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Consultation section

October consultation #5

Jeng, Bennie H. MD

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Journal of Cataract & Refractive Surgery: October 2014 - Volume 40 - Issue 10 - p 1750
doi: 10.1016/j.jcrs.2014.08.008
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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.

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. 3, 2013, 39, Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3605078/pdf/1869-5760-3-39. Accessed August 4, 2014.
© 2014 by Lippincott Williams & Wilkins, Inc.