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Dr. Miller: Rubbing your eyes might feel good, but it is really bad. Is that true? We're going to talk about that next on Scope Radio.

Hi, I'm here with Dr. Mark Mifflin. He's a professor of ophthalmology at the University of Utah. Mark, is rubbing your eyes too much a problem? Can that lead to some bad outcomes?

Dr. Mifflin: Yes, actually, it wouldn't be necessarily intuitive that rubbing one's eyes could result in actual damage to the eye, but it's fairly common.

Dr. Miller: Now everybody at some time has got to be rubbing their eyes. So are we talking about a small number of people?

Dr. Mifflin: Well, we actually see a category of disease, perhaps two, that are related to chronic eye rubbing. Certainly, short term eye rubbing is probably not going to cause a problem except for maybe a very few patients who may have some kind of severe problem underlying their eye condition. But chronic eye rubbing can result in the weakening of the cornea and distortion of the cornea called keratoconus.

And it's often associated with people with very bad allergic conjunctivitis or itchy eyes and, unfortunately, some of these people are so itchy that they nothing feels better that . . . I call it the knuckle rub to the eye. Unfortunately, over time, that can actually weaken and distort the eye.

Another thing that can be associated with chronic eye rubbing is actually laxity of the eyelid. The eyelid can, over time, lose its elasticity and that's a less serious problem, but still not something that we want to happen.

Dr. Miller: So if somebody was rubbing their eyes because they have severe allergies in the spring or even year-round, how do they end up at your doorstep? Is it that their vision is blurred at some point?

Dr. Mifflin: Yes, typically, most of the patients who we feel that actually there is an association between chronic eye rubbing and disease fall into the diagnosis of the condition called keratoconus, which is a structural abnormality of the cornea causing poor vision due to an abnormal shape to the surface of the eye. The shape causes irregular astigmatism, which often cannot be corrected by glasses or even contact lenses in its severe stages.

One really important is that this disease may run in families and, typically, may start even in childhood. So certainly, parents should be advised to try to seek treatment for their young children who may have severe allergic disease and in the case of eyes, typically allergy eye drops are very effective in eliminating itch. And behavior modification just through teaching can help children not rub their eyes.

Dr. Miller: Now, how do you know if you're rubbing your eyes too hard?

Dr. Mifflin: I tell my patients that the amount of pressure needed to wash one's face with a washcloth gently or dry with a towel is the appropriate amount of pressure to put on one's eye. Anything more than that is probably unhealthy for the eye.

Dr. Miller: So if you're rubbing to the point where you're seeing stars, then it's a bad thing?

Dr. Mifflin: It is possible to induce the sensation of light or the perception of light without actually seeing light. And this can occur with the eyelid closed and these little sparks of light are called photopsia and certainly, when one rubs their eye hard enough to induce photopsia, that is not a good thing.

Dr. Miller: And if you do that repetitively, you might end up in the ophthalmologist's office.

Dr. Mifflin: I would say that there is a good chance that if you do it over a period of years, you could end up with even worse than that.

updated: October 12, 2018
originally published: April 17, 2016

Dr. Miller: Treatments for a damaged cornea. We're going to talk about that next on Scope Radio.

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Dr. Miller: Hi, I'm here with Dr. Mark Mifflin. He's a Professor of Ophthalmology here at the University of Utah. I'd like to talk a little bit about what patients might expect if they go in for corneal transplantation or mention of some of the newer technologies related to corneal repair. I know you're an expert in that area so you might just tell us a little bit about that.

Dr. Mifflin: Traditionally, corneal transplantation involves basically replacing the front of the eye, the windshield, if you will, which is the curved clear dome of our eye is the cornea. And so in the traditional technique that is actually cut with a special instrument and replaced with a clear cornea from a human donor cadaver eye. The cadaver tissue is processed through an eye bank and it's very safe. It's much safer than obtaining, for example, a unit of blood from a transfusion.

The tissue is carefully screened and selected and amazingly does not need to be tissue-matched, unlike a kidney or a heart or something like that because the cornea does not have blood vessels and the eye has what we call immune privilege, meaning it's designed or evolved or whatever one believes to not scar and to not create an excessive immune response to injury or surgery.

In terms of some of the newer procedures, within the last ten or so years we have made really amazing advances in just transplanting the part of the eye that is actually diseased. So for example, in a condition called keratoconus where basically the structural part of the cornea is weak and distorted, we can replace the anterior part of the cornea, leaving all of the posterior structure intact. This speeds recovery, decreases the rate of rejection and generally results in better vision.

Dr. Miller: How does one choose between the best surgery or technique?

Dr. Mifflin: Well, typically the surgeon has to kind of choose for the patient, and some of the more advanced techniques are not always possible. There are other diseases where only the very inner layer of the cornea is damaged or diseased, and certainly replacing the inner layer only allows for a very quick recovery. For example, comparing traditional cornea transplantation which might take six months for visual recovery, transplantation of the inner layer or the endothelial keratoplasty that we do now may result in good vision in as little as two weeks.

Dr. Miller: That's a huge difference. How many patients do you think would qualify for the partial thickness corneal transplant?

Dr. Mifflin: It's pretty much become the standard of care. It's not that the traditional technique is wrong, but certainly, for example, in our center here at the University of Utah we always try to do the most advanced technique if we believe that it's going to result in the best outcome for the patient. Not all surgeons are necessarily trained in the most advanced techniques, but certainly these things are literally becoming the standard of care for most patients.

Dr. Miller: Dr. Mifflin, could you talk a little about the durability of the corneal transplantation or the partial corneal transplantation?

Dr. Mifflin: Durability in terms of survival rates and longevity of the graft is actually very good. Graft rejection or failure is quite low, in the range of perhaps as low as 1% for some groups or maybe up to 30%. The most difficult transplant patients that we deal with in terms of making the graft work long-term are children. Unfortunately, children do sometimes need corneal transplantation and the success rate is lower, although sometimes there's no option and corneal transplantation is required to prevent irreversible amblyopia or loss of vision due to basically what in layman's terms is known as lazy eye.

Dr. Miller: So either transplantation technique should result in equivalent duration, longevity of the transplant?

Dr. Mifflin: Yeah, and typically transplants will last anywhere from . . . there have been documented successful transplantations lasting more than 60 years. I've only been practicing for 20 years, but most of my transplants from 20 years ago are still doing fine.

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Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. The Specialists with Dr. Tom Miller is on The Scope.

Dr. Miller: Hi, I'm Dr. Miller and I'm here with Dr. Mark Mifflin. He's the Professor of Ophthalmology and his practice includes refractive surgery, otherwise known as LASIK to many.

Now if we go to the operative day where they're going to have the procedure, is that a fairly involves surgery or is it fairly straightforward, done under local anesthetic, or do they have to be under general anesthesia? Just describe that procedure a little bit more.

Dr. Mifflin: Yeah, the actual procedure itself is outpatient and pretty user-friendly. I like to think of it that way. Amazingly, most modern eye surgery, at least on the anterior part of the eye, and this would include laser vision correction surgery, is done with what's called topical anesthesia which means we just actually numb the eye with several eye drops, maybe three or four sets of numbing drops. Amazingly, that can result in a pain-free surgery. And typically, for vision correction surgery there's no sedation, no IV, and it's done in kind of a clean setting in a laser room but the person doesn't have to change into a hospital gown or anything like that.

Dr. Miller: So patients coming in for the surgery might be anxious on the operative day. Some people are very concerned about having their eye touched, and I can understand that. That gives people a sense of squeamishness. How do you calm patients who are coming in for surgery? Obviously they're going to be awake. You mentioned that you're going to use a topical anesthetic so they're going to know pretty much what's going on during the surgery, and I would suspect a number of people would be anxious. How do you calm them and how do you get them through the surgery so that you have a really good outcome?

Dr. Mifflin: The day of surgery is actually a culmination of a long process of teaching the patient and kind of letting them know what the whole experience is going to be like, not only preoperatively, but during the surgery itself and then also the recovery phase. It's actually very easy for most people to go through. We literally handhold. We have a staff of about three or four people in the laser room. We have nurses and technicians who have been doing this for decades, some of them. So anything from gentle coaching by the surgeon in which there is constant verbal interaction. Some people even call it a vocal local, meaning kind of calming the patient by talking to the patient and coaching them and kind of telling them what to expect.

Dr. Miller: Vocal local. That's good. So I'm assuming that they've got to be completely still while that laser is performing the procedure, doing the changes, sculpting on the lens.

Dr. Mifflin: Interestingly and that . . . you're absolutely right. It's a great source of anxiety for patients. Not only, number one, we have really strong reflexes to keep things away from our eyes. That's just ingrained in us. The concept of somebody doing something to your eye is unpleasant, but again, through the educational process and also a very stepwise process where we kind of ease in to the surgery, it's amazing that pretty much anybody can tolerate it.

Part of that process again is the fact that it is pain-free and the laser technology actually tracks the eye just like a weapons technology laser or something would track a target. That's how the laser technology works, so even though the patient is a little bit worried about not looking in the right place . . .

Dr. Miller: The laser is sophisticated enough to be able to do that automatically.

Dr. Mifflin: That's absolutely right. The patient looks at a target. The surgeon is aligning the laser, and then the laser has a camera and/or lasers in it that is tracking the pupil. Between those things, I've never seen one of these laser tracker fail. It's very, very accurate. So if the patient should look away more than about a half a millimeter the laser automatically quits firing.

The actual sculpting or laser ablation typically would last between 5 and 20 seconds per eye, so it's very quick. In LASIK surgery the initial stage of the surgery is cutting a flap and that takes about maybe 30 seconds, so the actual time under the laser where they are really kind of critical things going on is really usually less than a minute per eye.

Dr. Miller: Do you usually do one eye per session or do you do them both?

Dr. Mifflin: Very early, we recognized that this was extremely reliable technology and by doing one eye at a time it was mostly just inconveniencing the patient. Rarely, we still see patients that are a little bit uncomfortable with the thought of doing both eyes and we offer that option. Most people are afraid to have this surgery, but by the time we have finished educating them and get them to the day of surgery they are very comfortable.

The other fear that patients have is that they are able to do something to cause a bad outcome, and that is actually not true. It is such a safe surgery and we have such a low tolerance for risk in an elective eye surgery like this that we have literally made it risk-free in terms of anything the patient can do to cause a bad outcome.

The patient can put themselves at risk by being non-compliant with postoperative care. There are medications, prescription eye drops that are necessary. There are certain protective and common sense things that are required during the healing period. Barring that, it's almost risk-free and that really boils down to having a good conservative screening process that steers away people who are better served by wearing glasses or contact lenses.

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