| | Behaviour modification in the management of chronic habits of abnormal eye rubbing published online 02 February 2009. Abstract ObjectivesTo describe how and why many keratoconus patients do not comply with strong advice to control chronic habits of abnormal rubbing. To outline a behaviour modification approach for controlling chronic habits of abnormal rubbing. MethodsCommon reasons for chronic habits of abnormal rubbing have been reviewed as a basis for specifying a behavioural modification approach to habit reversal. ResultsThe methods described are organized into the classic behavioural modification structure of: (1) habit awareness, (2) competing responses, (3) development of motivation, and (4) social support. This structure is supported by the application of social influence principles to achieve optimum compliance. ConclusionsThe use of take-home written information in the form of an Abnormal Rubbing Guide is the basis for the development of motivation. Family social support is based upon a widening of the responsibility for avoiding eye rubbing to all family members. Some patients will need minimal application of these principles with patient education being sufficient intervention to achieve habit reversal. For patients with strong provocation to rubbing and/or by having a well established rubbing habit, a greater exposure to the habit reversal program described is indicated. Successful habit reversal may slow the rate of ectasia progression. Prophylactic application of the methods described for patients who are at risk for developing keratoconus, or post-laser assisted in situ keratomileusis keratectasia, may show that some forms of keratectasia are preventable. 1. Introduction  Chronic habits of abnormal rubbing (AR) appear to be at least a contributory causal factor in the development and/or progression of some forms of keratoconus (KC) [1], [2]. Chronic habits of AR may be a sufficient cause in some cases [3], but a definite causal link has not yet been established [4]. Advice to patients with keratoconus that they should control AR habits has been a common recommendation [5], [6], [7], [8], [9], [10]. This advice may also be indicated for patients with, or at risk for developing post-laser assisted in situ keratectasia [1]. The level of rubbing practiced by an unselected (consecutive) sequence of over 30-year-old KC subjects, was measured using visual analogue scales, and found to be significantly greater than that reported by normal over 30-year-old control subjects. The control subjects also routinely wore rigid gas permeable contact lenses all day everyday and are assumed to have had the same limited opportunities to rub their eyes [11]. All of the KC subjects had been given an oral explanation of how AR might be a contributing causal factor in the development and progression of their KC, and had been advised to abstain from rubbing. Clearly, many had not been able to comply with that advice. Compliance with treatment recommendations is often poor in other areas of eye care. A review of 100 patients revealed that 74% of them were non-compliant with at least one aspect of the instructions provided regarding the maintenance of their contact lenses [12]. Patients with glaucoma are frequently non-compliant with their medication [13]. In addition, patients who are monitored for adherence to prescribed dosages have been found to overestimate their compliance with glaucoma therapy [13]. Similarly, in the treatment of amblyopia in children, patching times noted by parents were usually found to overestimate the times recorded by dose monitors [14]. Given their exposure to advice to abstain from rubbing, there may also have been some under-reporting of rubbing levels by the KC sample that was studied [11]. The true level of non-compliance may have been higher than was found [11]. Clearly oral advice to abstain from rubbing that included discussion of a possible causal role was shown to be ineffective for a significant number of patients. One of the reasons for the lack of success may be that the advice was based on the possibility that AR may be a contributory causal factor in some forms of KC. In Australia, “Smoking may be injurious to your health” as a warning on cigarette packets has been replaced by statements such as “Smoking causes lung cancer”. Credibility of smoking related warnings is enhanced by using messages that are direct and unambiguous [15]. The change to a clear causal statement, leaving no room for doubt, appears to be contributing to a reduction in smoking prevalence [15]. Smokers have been found to recall causal smoking messages in more detail [15]. Similarly, advice to control AR may be more effective if AR was known to be a cause of KC. The impact of this advice could be greater if rubbing was known as a sufficient cause in addition to being a contributory cause. Presumably, rubbing by KC patients who wear contact lenses, occurs before lens insertion, or after removal. The risk of dislodging and possibly losing lenses, especially rigid lenses, appears to prohibit rubbing except for these times. These limited opportunities to rub are apparently taken by too many KC patients [11]. Many KC patients insert their lenses soon after waking and any rubbing that occurs prior to lens insertion may have greater potential to cause corneal trauma. For example, closed eye conditions may cause the cornea to be oedematous in response to overnight hypoxia and expose the cornea to increased rubbing-related trauma risk. After lens removal at the end of the day, the stimulus to rub may be symptoms of irritation, dryness, allergy related itch, and/or eye or general tiredness, for example. Provocations to rub may increase gradually during the day, and be high prior to lens removal, due to irritation associated with lens soiling and drying for example. Because rubbing must be suppressed during lens wear, the release from any suppressed urge to rub when lenses are removed, may predispose to “removal relief” rubbing. Anecdotally, such “removal-relief” rubbing is sometimes confessed to be especially vigorous and prolonged, as well as irresistible and satisfying. For example, dryness may be relieved if accessory lacrimal glands release extra tears under compressive rubbing mechanical forces, and combine with rubbing-related reflex tears to rewet the ocular surface. In addition, inability to rub in response to symptoms of itch during lens wear, may create an additional strong provocation for removal relief rubbing, due to the release from a pent up urge to rub. Although rubbing habits may be negatively reinforced by associated post-rubbing inflammation and irritation, relief from itch symptoms can serve as a positive reinforcement, and help to perpetuate subsequent rubbing episodes. For these reasons, contact lens removal may be a daily high point for risk of relapse to a rubbing habit. KC patients may also be susceptible to rubbing while drowsy or even asleep. Thick fluid lenses associated with apical clearance corneal lenses may create hypoxia [16]. Similarly, scleral lenses may create resistance to oxygen transmission in series with a thick fluid lens and induce an oedema response [17]. In addition, piggy back lens combinations (rigid lens combined with a soft lens), which also create resistance in series to the oxygen delivery to the cornea, may create hypoxia if the lens combination has an inadequate oxygen transmission function [17]. Unfortunately, epithelium that might be abraded or become oedematous during lens wear [18] may be more susceptible to additional trauma from rubbing that occurs on lens removal. The risk that rubbing, which occurs before and/or after contact lens wear, may contribute to the accelerated progression of KC appears to be a strong indication for AR habit control. In dermatology, simply advising a patient not to scratch their itchy skin, is a counsel of perfection which rarely achieves very much, particularly if a good deal of the damage is being done while the patient is asleep, and in no position to control his behaviour [19]. As described above, advice to KC patients to control AR, that is limited to counseling, appears to be similarly ineffective in too many cases. This report discusses some of the reasons why KC patients might have difficulty complying with advice to control their AR habits. The issues raised serve as a basis for describing the application of the principles of behaviour modification, social influence, and habit reversal, to the management of chronic habits of AR. 2. Why are some rubbing habits so difficult to break? 2.1. Part A: itch Allergy histories are significantly more common in KC patients, both as teenagers and as adults [11]. Although most allergy sufferers do not have eye allergies [20], ocular itch appears to be a common provocation for rubbing in KC subjects [11]. Itch is an unpleasant sensation provoking the desire to scratch [21]. It is one of the most distressing skin sensations that substantially impair the quality of life [22]. Itch can be one of the most noxious sensations in the human experience [23]. A skin itch sensation can be reduced by the pain induced by scratching [24]. When discussing itch and difficulty in controlling AR, patients with keratoconus sometimes make remarks like: “I feel like scratching my eyes out!” Using finger nails to cause tactile and pain sensations to relieve skin itch can be efficient. By comparison, the low friction resulting from rubbing the lubricated palpebral conjunctiva across the ocular surface, appears to be an inefficient method of achieving ocular itch relief. This factor may explain why some patients resort to the use of great force and long rubbing episodes to get relief [7]. Unfortunately the relief from itch achieved, although frequently only temporary, appears to serve as a positive reinforcement. The fact that “It feels great” helps to positively reinforce and perpetuate the habit. Allergic conjunctivitis is a common source of itch symptoms [25]. The perception of minor stimuli as itch can be facilitated in atopic patients compared to non-atopic patients [19]. Rather than the bulbar conjunctiva or cornea, the most affected tissue when there is a history of itch and AR may be the palpebral conjunctiva [26]. Some people rub their eyes to relieve itch experienced in the skin of the lids. For example, inflammatory dermatoses may be involved or the ‘dry itch’ of senescent skin [27]. Firm eye-rubbing has been found to cause a mild and transient increase in ocular itching, chemosis and hyperaemia [28]. The increase in itch and other responses are longer and more dramatic for cat sensitive individuals after exposure to cat allergens [28]. The reasons why firm rubbing causes increased itch symptoms are not clear. Perhaps rubbing causes allergens, and other particles collected by the eyelashes, to be relocated to the ocular surface where they may have an increased potential to provoke rubbing. Rubbing has been shown to degranulate palpebral conjunctival mast cells in animal studies [29] and histamine release may perpetuate itch cycles, and corresponding additional rubbing episodes. Prostaglandins were found to act directly to induce itch in conjunctiva [30]. Any prostaglandin released in association with rubbing-induced conjunctival inflammation, may also contribute to itch that develops after a rubbing episode. 2.2. Part B: psychogenic factors Anecdotally, KC patients are commonly described as having unusual personality characteristics [31]. However subjective judgments about the patient made by a practitioner might be saying more about the diagnostician than about the patient [19]. In a study of 75 KC patients, no significant differences from controls for history of psychoneurosis, or differences for anxiety, depression, phobia, obsessionalism, psychoneuroticism, and hysteria were found [32]. Three age-matched samples of KC patients, patients with other chronic eye diseases, and healthy normals, were examined on 20 personality scales, using a standardized personality inventory [33]. Patients with KC were found to differ from normal controls in much the same way as did patients with other chronic eye diseases [33]. A sample of 153 patients with KC completed the Million Behavioural Health Inventory, a psychological instrument designed to assess factors relevant to patient care [31]. The results suggested that KC patients are less respectful of practitioners, uncooperative, and non-compliant with treatment plans [31]. As is the case for patients with other diseases, attitude or personality changes in response to the diagnosis, and progression of keratoconus, may have influenced these results. In dermatology it is impossible to separate current mental state from pre-morbid personality [19]. Any influence of KC on personality may be a function of the timing and nature of its onset in the context of the patient's psychosocial development [33]. In addition, the study that found that KC patients are less cooperative [31] was not able to indicate if these characteristics were associated with an as yet unidentified distinct KC profile, or even, perhaps a reflection of an inappropriate practitioner style of patient management [31]. Failure to establish rapport with a patient may influence practitioner assessment of the patient. For example, in the management of adolescent dermatology patients, an unhurried private talk with the patient on the first visit, is the sine qua non for establishing the rapport required [34]. One potentially damaging influence on practitioner/patient rapport, is the need to advise some KC patients to control an AR habit that is very well established. How the advice is delivered may be an important factor. A discussion of a holistic approach to the management of KC patients included an essential message regarding the need to be kind to these patients [35]. Apart from itch, numerous other conditions and reasons have been cited as being associated with or provocative for rubbing. These include dryness-induced ocular irritation, blepharitis, persistent styes, infection, ritual meditation, punctal agenesis, blepharoptosis, sexual deviation, an atrial-ventricular septal defect, psychogenesis, mental stress, emotional tension, psychosis and compulsion [11]. In addition, rubbing can be a means of inducing a pleasurable subjective phosphenic sensation [32] as well being common on waking [9], when rubbing might be a response to irritation caused by dried mucus that has collected overnight. Rubbing is also common when tired [9], and could be a response to irritation associated with dust and air-borne allergenic particles that have collected in the lashes during the day. Some of the cited provocations for eye rubbing listed above indicate that psychogenic factors, including emotional tension and mental stress, can be associated with AR habits [11]. The evidence suggests that in dermatological practice a good many of the untoward emotional symptoms are the response to, rather than a cause of the illness [19]. The same may be true for KC patients. However, in some instances in dermatological practice, responses to scratching can be considered as an innate displacement reaction, which has many of the characteristics of a conditioned response to emotional tension [19]. Again, the same may be true for KC patients. AR may appear to be an unprovoked habit. For example, continuous licking of the lips could well be attributed to dehydration, if it were not for the fact that an individual may persist in this habit to such a degree, that it appears to afford an oral satisfaction, which transcends an immediate organic need [36]. Some forms of eye rubbing might have a similar basis, having started in response to significant provocation, but being sustained partly as an unprovoked habit. There are a number of troublesome symptoms occurring in childhood, and occasionally persisting into adulthood, which may exist as the principal difficulty without evidence of any other psychopathology, or which may be the symptomatic expression of a wider pathological picture [36]. Such symptoms are not necessarily indicative of serious mental disturbance, but they do constitute important practical problems, and may be a source of secondary unfavorable emotional reactions [36]. These special symptom reactions include learning disturbances, speech disturbances, enuresis, sleep disturbances and habit reactions such as tics, thumb-sucking, nail biting and excessive masturbation, as well as lying, stealing and truancy [36]. For example, nail biting has been interpreted as expressing a variety of emotional problems, occurring as a tension-releasing device in the face of stressful or threatening situations [36]. Skin scratching and rubbing can be displacement behaviours that occur when discussing emotionally disturbing topics [19]. In dermatology, stress in a variety of forms may manifest in a similar fashion for particular individuals [19]. Threats to emotional stability can trigger bouts of itching [19]. Emotional factors may exacerbate the intensity and persistence of itch [19]. Emotional modulation of the perception of itch is well known and results in marked intra- and inter-individual variations [37]. Again, it is possible that some cases of eye rubbing could be interpreted in a similar way. This type of AR might have particular significance for adolescents. The oculocardiac reflex is a physiological response of the heart to physical stimulation of the eye or the ocular adnexa, characterized by bradycardia or arrhythmia, which sometimes leads to cardiac arrest [38]. Pressure on the eyeball slows the heart rate due to the association of the fifth cranial nerve and the vagus nerve, being the basis for the oculocardiac reflex [39]. Producing a vagal response by eye rubbing (sometimes to the degree of inducing a faint) is used in the martial arts, massage therapies, hypnotism, and is a method for disabling violent prisoners/patients [40]. Shiatsu massage uses this form of vagal response to bring about a deep sense of relaxation [40]. Control of heart irregularity, due to an atrial-ventricular septal defect, has been reported to be achieved by eye rubbing [8]. Bradycardia induced by eye rubbing (the oculo-cardiac reflex) may be used by some people to help them to cope with stress. Anxiety can be a significant problem for adolescents [36], but is also a major health problem for older adults [41] and, as suggested above, AR associated with stress may be more prevalent in patients with KC at any age. Consideration of alternative approaches to stress management may be an important factor in helping these patients to achieve rubbing habit-reversal. 2.3. Management of abnormal rubbing Can exposure to allergens be reduced or avoided? A patient who has been dependent on anti-histamines and compresses for many years may benefit from new topical therapies with a potential to reduce chemosis, redness and itch [42]. Lash hygiene on waking to remove overnight dried mucus may remove a provocation to rubbing. Lash hygiene in the evening, may eliminate sources of irritation or itch that can provoke rubbing and contributes to repeat rubbing cycles. For example, dust and airborne allergens which have collected on the lashes during the day, can be removed in this way. Similarly, compliance with the treatment of dry eye, blepharitis and any other source of ocular irritation may reduce rubbing provocation. 2.4. Behaviour modification Behavioural modification and habit-reversal [43] methods have been used to manage habitual skin scratching in neurodermatitis [44]. After reviewing other applications of behaviour therapy in dermatology, it was concluded that the greatest use of these methods would be in the control of scratching in patients with conditions that included significant itch symptoms [19]. These dermatological applications suggest that behaviour modification might be an appropriate basis for the management of abnormal eye rubbing. 3. A behaviour modification approach to habit reversal for patients who rub their eyes abnormally 3.1. Stage 1: rubbing habit awareness 3.1.1. Aim: to obtain a reliable assessment of rubbing activity and increase awareness of this activity Awareness that abnormal rubbing can be associated with the development and progression of KC, might cause patients to under-report their level of this activity. Prior to any discussion of the association between rubbing and keratoconus, a patient is asked to keep a diary of rubbing-related information for a period of 1 week. Sometimes rubbing is an unconscious activity, at least at the start of a rubbing episode. Family or partner help is recommended as a means of obtaining the most comprehensive and accurate details for this diary. This information serves as a reference for planning strategies for rubbing control and against which the numerous aspects of rubbing activity can be compared, as attempts to control the habit proceed. The diary includes daily records of rubbing episode frequency and duration. Is the force used mild, moderate or severe? Are finger tips, knuckles or the back of the hand usually used for rubbing? Is one eye rubbed more than the other? When is the most common time of day for rubbing? Where does rubbing usually take place? What conditions provoke rubbing? Is worry, stress or anxiety associated with rubbing? Is itch involved? Does the urge to rub return soon after you have stopped rubbing? How long has your rubbing habit been established? A take-home record sheet for collecting rubbing-related information is shown in Fig. 1. However, for some patients it may be better to collect the information in-office (when there is a language difficulty, for example). 3.2. Stage 2: competing responses 3.2.1. Aim: to find activities that could substitute for rubbing and/or distract from the urge to rub Examples: (1) Gentle lid/lash hygiene using cold?/warm?/hot? cleansing to remove allergens, dust, blepharitis scales, dried mucus, and/or to improve meibomian gland health and function. Cold cleansing is indicated for allergic and other inflammatory conditions. However, many KC patients do not suffer from allergy [11] and many allergic people do not have ocular allergies [20]. Warm or hot cleansing may be preferred by these patients. Higher cleansing temperatures may yield more relief from meibomian gland dysfunction for example. Patient preference for temperature can be a key factor in the comfort and relief achieved. Geographical or seasonal variation in temperature may modify preferences and improve compliance. That eye comfort is improved by this procedure can be the key factor in maintaining good lid hygiene habits as alternatives to rubbing. Patients can be taught to use a clean face cloth or make-up removal pads with minimal force when cleansing. Forces against the eye will raise IOP which may promote cone formation or progression [1]. During cleansing, any force should be directed away from the eye, and onto the side of the nose at the inner canthus, to remove dried mucus or accumulated mucus and tear waste. Lash cleansing procedures should only be a very light brushing ‘butterfly wing’ action. Lid hygiene can be a very useful morning, evening and before sleep routine for many patients. This routine may serve as a substitute for abnormal rubbing as well as to reduce or prevent irritation and itch development. (2) Instill allergy drops. Do chilled drops give more relief? Do tear supplements give relief? (3) Does squeezing the ear lobes or the bridge of the nose (or any other source of competing/distracting sensation), give itch relief? Ideally, patients will adapt these suggestions to their own use or devise alternative methods that give them the most effective competing response. Psychological factors, including emotion, inattention, and a variety of auditory, visual and other sensory inputs, may act to modulate the perception of itching [27]. Anecdotally, some patients with AR habits report being better able to avoid rubbing when they are busy interacting with other people in a school or work environment for example. Concern about a negative and potentially embarrassing appearance due to post-rubbing ocular and lid redness may be a factor in this regard. The opposite can be the case at home, especially in the privacy of the bathroom or bedroom. The need for competing responses and the choice of the most appropriate and effective method used by any patient, may vary according to where they are, and whom they are with when the urge to rub arises. 3.3. Stage 3: developing high motivation 3.3.1. Aim: to raise awareness of the association between KC and chronic habits of abnormal rubbing Ocular hypertensive individuals who are educated about the importance of their medication, and about the consequences of not taking the prescribed dosage, showed better compliance with their prescribed drug regimen than those who are not educated [45]. Concordance with occlusion therapy for amblyopia in children is reduced by poor parental understanding of treatment [46]. Written information is a simple, inexpensive, easy to implement, yet effective method of improving parental understanding of amblyopia therapy and subsequent concordance [46]. Similarly, education regarding the significance of rubbing in the etiology and progression of keratoconus [1], can be used to motivate patients to develop and maintain compliance with habit reversal. A patient's desire and determination to avoid rubbing may be a key factor in their success. For example, motivation may be raised by an understanding of risks that increase with the frequency, episode duration, force involved and habit chronicity. Key points in patient education include: (1) Rubbing-related corneal trauma and increases in intraocular pressure may promote cone formation and progression of corneal distortion [1]. (2) Rubbing may cause or increase corneal scarring, glare and vision loss. Contact lens fitting becomes more difficult with cone progression and day-to-day symptoms increase with associated reduction in quality of life. (3) Motivation may also be increased by the knowledge that rubbing is more likely to be damaging when it occurs before the eye has recovered from the previous episode of rubbing, before the cornea has recovered from oedema due to sleep related eye closure, and if it occurs after removal of contact lenses that may have induced changes to the cornea that increase susceptibility to rubbing trauma. Motivation to control AR habits may depend on the correction of any patient misconceptions regarding their prognosis. Advertisements for refractive surgery procedures, for example, may give rise to an expectation that a surgical procedure is a satisfactory alternative to the need to control AR. The complexity and depth of this information reduces patient capacity to understand and retain the several issues raised if the information is only provided orally. The patient's education can be supported by a take-home Abnormal Rubbing Guide (ARG) [47]. The ARG text and illustrations can be used as the basis for an oral consulting room presentation. The text is shown in Fig. 2. Displayed in an easily referenced position at home, the ARG can help to maintain motivation. The ARG is intended to be used to involve the patient's family in rubbing avoidance responsibilities. Family involvement is based on the possible role of AR in a range of conditions and circumstances (apart from KC and post-LASIK keratectasia), for which rubbing is contraindicated. In addition, the ARG may be a suitable basis for educating patients to not rub their eyes following corneal grafts as well as following refractive or other forms of ocular surgery. Similarly, the ARG may have applications for patients with recurring styes, or any other form of ocular infection. Awareness of reasons for controlling AR which are unrelated to KC may help strengthen the KC patient's motivation and, also help to involve the family in rubbing avoidance responsibilities, some of whom (the patient's siblings or children, for example), may be genetically at risk for developing KC. The application of elements of approaches that have been successfully used to control smoking habits may help patients to control AR. For example, repeated mailing of relapse-prevention information at intervals of 6 weeks was found to significantly reduce smoking relapse in a sample who had recently stopped smoking [48]. It was suggested that this approach could also be valuable for a range of problem behaviours that are characterized by high relapse rates [48]. Abnormal rubbing habits appear to fit this criterion. For example, KC patients can be invited to receive email or text (Newsgroup) messages that remind them of the negative consequences of rubbing, and the positive consequences of rubbing avoidance. These messages can include suggestions for alternative competing responses to substitute for, or distract from, the urge to rub. Of course the patient's privacy must be guaranteed but these messages can be efficiently broadcast to all participating patients to help build and maintain the motivation needed to sustain habit reversal. For longer messages, an email Newsgroup is a suitable format but a telephone text message may be appropriate for shorter messages. In interviews, glaucoma patients have cited forgetfulness as an impediment to adherence to their prescribed treatment regimen [13]. Consequently, forgetfulness is recommended to be one of the prime issues to be addressed in improving patient compliance with glaucoma treatment [49]. Email or text messages may reduce the tendency for patients to forget the details of information provided orally during a consultation. Sample email messages for KC patients are shown in Fig. 3. 3.4. Stage 4: social support 3.4.1. Aim: to create an understanding and sympathetic family approach to the need for rubbing habit reversal Family members should be advised to avoid a negative, ‘rubbing police’ attitude, in their role of helping to monitor or control rubbing activity in a KC patient. Family members, who are supportive and use techniques that positively reinforce abstention, rather than draw attention to, criticize, or punish any relapses, can be a vital component of successful management [19]. Family members can usefully recognise absence of rubbing and successful use of competing responses, or distraction activities. Also, recognition by family members of the absence of post-rubbing ocular responses such as redness, chemosis, lid oedema and lacrimation, can be a basis for positive reinforcement of successful control. After a rubbing relapse episode, sympathetic encouragement for the patient to look in a mirror to see the negative rubbing effect on appearance, might help by serving as negative reinforcement. As discussed above, emotional tension and/or mental stress may be the main provocations for rubbing in some cases. Telling people not to worry is most unlikely to be helpful if the provocation to worry has a rational basis that cannot be altered, or easily avoided. Telling people not to worry may have even less chance of being helpful when the source of worry has an irrational basis. Many patients in dermatology will develop somewhat negative responses to their illness and to a proposal that a visit to a psychologist or psychiatrist might be a useful adjunct to treatment [19]. The same caveat may be relevant to patients with KC. If a referral is intended it may be advisable to choose appropriately between the use of terms like anxiety and stress, when preparing a report. Health insurance may cover one of these areas but not the other. However, patients may be more amenable to the suggestion that benefit could be gained from a life coaching program, a meditation course, or professional relaxation therapy. In addition, there are numerous stress and anxiety management websites as well as self-help books that may be useful in some cases. 3.5. Compliance Although it may be considered to be the patient's responsibility to follow advice, compliance is based on a good relationship with health care givers [45]. Parent's expectations regarding their children's eye care were examined by interview in a paediatric ophthalmology clinic [50]. The six areas identified by parents as the most important expectations regarding paediatric ophthalmologists were: (1) clinical competence, (2) interaction with child, (3) education/training, (4) explanation in clear language, (5) information about diagnosis, and (6) personal connection [50]. The responses from parents whose child has keratoconus may be similar. The demands of fitting contact lenses, and the associated follow-up care, are frequently higher for KC patients. The steep contact lens-related learning curve is associated with the limited time available for patient instruction regarding the correct handling and maintenance of contact lenses. The initial experience of wearing diagnostic trial contact lenses may inhibit a patient's capacity to absorb a lot of information about their disease. Barriers to good compliance include the provision of too much information [51], suggesting that a progressive staging of patient education might have greater influence on patient understanding and behaviour. However, notwithstanding the achievement of high motivation to control an AR habit per medium of counseling and education, some people will still have great difficulty complying with advice given. For some people, the need to rub their itchy eyes is an irresistible urge. Rubbing may occur during sleep or as an unconscious or reflex response. In some cases, there may be similarities between physical dependence on alcohol, nicotine or any other drug of addiction, and the need to respond to an itch stimulus. Reflexes are powerful determinants of behaviour. Smoking is apparently easier for habitual smokers to avoid during a concert when, by comparison, a cough reflex stimulus is irresistible. For some patients, an inability to cope with stress and anxiety (including an absence of other stress management alternatives), may provide a very strong stimulus for relapse to an eye rubbing habit. Competing responses might be more or less successful alternatives to rubbing, but sometimes rubbing may simply be more convenient at times of high levels of rubbing provocation. A positive view on any relapse episodes is that rubbing trauma is reduced if there a fewer rubbing episodes, that are shorter, and which involve a reduction in force used. Fortunately in some cases, an understanding of the potential for rubbing-related corneal trauma is a sufficient basis for the complete control of AR. The reasons for non-compliance with recommendations from health care professionals were examined and distilled into six principles of social influence that can be incorporated in a rubbing avoidance management plan [51]. (1) The principle of scarcity (associating greater value on a scarce commodity) [51] suggests that an explanation of how rubbing might be associated with hydrops, and permanent loss of vision, or post-graft complications (see the Abnormal Rubbing Guide, Fig. 2) may be helpful. (2) The principle of authority [51] suggests that reference to journal publications that support an adverse role for rubbing will be helpful. (3) The principle of social proof [51] suggests that recognition of benefits that are associated with control of rubbing habits (less ocular redness and better appearance, less corneal distortion) might be helpful. (4) The principle of liking [51] indicates that people prefer to comply with the requests of a practitioner whom they like. Amplifiers of liking include empathy with the difficulty associated with rubbing habit control. Ideally a practitioner can relate, empathically, some benefits that they have personally gained from rubbing avoidance. Similarly, acknowledgement of personal experiences of negative rubbing consequences could help. Amplification of liking and receptivity to a persuasive discussion can be assisted by judicious use of valid compliments and praise. In addition, cooperation can be increased if a treatment plan and treatment goals are jointly owned. Of course, the contact lens fitting and the monitoring of the progress of KC are the practitioner's responsibility. However, contact lens maintenance and rubbing avoidance are always primarily the responsibility of the patient. Mutual goals, and shared responsibility for them, can be the foundation for good rapport with patients, and associated better compliance when delivered in the context of working together. (5) The principle of reciprocity [51] is based on the tendency for people to feel obligated to respond favorably when concessions are made. For example, the burden of rubbing avoidance can be softened by the concession that careful and gentle lid hygiene measures (as described above), can be a substitute for rubbing. Ideally comfort achieved by lid hygiene practices, which eliminate or reduce itch and other forms of irritation, can become a routine source of positive reinforcement for rubbing avoidance. (6) The principle of consistency [51] indicates that people feel strong pressure to be consistent with their own words and actions. A patient who signs a statement which expresses their intention to make every effort to avoid rubbing (Fig. 4), might be more likely to be successful in this endeavor. 4. Conclusions Nearly 50% of KC patients report significant eye rubbing [52], [53]. Oral advice to abstain from eye rubbing is too frequently an ineffective form of patient management [11]. The suggestions for a behavioural modification approach to AR habit control described above may be a useful alternative. Patient education is the foundation for behaviour modification [54]. Best results may be obtained if practitioners choose, adapt, create and substitute elements of the behavioural modification approach described, according to their own preferences, as well as according to their patient's needs and preferences. Some patients will need minimal application of these principles, with education on the risks associated with AR being sufficient intervention to achieve habit reversal. For other patients, who are burdened by strong provocation to rubbing, there will be a need for greater exposure to the type of habit reversal program described. A behaviour modification approach, to the management of chronic habits of abnormal rubbing, may be indicated for patients with KC and a history of AR, in the hope that progression of cone development and corneal thinning might be slowed. The same methods could be adapted prophylactically for patients, and/or their siblings or children, who appear to be at risk for developing keratoconus. Rubbing avoidance patient education is indicated for patients with keratoconus who might acquire abnormal rubbing habits after being diagnosed with KC. There may be a similar prophylactic application of the methods described for patients who are at risk for developing post-laser assisted in situ keratomileusis keratectasia or post-corneal graft complications. Some forms of keratectasia and graft complications may be preventable. Conflict of interest The author has no financial interests to declare in relation to this paper. References [1]. [1]McMonnies CW. Abnormal rubbing and keratectasia. Eye Contact Lens. 2007;33:265–271.
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PII: S1367-0484(08)00163-X doi:10.1016/j.clae.2008.11.001 © 2009 British Contact Lens Association. Published by Elsevier Inc. All rights reserved. | |
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