EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
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60 EW CORNEA October 2013 An eye-opening look at eye brightening procedures by Vanessa Caceres EyeWorld Contributing Writer Surgeons focus on removing redness P atients with eye conditions such as conjunctiva hyperemia, pigmentation of the conjunctiva, or even rosacea or ocular allergies may want to remove the redness in their eyes. Some surgeons are helping those patients get the red out. With a growing interest around the world in cosmetic surgery, including eye-related cosmetic procedures, it should come as no surprise that there's a procedure now to help patients get rid of the redness in their eyes. In this article, we share the details on two such procedures, one called I-BRITE and performed by Brian Boxer Wachler, MD, director, Boxer Wachler Vision Institute, Beverly Hills, Calif.; and the other called Cosmetic Eye Whitening, performed by Bong-Hyun Kim, MD, Seoul, South Korea. I-BRITE With I-BRITE (or, in more technical terms, a conjunctivoplasty), Dr. Boxer Wachler removes the conjunctiva covering the Tenon's layer, the former of which holds the red veins and yellow and brown hyperpigmentation. Afterward, a new conjunctiva grows back in its place. Mitomycin-C (MMC) is also used. The procedure takes about 20 minutes, and patients usually see results within three weeks to four months. The procedure is similar to pterygium or pinguecula removal. Some patients experience sensitivity to light and general discom- fort or scratchiness during the recovery period. Patient recovery can range from returning to work the next day or needing up to two weeks off of work. During the postop recovery, patients use antibiotics as well as corticosteroids and nonsteroidal anti-inflammatory drugs. The vast majority of patients he has treated have not required a retreatment, although patients with pterygium have a 3% chance of requiring a retreatment. Those with excessive brown pigmentation have a 9% chance of needing a secondary treatment. Patients who are pregnant or nursing or who have uncontrolled autoimmune diseases or uncontrolled vascular disease, diabetes, or glaucoma are contraindicated for the procedure. Patients with dry eye on average tend to have an improvement in symptoms after the procedure. Patients are advised to wear sunglasses outside, use artificial tears once or twice daily, and take 3000 mg daily of flaxseed oil, all in an effort to avoid further problems with redness. Dr. Boxer Wachler began performing an earlier iteration of the procedure more than 15 years ago. The procedure comes with a price tag of $3,500 to $5,500 and is not usually covered by insurance. Cosmetic Eye Whitening In Seoul, South Korea, Dr. Kim has performed more than 13,000 cases of his version of eye whitening since 1996. He developed the name Cosmetic Eye Whitening in 2007 but uses the term regional conjunctivectomy in the medical community. Dr. Kim, who was a fellow at the Descemet's continued from page 59 13. Terry MA, Saad HA, Shamie N, et al. Endothelial keratoplasty: The influence of insertion techniques and incision size on donor endothelial survival. Cornea 2009; 28: 24-31. 14. Price MO, Bidros M, Gorovoy M, et al. Effect on incision width on graft survival and endothelial cell loss after Descemet stripping automated endothelial keratoplasty. Cornea 2010; 29: 523-7. 15. Holweger RR, Marefat B. Corneal changes after cataract surgery with 5.0 mm sutured and 3.5 mm sutureless clear corneal incisions. J Cataract Refract Surg. 1997 Apr; 23(3):342-6. EditorsÕ note: Dr. Cerda is staff ophthalmologist and cornea specialist, Oftalmolaser Clinic City, Vi–a del Mar, Chile. Dr. Cerda has no financial interests related to this article. Contact information Cerda: dr.cerda@gmail.com Before eye whitening After eye whitening Source (all): Bong-Hyun Kim, MD Massachusetts Eye and Ear Infirmary, Boston, has presented on his technique at meetings such as the ASCRS•ASOA Symposium & Congress. Dr. Kim's uses MMC drops— specifically, MMC 0.02% for two to five days as well as intensive steroid therapy, both of which inhibit fibroblast and fibrous tissue formation, Dr. Kim said. Dr. Kim also administers a subconjunctival bevacizumab injection one week postoperatively to inhibit unnecessary blood vessels. The recovery period is about two months. Dr. Kim has patients take an antibiotic, steroid, and NSAID mix for several weeks postoperatively. Postoperatively, some patients experience a foreign body sensation or a feeling of dryness, Dr. Kim said. Some also experience mild pain, and a number of patients have recurrent hyperemia for one or two months after the procedure. The hyperemia usually disappears, but Dr. Kim will inject bevacizumab again if the hyperemia is severe. Dr. Kim reported in the journal Cornea last year on the results of his procedure in 571 patients.1 Of those patients, 18% had surgical revision for the growth of fibrovascular scar tissue. Postoperative complications included a higher IOP in 17%, granuloma (8.4%), transient subjective visual decreases (7.5%), and other mild side effects. Nearly 95% of patients in the study said they were satisfied with the procedure's results. Cosmetic Eye Whitening had been challenged in Korea in a case taken to the Seoul High Court, Dr. Kim said. In August, the court judged that the procedure was safe and effective and that Dr. Kim could not be blocked from performing the procedure. The judgment came despite recently published study results with 1,713 subjects that found a complication rate of nearly 83% with the procedure, including fibrovascular conjunctival tissue proliferation (43.8%), scleral thinning (4.4%), IOP elevation (13.1%), diplopia (3.6%), and recurrent hyperemic conjunctiva (28.1%).2 However, the court order noted that a number of the procedure's complications are transient, so that it would be unfair to present them as true complications. Weighing in Ophthalmic surgeons like Robert A. Latkany, MD, associate professor, New York Medical College, New York Eye & Ear Infirmary, are observing the results from these eye whitening