Cosmetic eye whitening with MMC yields high complication, re-treatment rates

More than 82% of patients who underwent regional cosmetic conjunctivectomy with or without bevacizumab injection experienced complications.

Regional cosmetic conjunctivectomy with postoperative topical mitomycin C with or without bevacizumab injection had high complication and re-treatment rates, according to a study.

The study authors concluded that regional conjunctivectomy followed by postoperative use of MMC is not an appropriate treatment for cosmetic symptoms of chronic conjunctival hyperemia because the rate of significant complications outweighs the potential benefits of a cosmetic surgical procedure.

“The most important problem with cosmetic regional conjunctivectomy is that this procedure destroys normal conjunctival tissue, including goblet cells, and breaks the balance of the normal physiologic status of the external eye,” Kyoung Yul Seo, MD, the corresponding author, said in an email interview with Ocular Surgery News. “It also implies that this procedure will make an ischemic area of sclera. So, many surgeons do not agree to the surgical removal of normal conjunctiva at all if the purpose is for only cosmetic reasons.”

The procedure involves wide excision of the medial and/or lateral conjunctiva and Tenon’s capsule, followed by application of topical 0.02% MMC four times daily for 2 to 5 days postoperatively. Some surgeons use subconjunctival injections of Avastin (bevacizumab, Genentech) to improve outcomes and reduce the risk of recurrence.

Patients and methods

The retrospective study, published in the American Journal of Ophthalmology, included 1,713 patients in Korea who underwent cosmetic wide conjunctivectomy with MMC with or without injections of bevacizumab for conjunctival hyperemia. The mean age of the patients was 39.2 years.

Indications for surgery were hyperemia (8.8%), pterygium (14%), dry eye (3.5%), pinguecula (1.5%) and unspecified conjunctival disorders (23.3%). No diagnosis was recorded or surgery was performed for cosmetic purposes on 48.9% of patients.

Kyoung Yul Seo, MD 

Kyoung Yul Seo

Patients underwent a mean of 1.4 procedures each.

Bevacizumab was injected intraoperatively in 350 patients to reduce conjunctival hyperemia and fibrovascular proliferation.

Investigators conducted a follow-up telephone survey of 557 of the 1,713 patients; the 557 patients had a mean age of 29.9 years. A five-point subjective scale was used to rate patient satisfaction and improvement in dry eye symptoms.

Mean duration of follow-up was 10.9 months.

Results and conclusions

The overall complication rate was 82.9%, and 55.6% of complications were considered severe, according to the patients’ medical records. Complications included fibrovascular conjunctival tissue proliferation (43.8%), scleral thinning (4.4%), scleral thinning with calcified plaque (6.2%), IOP elevation (13.1%), diplopia (3.6%) and recurrence of hyperemic conjunctiva (28.1%).

Surgical intervention was required for management of complications in 483 of the 1,420 patients with complications (34%).

The 557 patients who participated in the telephone survey underwent an average of 1.6 eye-whitening procedures. Of these patients, 387 (69.5%) reported postoperative complications and 187 (33.6%) reported severe complications. The re-treatment rate attributed to complications was 34.5% in this subgroup.

Of 539 patients who answered a survey question on satisfaction, 307 patients (56.9%) were satisfied or very satisfied with cosmetic outcomes.

Of 464 patients who reported dry eye symptoms, 264 (56.9%) reported dissatisfaction or no improvement in dry eye symptoms.

The complication rate was 61.8% with bevacizumab injection and 70.6% with no injection.

“We do not have direct evidence that bevacizumab injection corresponded with the complications,” Seo said. “However, as it is used to inhibit angiogenesis after causing injury to normal conjunctival tissue, we think it may interrupt the normal healing process of the conjunctiva and promote the expression of complications.”

Seo expressed concern about potential long-term complications in the young patient cohort.

“We are concerned that the long-term effects of surgical and medical disturbance of the ocular surface may result in additional complications with time,” Seo said.

Discrepancy between studies

The authors noted a discrepancy between two referenced studies, both published in Cornea, on complication and satisfaction rates. Rhiu and colleagues reported a complication rate of 91.7%, while Kim reported no serious complications and a satisfaction rate of 94.6%. Seo and colleagues’ findings were in line with those of the Rhiu study.

“In this present study, the satisfaction rate was also lower than previously reported, and we postulate that selection bias, loss to follow-up and/or lack of a longer follow-up time might explain the fact that Dr. Kim reached a more favorable conclusion about the safety and efficacy of regional conjunctivectomy than we did,” Seo said. – by Matt Hasson

References:
Kim BH. Cornea. 2012;doi:10.1097/ICO.
0b013e318211467d.
Lee S, et al. Am J Ophthalmol. 2013;doi:10.1016/j.ajo.2013.01.035.
Rhiu S, et al. Cornea. 2012;doi:10.1097/ICO.
0B013E3182343073.
For more information:
Kyoung Yul Seo, MD, can be reached at Department of Ophthalmology, Severance Hospital, Institute of Vision Research, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, South Korea; email: seoky@yuhs.ac.
Disclosure: Seo has no relevant financial disclosures.