Audit Of Eye Rubbing, Allergy, And Sleep Patterns In Newly Presenting Keratoconus Patients: Implications For Early Behavioural Intervention

Keratoconus (KC) progression is associated with eye rubbing and allergic eye disease. Understanding the prevalence and patterns of these behaviours in newly presenting patients can inform early educational interventions and risk mitigation strategies. This audit evaluated eye rubbing habits, allergy history, and sleep postures, assessed compliance with patient education, and explored parameters relevant for future studies, including potential associations between hand dominance and eye rubbing patterns.

A registered cross-site audit was conducted at Moorfields Eye Hospital in collaboration with corneal specialists at the Royal Free Hospital, London, and the Rothschild Institute, Paris. Consecutive, newly presenting KC patients attending clinics over six months (October 2023–March 2024) were included. Data were fully anonymised, and ethical processes were followed. The audit was performed in a tertiary setting with a comprehensive clinical assessment.

A structured questionnaire was developed to capture self-reported eye rubbing behaviours (frequency, technique, laterality), history of allergy/atopy, clinical signs of allergic eye disease, and sleep habits and positions, and was completed on the day of primary clinical assessment. Clinical assessments included visual acuity, iCare intraocular pressure, corneal tomography (MS-39 and Pentacam), and subjective refraction. All patients received education on eye rubbing risks and allergy management. Demographic, behavioural, and compliance data were recorded. Hand dominance was noted for exploratory purposes to inform future larger-scale studies evaluating correlations with eye rubbing and corneal ectasia patterns.

Complete datasets were available for 41/46 patients (mean age 28.8 years; 59% male). History of allergy/atopy was reported in 57%, with clinical signs in 80%. Eye rubbing was reported in 83%, predominantly using fingerpads/knuckles; 54% employed multiple techniques. Side sleeping was reported in 83%, with 61% using multiple positions; 24% reported prone sleeping. Hand dominance was recorded but, due to the sample size, no meaningful correlation with eye rubbing or disease laterality could be established. All patients received education; audit compliance was 100% for allergy assessment, eye rubbing evaluation, and provision of educational resources.

Newly presenting KC patients frequently exhibit eye rubbing behaviours and a history of allergic disease. Sleep posture may contribute to asymmetric corneal stress; this has previously been noted in limited literature. Early identification of modifiable behaviours, combined with immersive patient education and prompt allergy management, offers opportunities to mitigate ectasia progression. Future larger-scale studies are warranted to investigate the extent to which sleep laterality and hand dominance influences eye rubbing patterns and disease laterality. Integrating behavioural interventions and exploring self-management education strategies may enhance patient compliance and long-term outcomes.