1750

CONSULTATION SECTION

supply to this area because avascular necrosis is the major issue. Randy J. Epstein, MD Chicago, Illinois, USA REFERENCES 1. Rubinfeld RS, Pfister RR, Stein RM, Foster CS, Martin NF, Stoleru S, Talley AR, Speaker MG. Serious complications of topical mitomycin-C after pterygium surgery. Ophthalmology 1992; 99:1647–1654 2. Majmudar PA, Forstot SL, Dennis RF, Nirankari VS, Damiano RE, Brenart R, Epstein RJ. Topical mitomycin-C for subepithelial fibrosis after refractive corneal surgery. Ophthalmology 2000; 107:89–94 3. Kim B-H. Regional conjunctivectomy with postoperative mitomycin C to treat chronic hyperemic conjunctiva. Cornea 2012; 31:236–244 4. Rhiu S, Shim J, Kim EK, Chung SK, Lee JS, Lee JB, Seo KY. Complications of cosmetic wide conjunctivectomy combined with postsurgical mitomycin C application. Cornea 2012; 31:245–252 5. Yoon SC, Seo KY. The safety and effectiveness of cosmetic wide conjunctivectomy with postsurgical mitomycin C to treat chronic hyperemic conjunctiva [letter]. Cornea 2013; 32:379

- This patient has bilateral necrotizing scleritis after a cosmetic eye-whitening procedure. This procedure involves dissection of the nasal portion of the conjunctiva and Tenon capsule with cautery of the vasculature in the bed in the interpalpebral fissure, along with intraoperative MMC application and postoperative MMC eyedrops. Numerous complications from cosmetic eye-whitening procedures have been reported, including chronic conjunctival epithelial defects, scleral thinning with or without calcified plaques, and fibrovascular conjunctival adhesion at the muscle insertion site.1 Necrotizing scleritis has been specifically reported after the I-Brite procedure.2 At this point, an aggressive attempt to halt the necrosis and promote reepithelialization should be taken. I would recommend stopping the topical prednisolone acetate 1.0% eyedrops and starting lubrication with preservative-free artificial tears along with antibiotic prophylaxis with a broad-spectrum topical antibiotic, such as moxifloxacin. Systemic therapy with oral NSAIDs could be considered as well. If improvement in the conjunctival epithelial defects along with halting of the melting process can be seen within a few days of therapy, continued observation with medical management could be considered. Autologous serum eyedrop therapy could be added along with topical medroxyprogesterone acetate 1.0% eyedrops. However, given the rapid course of the melting in the eyes before the patient's presentation, I

would have a low threshold to offer surgical intervention. If rapid improvement of the condition were not seen within the first few days of therapy, I would consider surgical intervention. My first choice of surgical procedures would be a conjunctival flap to cover the area of necrosis; however, given that most of the conjunctiva was likely removed in that area during the cosmetic eye-whitening procedure, a free conjunctival flap would probably have to be considered, although the likelihood of success is slightly lower with this procedure than if the flap were attached. If significant scleral melting is evident, a scleral patch graft can be considered along with a conjunctival flap or an amniotic membrane graft on top of the scleral patch graft. Even if the patient receives a scleral patch graft with conjunctival or amniotic membrane grafting, there is a high rate of recurrence of the process. As such, the prognosis for this patient is guarded, and he should be watched very closely even if he has a surgical procedure. Bennie H. Jeng, MD Baltimore, Maryland, USA REFERENCES 1. Rhiu S, Shim J, Kim EK, Chung SK, Lee JS, Lee JB, Seo KY. Complications of cosmetic wide conjunctivectomy combined with postsurgical mitomycin C application. Cornea 2012; 31:245–252 2. Leung TG, Dunn JP Jr, Akpek EK, Thorne JE. Necrotizing scleritis as a complication of cosmetic eye whitening procedure. J Ophthalmic Inflamm Infect 2013; 3:39. Available at: http://www. ncbi.nlm.nih.gov/pmc/articles/PMC3605078/pdf/1869-5760-3-39. Accessed August 4, 2014

- This 33-year-old man has bilateral progressive scleral thinning (scleromalacia), scleral calcification, and persistent conjunctival epithelial defects 5 years after a cosmetic eye-whitening procedure. Presumably this was a procedure involving conjunctival–Tenon resection with adjunctive use of MMC. This procedure has been described as regional conjunctivectomy with postoperative mitomycin-C by Kim1 and as I-Brite by Boxer Wachler.A Both procedures include the use of topical MMC postoperatively, while the latter procedure uses it intraoperatively as well. Scleral calcification and thinning with persistent conjunctival defects have been well reported. In his initial publication, Kim1 noted scleral calcification in 3.9% of patients with a mean follow-up of only 12.9 months. Rhiu et al.2 report 48 patients with complications stemming from the same procedure, including 22 with persistent epithelial defects and 21 with scleral thinning, 19 of

J CATARACT REFRACT SURG - VOL 40, OCTOBER 2014

October consultation #5.

October consultation #5. - PDF Download Free
57KB Sizes 0 Downloads 10 Views