First introduced in 2008 as a surgical treatment of chronic conjunctival injection, cosmetic eye whitening became popularized in South Korea1 and has been performed in more than 1800 patients in the United States.1-3 Individuals with healthy eyes who elect to undergo this procedure often present with concerns of hyperemia, undesirable ocular pigmentation, or pingueculas. An initial report from Kim4 described 571 patients who underwent regional conjunctivectomy for persistent irreversible hyperemic conjunctiva with a 94.6% postoperative satisfaction rate. In contrast, over the last 5 years, various reported permanent complications raised concerns of the risk-benefit ratio of this cosmetic procedure.
The procedure involves performing a localized conjunctivectomy with or without removal of the Tenon capsule.4 Brimonidine tartrate is given for vascular constriction. When conjunctivectomy is performed in the right eye, the medial conjunctiva is incised from the 2-o’clock to 5-o’clock positions and the lateral conjunctiva is incised from the 10-o’clock to 7-o’clock positions. After the conjunctiva and Tenon capsule are excised, hemostasis is achieved with electrocauterization. Postoperative management may consist of topical mitomycin C (MMC) 0.02% 4 times daily for 2 to 5 days along with topical steroids. The addition of bevacizumab 1.25 mg/mL also has been described.5
In this report, we provide a comprehensive review of the complications of cosmetic eye whitening based on a review of the literature. Clinicians in both aesthetic practice and ophthalmology should be aware of the potential complications to accurately educate their patients about the possible risks and benefits of this procedure.
Methods
A review of PubMed articles indexed for MEDLINE (January 2009 to July 2017) using the search terms cosmetic eye whitening, cosmetic wide conjunctivectomy, I-Brite, and chronic hyperemic conjuctiva was conducted to evaluate the number of reports of complications from cosmetic eye whitening. A total of 10 articles were included in the study based on a review of abstracts. Non–English-language abstracts were not reviewed.
Results
Based on a review of 10 articles commenting on the complications of cosmetic eye whitening, a total of 2400 patients had undergone a cosmetic conjunctivectomy with various postoperative complications and recurrences (Table).4-13 The most commonly recurring complications based on the reported frequencies in the articles included chronic conjunctival epithelial defects, scleral thinning, calcific plaques, dry eye syndrome, diplopia (sometimes requiring strabismus surgery), and elevated intraocular pressure.
Kim4 was the first to report this surgical technique for irreversible hyperemic conjunctiva (N=1815). The reported success rate in South Korea was overwhelmingly high at 94.6%. In a mean (SD) follow-up time of 12.9 (7.8) months (range, 2–27 months), less than 20% of patients required surgical revision. During this time, the most common postoperative complications included elevation in intraocular pressure (17.2%), conjunctival granuloma (8.4%), transient vision decrease (7.5%), pigment deposition (5.3%), scleral calcifications (3.9%), and diplopia secondary to conjunctival adhesions (1.6%). No permanent defects were reported, and complications improved with surgical and medical management.4
Contrary to the findings of Kim,4 a large number of complications were seen; thus, on March 4, 2011, the Korean Ministry of Health & Welfare issued a declaration to discontinue the procedure under Article 49 of the Medical Service Act. Medical records from the single clinic in Korea from November 2007 to May 2010 were reviewed.5 One of the largest reviews of cosmetic eye whitening complications reviewed 1713 patients who underwent conjunctivectomy plus topical MMC with or without bevacizumab injection. Pterygium and chronic conjunctival hyperemia were the most common diagnoses that prompted patients to undergo treatment. Over an average follow-up period of 10.9 months, the overall complication rate was 82.9%, with severe complications being fibrovascular conjunctival proliferation (43.8%), recurrent hyperemic conjunctiva (28.1%), intraocular pressure (13.1%), scleral thinning with calcified plaques (6.2%), scleral thinning (4.4%), and diplopia (3.6%). A total of 56.9% of patients reported being satisfied with the cosmetic outcome of the surgery.5
In some of the smaller case series and case reports we reviewed, more vision-threatening complications have been described. Infectious endophthalmitis, infectious scleritis, and necrotizing scleritis have all been reported as complications of cosmetic eye whitening.8,10