Purpose
To report sight-threatening complications following extensive bulbar conjunctival resection and postoperative mitomycin C therapy for cosmetic eye-whitening in the United States.
Design
Retrospective noncomparative case series.
Methods
Multicenter report of 9 patients referred for evaluation and management of complications following bilateral cosmetic eye whitening.
Results
Seventeen eyes of 9 patients underwent cosmetic eye-whitening performed between 2 and 48 months prior to referral to one of the centers. Sixteen of the 17 eyes had persistent conjunctival epithelial defects, with 10 eyes requiring amniotic membrane grafting to facilitate re-epithelialization. Four eyes of 2 patients developed limbal stem cell compromise confirmed with in vivo confocal laser scanning microscopy. One patient developed infectious scleritis and diplopia resulting from Tenon capsule scarring. Another patient developed scleral necrosis, secondary infectious scleritis, and infectious endophthalmitis. This patient subsequently developed noninfectious scleritis that required 3-drug-regimen immunosuppression.
Conclusion
Severe adverse effects can occur after extensive cosmetic conjunctival resection followed by topical mitomycin C application. Patients and physicians should be aware of the potential sight-threatening complications associated with this eye-whitening procedure.
Eye whitening as a cosmetic procedure was popularized in South Korea for the management of asymptomatic benign conditions such as persistent conjunctival hyperemia, pingueculae, and pigmentation. This procedure involves extensive conjunctival resection and sometimes tenonectomy, much like the dissection performed for excision of pterygia, but with no conjunctival or amnion grafting to cover the bare sclera. Mitomycin C (MMC) 0.02% is used intraoperatively and postoperatively 4 times a day for up to 1 week, depending on the appearance of the ocular tissues. A topical antibiotic is used 4 times a day for 2 months. Patients are also given topical corticosteroids every hour for 1 week, then 4 times daily for 2 months. Some physicians have also prescribed nonsteroidal anti-inflammatory and anesthetic eye drops during the immediate postoperative period. Enhancement procedures are performed to excise additional conjunctiva and Tenon capsule in some patients who developed hyperemia after the initial surgery.
Complications have been reported in patients who have undergone eye-whitening procedures in South Korea, including persistent conjunctival epithelial defects, diplopia secondary to scarring, and scleral thinning with and without calcific plaque formation.
In the United States, cosmetic eye whitening is a relatively new procedure. The true incidence of complications following regional conjunctivectomy performed in this country is unknown because the total number of patients who have undergone the procedure is unknown. However, as patients experiencing complications secondary to this procedure are presenting to physicians other than the operating surgeon for management, it is important to understand the technique and possible postoperative complications. A case of scleritis after cosmetic conjunctivectomy performed in the United States has been reported. Here we report a series of 9 additional patients who developed postoperative complications following cosmetic eye whitening performed by the same surgeon as the previous case report details.
Methods
This retrospective review was approved by the Institutional Review Board at the University of California, Los Angeles. The charts of 9 patients who received cosmetic eye whitening by 1 surgeon were reviewed. Most of the patients were originally seen by and referred from outside physicians in the community. These patients were referred to our clinics between April 1, 2010 and June 30, 2014. The following information was obtained from the available medical records: indication for eye-whitening procedure, patient age and sex, preoperative best-corrected distance visual acuity (BCDVA), complications and time to onset thereof, medical and surgical treatment administered, and final outcome including BCDVA.
All patients underwent a complete ophthalmologic examination that measured best-corrected visual acuity, intraocular pressure, slit-lamp examination including fluorescein staining, and dilated fundus examination. In vivo laser scanning confocal microscopy was performed if there was clinical suspicion for limbal stem cell damage to confirm microstructural changes.
Results
Patient Characteristics
The characteristics of 9 patients are summarized in the Table . Eight patients (#1-8) received cosmetic eye whitening by extensive conjunctivectomy and intraoperative/postoperative topical MMC treatment in both eyes, and Patient #9 received the procedure in 1 eye. All procedures were performed by a single surgeon. The mean age of the patients in our study was 41.78 (range, 29–59 years). Six patients were female and 3 were male. The patients presented to 3 different institutes for the management of complications between 2 and 45 months after the eye-whitening procedure (6 at a single center: Patients #1–5, 9). Five patients underwent the procedure for persistent conjunctival hyperemia, 2 for benign conjunctival pigmentation, 1 for a pinguecula, and 1 for a pterygium in 1 eye and a pinguecula in the other. Patient #2 had a history of quiescent ulcerative colitis; no other patients had a history of underlying rheumatologic or connective tissue disease.
| Patient # | Sex | Age | Indication for Eye Whitening | Complications | Onset (mo) | Treatment | Outcome at Last Visit | |
|---|---|---|---|---|---|---|---|---|
| Medical a | Surgical | |||||||
| 1 | M | 29 | Pterygium OD, pinguecula OS | • CED OU • Calcific plaque OU • Infectious scleritis OS | 11 | • Moxifloxacin • PF | • AMT OU sutured as inlay | Seen only once |
| 2 | F | 43 | Conjunctival hyperemia OU | • CED OU • Calcific plaque OU • Scleral ulcers OU | 24 | • Autologous serum 50% | • Removal of calcific plaques OU • AMT OU secured with fibrin glue as onlay and inlay | Recurrence of calcific deposits 4 mo after AMT, stable at 40 mo after initial surgery |
| 3 | M | 29 | Racial melanosis OU | • CED OU • Limbal stem cell damage OU | 2 | • Moxifloxacin • PF | None | Healed CED 6 mo after surgery |
| 4 | F | 46 | Conjunctival hyperemia OU | • Scleral thinning OU • CED OU • Infectious scleritis OS • Endophthalmitis OS | 24 | • Moxifloxacin • PF • Vitreous tap/injection OS • Hyperbaric oxygen | • AMT OU secured with sutures and fibrin glue as onlay and inlay • Scleral patch graft with AMT onlay (secured with sutures and fibrin glue) OS | Stable scleral thinning OU, stable calcific plaque OD 45 mo after surgery |
| 5 | F | 54 | Conjunctival hyperemia OU | • Limbal stem cell damage OU • CED OS | 12 | • Ciprofloxacin • Autologousserum 50% • Oral prednisone | Healing CED OS 36 mo after surgery | |
| 6 | M | 39 | Racial melanosis OU | • Scleritis with ulcers OU • Calcific plaque OS • Infectious scleritis OD • Anterior uveitis OU • Diplopia | 9 | • Moxifloxacin • Autologous plasma 70% • Oral ciprofloxacin, doxycycline and prednisone | • AMT OD secured with fibrin glue as inlay • Conjunctival/Tenon flap to cover AMT OD • Tarsorrhaphy OD | Stable scleral thinning OU 36 mo after surgery. Required paste-on prism |
| 7 | F | 32 | Conjunctival hyperemia OU | • CED OU • Calcific plaques recurrent ×3 | 15 | • Autologous serum 30% | • Removal of calcific plaque and AMT OU secured with fibrin glue as onlay and inlay | Stable 44 mo after surgery |
| 8 | F | 45 | Conjunctival hyperemia OU | • CED OU • Calcific plaques OU | 33 | • Moxifloxacin • PF • All-trans retinoicacid | Removal of calcific plaque and AMT OS secured with fibrin glue as onlay and inlay | Stable OU at 42 mo after surgery |
| 9 | F | 59 | Pinguecula OD | • Calcific plaque OD • Scleral thinning OD • Scleral ulcer OD • Panuveitis OD • Macular edema OD | 45 | • Gatifloxacin • PF | Planned removal of calcific plaque, scleral patch graft, and rotating conjunctival autograft | Planned surgical intervention |
a All medical treatment administered was topical unless otherwise specified.
Clinical Presentation
Seven of 9 patients had best-corrected visual acuities of 20/40 or better in both eyes at presentation. The other 2 patients (Patients #2 and #6) had best-corrected visual acuities of 20/100 or better in both eyes, with no other pathology on examination to account for decreased vision. No patients had increased intraocular pressure during the follow-up period. All 17 eyes of 9 patients developed persistent conjunctival erosions and scleral thinning, with 9 of those eyes progressing to scleral ulceration ( Figure 1 , Top row). Three eyes developed infectious scleritis; 1 of these cases resulted in endophthalmitis that required 2 intravitreal injections of antibiotics.
Four eyes of 2 patients (Patients #3 and #5) had clinical signs of limbal stem cell damage confirmed with confocal microscopy ( Figure 1 , Middle row and Figure 2 , Middle and Right). Patient #6 developed bilateral anterior uveitis and diplopia attributable to scarring of Tenon tissue. Patient #9 had panuveitis and cystoid macular edema. There were 2 cases of culture-proven infectious scleritis. Culture obtained from the right eye of Patient #6 was positive for Pseudomonas aeuroginosa and that of the left eye of Patient #8 yielded Moraxella catarrhalis .
All 17 eyes of these patients were treated with aggressive lubrication and topical antibiotic and corticosteroid. Patients with conjunctival erosions were prescribed autologous serum or plasma eye drops, and those that had symptomatic calcific plaques or nonhealing conjunctival defects were treated with amniotic membrane transplantation (AMT) with removal of the calcific plaques, except in Patient #1. Ten eyes of 6 patients underwent AMT. Scleral thinning was stabilized in all eyes with BCDVA 20/40 or better at the last follow-up (mean 34.5 months, range 6–45 months).
The clinical courses of 2 patients who developed severe scleritis are described below in detail.
Case 1
A 46-year-old patient (Patient #4) was treated with bilateral cosmetic eye whitening for persistent conjunctival hyperemia 2 years prior to presentation. She developed significant scleral thinning and infectious scleritis that led to endopththalmitis in her left eye. A rheumatologic evaluation was negative for vasculitis or connective tissue diseases. Following a vitreous tap, she was treated with intravitreal antibiotics twice. The scleral melt was treated with an amniotic patch graft followed by a scleral patch graft and subsequently 60 sessions of hyperbaric oxygen for a persistent conjunctival defect. The epithelial defect eventually healed after 6 months of treatment. However, she developed recurrent scleral thinning and inflammatory uveitis. She was last seen 45 months after her eye-whitening procedure. Her corrected distance visual acuity (CDVA) was 20/30 in the left eye and she had stable scleral thinning in both eyes, with a calcific plaque in her right eye. Currently, she requires co-management by rheumatology and is on oral cyclosporine 250 mg daily, mycophenolate mofetil 3 g daily, and prednisone 10 mg daily to control the uveitis.
Case 2
A 39-year-old Indian man (Patient #6) underwent bilateral cosmetic eye whitening followed by an enhancement for racial melanosis. Nine months after the second procedure, he developed progressive bilateral scleral thinning, scleritis, and anterior uveitis. Despite treatment with oral prednisone, the scleral thinning continued to progress.
The patient presented with necrotizing scleritis in the right eye, with a deep nasal scleral ulcer and uveal exposure ( Figure 1 , Bottom row). The left eye was noted to have a nasal scleral ulcer with a calcium plaque at its base and an overlying conjunctival epithelial defect. His CDVA was 20/100 in the right eye and 20/20 in the left eye. Topographic mapping demonstrated 5 diopters of oblique astigmatism in the right eye. The patient had only 0.25 diopters of astigmatism on refraction before the development of scleral ectasia. Culture of the nasal scleral ulcer in the right eye was positive for Pseudomonas aeruginosa , for which he was treated with topical 0.5% moxifloxacin 6 times daily in the right eye and oral ciprofloxacin 750 mg twice a day for 2 weeks. The left eye was also treated with topical 0.5% moxifloxacin 4 times daily. Oral doxycycline 50 mg twice daily was added to the regimen. The scleral necrosis improved in the right eye, and the epithelial defect decreased in size in the left eye, but remained persistent.
Autologous plasma (70%) drops were initiated 6 times daily in both eyes to promote re-epithelialization over the exposed sclera. The patient underwent a comprehensive rheumatologic evaluation that did not reveal underlying systemic autoimmune disease.
As the bacterial scleritis was not improving after 2 weeks of topical and oral antibiotic therapy, an amniotic membrane transplant was performed to fill the ulcer in the right eye, and a pedicle conjunctival and Tenon flap from the inferior fornix was advanced to cover approximately 90% of the nasal ulceration. A nasal tarsorrhaphy was also performed at the same time. On postoperative day 7, the CDVA was 20/60 in the right eye and 20/20 in the left eye.
Over the next 2 months, the scleritis in the right eye slowly improved. The epithelial defect on the bulbar conjunctiva of the left eye almost completely healed. Scleral thinning in both eyes remained stable. However, the patient developed vertical diplopia and was noted to have a right hypertropia attributable to scarring of Tenon tissue. A 22 diopter base-up paste-on prism was prescribed, and at last follow-up, CDVA was 20/25 in the right eye and 20/20 in the left eye.
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