Eyeworld

EW NEWS & OPINION 16 A n elective eye-whitening surgical procedure for the cosmetic treatment of chronic red eyes has been introduced and practiced in East Asia and has also been offered in the U.S. This procedure, known as regional con- junctivectomy with mitomycin-C (MMC) application or eye whiten- ing, involves the excision of the medial and/or lateral conjunctiva with or without excision of Tenon's capsule combined with the applica- tion of topical MMC intra- and/or postoperatively. 1 The procedure originally gained popularity in East Asia, with one clinic in South Korea performing more than 1,800 procedures as of 2013. 1 A very similar procedure has been offered in the U.S. and goes by the name I-BRITE. 2,3 Although both procedures have gained attention for their attractive claim of treating con- junctival hyperemia, they have also drawn scrutiny and criticism for their potentially serious and sight- threatening complications. Based on the high rates of com- plications from the operation in East Asia, the Korean Ministry of Health and Welfare banned the procedure in 2011, citing among its reasons the number of lawsuits arising from patients who claim they were in- jured or suffered damages from the operation. 4 Among the issues cited by researchers examining the proce- dure were complications from the operation's large incision, the ques- tionable practice of removing so much conjunctiva for cosmetic pur- poses, and the use of MMC, which has been associated with serious vision-threatening complications that may develop many years after surgery. 5-8 Reports in the peer-reviewed literature have pointed to the ex- tremely high rate of complications, some of them very severe, associated with this procedure. The first retro- spective study published in Cornea reviewed the medical records of 48 consecutive patients who underwent cosmetic wide conjunctivectomy with topical MMC application and presented between January 2009 and January 2011 to the authors with various complications. 9 This study revealed that roughly 92% of patients who had the procedure presented with complications that ranged from less severe (i.e., fibrovascular conjunctival adhe- sions, chronic dysfunctional tear syndrome, abnormal vessel growth, and lymphangiectasis) to more severe (i.e., chronic conjunctival epithelial defects, scleral thinning with or without calcified plaques, adhesions of Tenon's capsule to the conjunctiva at the extraocular mus- cle insertion site, extraocular muscle fiber exposure, diplopia) in nature. Another large cross-sectional cohort study from the American Journal of Ophthalmology reviewed the medical records of 1,713 consecutive subjects who received cosmetic wide conjunctivectomy plus postoperative topical MMC by a single surgeon at a single center with or without bevacizumab injection from November 2007 to May 2010. 4 Of the 557 subjects who could be contacted and agreed to participate in the study, the authors discovered a complication rate of 83%, with 56% of those considered serious in nature, including fibrovascular con- junctival tissue proliferation, scleral thinning with calcified plaques, and intraocular pressure elevation. In addition to these two large studies, smaller case series and case reports, including one from the U.S., have described the various medical and surgical treatments for these complications, which range from ag- gressive lubrication to conjunctival flap surgery, conjunctival and amni- otic membrane grafting, and strabis- mus surgery. 10-12 These treatments highlight the severity of the compli- cations that can arise from this eye- whitening procedure. The purpose of this ASCRS clinical alert is to draw attention to the risk for severe complications that can arise from this elective cosmetic procedure that is available both within and outside the U.S. April 2014 ASCRS issues clinical alert on eye-whitening procedure Like many of the pioneers, he contributed incrementally to Dr. Kelman's game-changing innova- tion. He refined his approach with the help of industry representatives like Henry Mitchell and Alan MacMillan, the revolution's unsung grunts. Employing an enhanced figure-of-eight "baseball" suture he used to secure a peripheral iridec- tomy wound, Dr. Hurite closed the implant-enlarged incision with a single, deeply buried knot. No big deal? Ask a surgeon who struggled to remove silk sutures at the slit lamp from an anxious patient who "hates anything near my eye." He never did adopt the two-handed phaco technique of Richard Kratz, MD; instead, he found advantage in holding the handpiece as Minnesota Fats lov- ingly cradled a cue stick. It allowed him to maintain the vibrating tip horizontal to the plane of the iris and lens surface obviating a lesser skilled surgeon's tendency to dive disastrously beyond the posterior capsule. The New York City-Pittsburgh collaboration solved other chal- lenges of the fledgling technology. Dr. Hurite remembers fabrication of the titanium phaco tip somewhere in the Pittsburgh area, perhaps at a precision engineering company in Irwin, Pa. This was an important improvement over the original steel tips. The titanium tips cost $500 (about $2,400 today) to the com- pany. They were used once and returned to Cavitron to be recondi- tioned. "Click fees" lie in the future. In the spring of 1980, I asked Dr. Hurite if he would oversee me performing phacoemulsification on an unsuspecting but closely vetted clinic patient. I was in my final year of residency; residents didn't do phacoemulsification. He agreed but stipulated that I must be prepared to answer questions in regard to all as- pects of the machine and procedure; one missed factoid and the case would be cancelled. Frank didn't scrub in. Like Dr. Kelman and Henry Mitchell had done assisting him, he viewed the procedure through the observer's microscope and offered advice—"not too deep"—and en- couragement—"good"—as I lost myself in a procedure that set the course of my professional career. A few years later in Dr. Hurite's office, I noticed a book on the shelf At the beginning continued from page 14 behind his desk. It was an impres- sive, leather-bound volume whose spine read Phacoemulsification Made Easy. I assumed it was given to him for his contributions at one of the many symposia at which he taught. Lifting the book's cover, an un- opened bottle of Scotch nestled therein. Yes, those few, those happy few, that band of brothers, they did change the world. EW Editors' note: Dr. Noreika has practiced ophthalmology in Medina, Ohio, since 1983. He has been a member of ASCRS for more than 30 years. Contact information Noreika: JCNMD@aol.com continued on page 18 Clinical alert C L I N I C A L A L E R T

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