【正文】 an 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 makeup 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 peting/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 peting 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 postrubbing 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 peting 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.. Stage 3: developing high motivation. Aim: to raise awareness of the association between KC and chronic habits of abnormal rubbingOcular hypertensive individuals who are educated about the importance of their medication, and about the consequences of not taking the prescribed dosage, showed better pliance 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 pliance with habit reversal. A patient39。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) Rubbingrelated 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 bees more difficult with cone progression and daytoday 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 plexity and depth of this information reduces patient capacity to understand and retain the several issues raised if the information is only provided orally. The patient39。s education can be supported by a takehome 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 patient39。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 postLASIK 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 patient39。s motivation and, also help to involve the family in rubbing avoidance responsibilities, some of whom (the patient39。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 relapseprevention 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 appea