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The prevalence of keratoconus in the general population is approximately 1 in 2,000 individuals (0.05%)(77 Rabinowitz, YS. Keratoconus. Surv Ophthalmol. 1998;42(4):297-319.). Its etiology is multifactorial, combining environmental, genetic, and behavioral factors. Of note, its distribution differs worldwide; countries with less sun exposure have a lower prevalence than those with greater exposure(11 Gordon-Shaag A, Millodot M, Shneor E, Liu Y. The Genetic and environmental factors for keratoconus. Biomed Res Int. 2015;2015:795738.2 Gomes JA, Rapuano CJ, Belin MW, Ambrósio R Jr; Group of Panelists for the Global Delphi Panel of Keratoconus and Ectatic Diseases. Global consensus on keratoconus diagnosis. Cornea. 2015;34(12):e38-9. Comment in: Cornea. 2015;34(4):359-69. Cornea. 2015;34(11):e33-4.3 Galvis V, Sherwin T, Tello A, Merayo J, Barrera R, Acera A. Keratoconus: an inflammatory disorder Eye (Lond). 2015;29(7):843-59. Comment in: Cornea. 2017;36(1):e1-e2.4 Vazirani J, Basu S. Keratoconus: current perspectives. Clin Ophthalmol. 2013;7:2019-30.5 Wisse RP, Kuiper JJ, Gans R, Imhof S, Radstake TR, Van der Lelij A. Cytokine expression in keratoconus and its corneal microenvironment: a systematic review. Ocul Surf. 2015;13(4):272-83.-66 Gordon-Shaag A, Millodot M, Kaiserman I, Sela T, Barnett Itzhaki G, Zerbib Y, et al. Risk factors for keratoconus in Israel: a case-control study. Ophthalmic Physiol Opt. 2015;35(6):673-81.). However, it is thought that the higher prevalence may be attributed to ethnic and behavioral characteristics rather than direct sun exposure. However, the association between atopy and the act of eye rubbing has been established as a trigger for the disease development and progression. In numerous studies, half of the participants with keratoconus reported that they rub their eyes, although these findings are variable in the literature. Other influential factors are the frequency and intensity of eye rubbing(88 Balasubramanian SA, Pye DC, Willcox MD. Effects of eye rubbing on the levels of protease, protease activity and cytokines in tears: relevance in keratoconus. Clin Exp Optom. 2013;96(2):214-8.9 Panahi-Bazaz MR, Sharifipour F, Moghaddasi A. Bilateral keratoconus and corneal hydrops associated with eye rubbing in a 7-year-old girl. J Ophthalmic Vis Res. 2014;9(1):101-5.10 McMonnies CW. Eye rubbing type and prevalence including contact lens 'removal-relief' rubbing. Clin Exp Optom. 2016;99(4):366-72.-1111 McMonnies CW, Korb DR, Blackie CA. The role of heat in rubbing and massage-related corneal deformation. Cont Lens Anterior Eye. 2012;35(4):148-54.).
In an investigation including only individuals with clinical unilateral keratoconus, the authors observed a tendency for patients to sleep on the same side with the eye that is most severely affected or the eye with a progressing disease. Some of these patients slept with their hand or fist positioned directly against their eyelid and were more likely to hug their pillow in a manner that caused compression around their eyes(1414 Carlson AN. Keratoconus: time to rewrite the textbooks. Rev Ophthalmol [Internet] 2009 [cited 2019 May 21];16:66. Available from: -time-to-rewrite-the-textbooks ). 1e1e36bf2d