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Scleral thinning after I-BRITE procedure treated with amniotic membrane graft

Published:April 22, 2016DOI:https://doi.org/10.1016/j.jcjo.2016.03.004
      A 39-year-old female was referred for punctal plug insertion for dry eye complaints and a nonhealing conjunctival defect in both eyes. She had a history of right eye pterygium and left eye pingecula removal with the I-BRITE (Boxer Wachler Vision Institute, Beverly Hills, Calif.) procedure 2 years previously. The I-BRITE procedure is advertized for the treatment of conjunctiva hyperemia, pterygium, and pinguecula.

      Boxerwachler Vision Institute. 〈www.boxerwachler.com/i-brite-eye-whitening〉 (accessed January 22, 2015)

      Postoperatively, she recounted using, in both eyes, topical antibiotics 4 times daily, preservative-free artificial tears, testosterone 10% ointment to the eyelids, mitomycin C (MMC) drops of unknown concentration 4 times daily, and a tapering course of topical steroids.
      Examination at the slit-lamp revealed bilateral nasal scleral thinning with corresponding avascular areas and absence of overlying conjunctiva (Fig. 1). She was started on hourly preservative-free artificial tears and ointment at bedtime, testosterone ointment to her lids was stopped, and she was offered amniotic membrane graft with lateral tarsorraphy. No rheumatology work-up was performed, as she had no complaints of joint pains or dry mouth. After much trepidation and 4 months without improvement, she agreed to proceed with amniotic membrane graft, which stabilized her ocular surface for 5 months, after which she presented again with calcific plaques overlying the areas of avascularity. She then refused any further surgical intervention and was lost to follow-up.
      Fig. 1
      Fig. 1Slit-lamp photographs of right eye after pterygium and left eye after pinguecula excision with the I-BRITE procedure. Note the nasal avascular areas (both eyes), scleral thinning (right eye), and conjunctival absence (both eyes).
      Cosmetic eye-whitening procedures for the treatment of chronic conjunctival hyperemia have recently become a topic of interest because of accumulating evidence of severe postoperative complications associated with their practice.
      • Kim B.H.
      Regional conjunctivectomy with postoperative mitomycin C to treat chronic hyperemic conjunctiva.
      • Lee S.
      • Go J.
      • Rhiu S.
      • et al.
      Cosmetic regional conjunctivectomy with postoperative mitomycin C application with or without bevacizumab injection.
      A large proportion of patients had undergone the surgery termed “regional conjunctivectomy” in South Korea, along with many patients in the United States. Each respective procedure entails resection involving significant amounts of bulbar conjunctiva with or without resection of Tenon’s capsule components within the nasal and/or temporal regions of the palpebral fissure, with concomitant intraoperative and postoperative MMC administration topically, subconjunctivally, or both.
      • Kim B.H.
      Regional conjunctivectomy with postoperative mitomycin C to treat chronic hyperemic conjunctiva.
      • Moshirfar M.
      • McCaughey M.V.
      • Fenzl C.R.
      • et al.
      Delayed manifestation of bilateral scleral thinning after I-BRITE(®) procedure and review of literature for cosmetic eye-whitening procedures.
      A multitude of postoperative complications have been reported in association with these procedures, including, but not limited to, scleral thinning with or without calcified plaques, chronic dysfunctional tear syndrome, dry eyes, diplopia induced by fibrovascular growth, necrotizing scleritis, and elevated intraocular pressure.
      • Moshirfar M.
      • McCaughey M.V.
      • Fenzl C.R.
      • et al.
      Delayed manifestation of bilateral scleral thinning after I-BRITE(®) procedure and review of literature for cosmetic eye-whitening procedures.
      • Rhiu S.
      • Shim J.
      • Kim E.K.
      • et al.
      Complications of cosmetic wide conjunctivectomy combined with postsurgical mitomycin C application.
      The Korean Ministry of Health and Welfare issued an order for discontinuation of the regional conjunctivectomy procedure,
      • Lee S.
      • Go J.
      • Rhiu S.
      • et al.
      Cosmetic regional conjunctivectomy with postoperative mitomycin C application with or without bevacizumab injection.
      and the American Society of Cataract and Refractive Surgery issued a clinical alert in March 2014 recommending use of alternative procedures for treatment of conjunctival hyperemia.

      ASCRS Cornea Clinical Committee. Clinical alert: eye-whitening procedure: regional conjunctivectomy with mitomycin-C application [press release]. Fairfax, VA: American Society of Cataract and Refractive Surgery. Available from: 〈http://www.ascrs.org/node/1352〉 (accessed January 22, 2015).

      In addition to creating a predisposition for the development of necrotizing scleritis/infectious scleritis,
      • Kim B.H.
      Surgical treatment of necrotic scleral calcification using combined conjunctival autografting and an amniotic membrane inlay filling technique.
      • Okhravi N.
      • Odufuwa B.
      • McCluskey P.
      • Lightman S.
      Scleritis.
      MMC has been known to cause scleral ulcerations/calcifications, corneal edema, limbal stem cell deficiency, and iritis, with a highly variable postoperative onset of symptoms, ranging from days to years.
      Conservative treatment like artificial tears and antibiotic ointments may be instituted at the clinician’s discretion for a discrete period of time while monitoring for signs of regression or progression. Implementation of autologous serum tears may also be considered, especially for cases demonstrating recalcitrance of conjunctival epithelial defect resolution. Removal of the calcific plaque also facilitates healing. In more severe cases, additional treatment options available for utilization include placement of amniotic membrane grafts, autologous conjunctival flaps, or simultaneous placement of both.
      • Rhiu S.
      • Shim J.
      • Kim E.K.
      • et al.
      Complications of cosmetic wide conjunctivectomy combined with postsurgical mitomycin C application.
      Forms of tissue media available for scleral surface repair include sclera, cornea, pericardium, fascia lata, dermis, and cartilage.
      • Hanada K.
      • Shimazaki J.
      • Shimmura S.
      • Tsubota K.
      Multilayered amniotic membrane transplantation for severe ulceration of the cornea and sclera.
      • Karalezli A.
      • Kucukerdonmez C.
      • Borazan M.
      • Akova Y.
      Successful treatment of necrotizing scleritis after conjunctival autografting for pterygium with amniotic membrane transplantation.
      • Ti S.E.
      • Tan D.T.
      Tectonic corneal lamellar grafting for severe scleral melting after pterygium surgery.
      • Mauriello Jr., J.A.
      • Pokorny K.
      Use of split-thickness dermal grafts to repair corneal and scleral defects—a study of ten patients.
      • Chechelnitsky M.
      • Mannis M.J.
      • Chu T.G.
      Scleromalacia after retinal detachment surgery.
      • Raviv T.
      • Greenfield D.S.
      • Liebmann J.M.
      • Sidoti P.A.
      • Ishikawa H.
      • Ritch R.
      Pericardial patch grafts in glaucoma implant surgery.
      This case of scleral thinning illustrates a complication that can arise after the I-BRITE procedure. Comprehensive ophthalmologists should be aware of the potential risks and complications with this surgery, the surgery known as regional conjunctivectomy with MMC, and the alert issued by the ASCRS regarding the procedure.

      ASCRS Cornea Clinical Committee. Clinical alert: eye-whitening procedure: regional conjunctivectomy with mitomycin-C application [press release]. Fairfax, VA: American Society of Cataract and Refractive Surgery. Available from: 〈http://www.ascrs.org/node/1352〉 (accessed January 22, 2015).

      • Kaufman S.C.
      • Jacobs D.S.
      • Lee W.B.
      • Deng S.X.
      • Rosenblatt M.I.
      • Shtein R.M.
      Options and adjuvants in surgery for pterygium: a report by the American Academy of Ophthalmology.

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