153 patients with keratoconus and ocular surface disease:

• Average Goodman score was 5.8 ± 3.1 1
• 63.2% of patients scored ≥5, indicating moderate to severe rubbing behavior 1
• Higher scores correlated with addiction-like behaviors and psychiatric family history 1

The score demonstrates that eye rubbing exhibits addictive-like cognitive and behavioral characteristics, playing an essential role in keratoconus onset/progression and maintenance of dry eye 1.

Clinical Significance by Score Range

Scores ≥5 (Moderate to High)

These patients require immediate, aggressive intervention because:

• They demonstrate significantly more frequent and intense ocular symptoms 1
• 74.4% meet CAGE criteria (≥2) for addiction-like behavior patterns 1
• Eye rubbing directly contributes to disease progression in both keratoconus and ocular surface disease 1

Association with Underlying Conditions

Elevated Goodman scores are strongly linked to:

• IgE-mediated allergic conditions that drive the itch-rub cycle 2
• Atopic dermatitis (66.6% lifetime prevalence of conjunctivitis in AD patients) 3
• Asthma and rhinitis (associated with higher rubbing frequency) 3

Management Algorithm for Moderate/High Scores (≥5)

1. Address Underlying Allergic/Inflammatory Drivers

Topical antihistamines and mast cell stabilizers are first-line for breaking the itch-rub cycle 4. For moderate-to-severe cases:

• Initiate dual-action antihistamine/mast cell stabilizer drops 4
• Add topical corticosteroids for acute exacerbations 4
• Consider proactive seasonal treatment before allergen spikes 4

2. Target IgE-Mediated Pathways

Assess and treat elevated IgE levels (both allergen-specific and total serum IgE) 2. This is critical because:

• Higher IgE correlates with worse eye rubbing behavior 2
• IgE drives aberrant extracellular matrix remodeling in keratoconus 2
• Modulating IgE-mediated responses improves disease prognosis 2

3. Behavioral Modification Strategies

Directly address the addictive component identified in high Goodman scores:

• Educate patients that eye rubbing is a modifiable risk factor with addiction-like features 1
• Screen for psychiatric comorbidities (more common in high scorers) 1
• Implement habit-reversal techniques targeting the eye-rubbing cycle 1

4. Ophthalmology Co-Management

Refer to ophthalmology for:

• Chronic vernal keratoconjunctivitis, atopic keratoconjunctivitis, or giant papillary conjunctivitis 4
• Any patient with keratoconus and high Goodman scores 1
• Consideration of advanced therapies including topical calcineurin inhibitors or biologics for severe atopic disease 5

Critical Pitfalls to Avoid

• Do not underestimate the addictive nature of eye rubbing in high scorers—standard patient education alone is insufficient 1
• Do not delay treatment of underlying allergic conditions, as the itch-rub cycle perpetuates both keratoconus progression and ocular surface disease 1, 2
• Do not overlook systemic atopic disease—49-50% of atopic dermatitis patients have ocular involvement that may be sight-threatening 5, 3
• Avoid contact lens use in patients with active keratitis or high rubbing scores (contact lenses increase keratitis risk 2-3 fold) 3