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Introduced in 2008 and subsequently popularized in South Korea, cosmetic eye whitening has been offered as a treatment of chronic conjunctival hyperemia. Patients undergo conjunctivectomy with topical mitomycin C (MMC) 0.02% application to achieve a whitened appearance from bleaching of avascular sclera. Much speculation has arisen from this procedure given the limited available evidence on its efficacy and safety. A literature search was performed to review common complications of cosmetic eye whitening, including chronic conjunctival epithelial defects, scleral thinning, avascular zones in the sclera, dry eye syndrome, and diplopia requiring strabismus surgery. Informing the general public of the risks of this procedure is of great importance for dermatologists and other cosmetic surgeons.

Purpose: To describe an unusual cicatrizing manifestation of periocular amyloid and the utility of adjuvant antimetabolite therapy., Methods: This is a case report of a 49-year old woman with progressive bilateral upper lid ptosis, who was found to have bilateral inferior forniceal masses with thickening of the conjunctiva. Conjunctival and eyelid biopsies showed evidence of amyloid deposition. Systemic evaluation did not reveal any evidence of systemic amyloidosis. Her blepharoptosis continued to deteriorate, and she underwent bilateral sequential upper lid ptosis correction surgery and debulking procedures. Subsequently, she developed severe and progressive cicatricial conjunctivitis with extensive symblepharon formation in all 4 fornices and restriction of ocular motility, simulating a clinical picture of ocular mucous membrane pemphigoid., Results: She was treated surgically by division of symblepharon augmented with application of topical mitomycin C intraoperatively. This has been partially successful in freeing up differential movement between her lid and her eye and consequently improving eye protection and lubrication., Conclusions: Pseudopemphigoid represents a rare manifestation of periocular amyloid. Risks and benefits of surgical procedures in this context need to be carefully weighed to minimize the risk of secondary complications. Topical mitomycin C may be considered as a relatively safe adjunct in managing the cicatricial component of the disease.

A 40-year-old woman presented with ocular discomfort in both eyes that had persisted for several months. Six months ago, she had undergone a bilateral nasal and temporal conjunctivectomy using a bare scleral technique followed by a postoperative application of 0.02% mitomycin C (MMC) to treat her chronic hyperemic conjunctiva for cosmesis. Slit-lamp examination revealed that the patient had bilateral nasal and temporal scleral thinning, and a calcified plaque on her nasal conjunctiva. There was no episcleral tissue present around the wound area, and it was difficult to detect any normal conjunctival tissue in the adjacent area for covering the lesion. We believe that performing an aggressive conjunctival excision procedure followed with MMC application for cosmetic enhancement may be disastrous in certain cases.

Purpose: To raise awareness among clinicians about the risk of severe complications after cosmetic conjunctivectomy plus postsurgical topical mitomycin C (MMC) treatment., Methods: We retrospectively reviewed the medical records of 48 consecutive patients who received cosmetic wide conjunctivectomy plus postsurgical topical MMC treatment to eliminate conjunctival injection and visited our outpatient clinic between January 2009 and January 2011., Results: Forty-four patients (91.67%) developed complications after cosmetic wide conjunctivectomy plus postsurgical topical MMC treatment. Complications included chronic conjunctival epithelial defects (22 patients), scleral thinning with (19 patients) or without (2 patients) calcified plaques, fibrovascular conjunctival adhesion at the muscle insertion site (15 patients), chronic dysfunctional tear syndrome (11 patients), avascular zones (10 patients), abnormal vessel growth (5 patients), lymphangiectasis (3 patients), adhesions of Tenon capsule and the conjunctiva at the extraocular muscle insertion site (1 patient), extraocular muscle fiber exposure (1 patient), and diplopia (9 patients). The mean time between surgery and the onset of diplopia was 1.67 months (range, 1-3 months), and the mean deviation was 11.0 prism diopters (range, 0-25 prism diopters) in the primary position. Three patients underwent strabismus surgery due to incomitant esotropia. Eight patients underwent calcified plaque removal because of severe progression of the calcification. Five patients underwent conjunctival flap operation because of severe progressive scleral thinning., Conclusions: Cosmetic wide conjunctivectomy, which has been advertised as a simple and effective surgical option for the treatment of conjunctival injection, has caused disruption in the normal physiology of the ocular surface, which leads to various devastating complications.

Purpose: To describe the incidence, characteristics, risk factors, and clinical outcome of limbal stem cell deficiency (LSCD) resulting from topical treatment with mitomycin C (MMC) for primary acquired melanosis (PAM) with atypia., Design: Retrospective, observational case series., Participants: Patients with LSCD who had been managed with topical MMC for PAM with atypia at the Ocular Oncology Service at the Department of Ophthalmology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel, between 2000 and 2007., Methods: Retrospective chart review of all patients with PAM with atypia was performed. Impression cytologic analysis of the corneal and conjunctival epithelium was performed in patients suspected of having LSCD., Main Outcome Measures: Evaluation of risk factors for LSCD, including demographic characteristics, MMC dosage, and length of treatment; and clinical and visual outcome of patients diagnosed with LSCD., Results: Limbal stem cell deficiency was identified in 5 (23.8%) of 21 patients. The mean age+/-standard deviation of the 5 patients was 61.8+/-12.7 years compared with 43.7+/-16.1 years in patients in whom this complication did not develop (P = 0.025). Longer treatment periods of MMC were noted in eyes in which LSCD developed (78.4+/-24.8 days) compared with eyes without LSCD (37.7+/-3.1 days; P = 0.07). In 3 patients, spontaneous partial resolution of the LSCD was noted., Conclusions: High-dose topical MMC for PAM with atypia may be associated with a relatively high incidence of LSCD. Mitomycin C concentration and treatment regimen should be reevaluated to improve the safety of this treatment protocol., (Copyright 2010 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

The authors report the case of a 56-year-old Caucasian man who was found to have prominent melanotic conjunctival pigmentation inferotemporally in his right eye. Histopathologic evaluation disclosed malignant melanoma of the conjunctiva arising within primary acquired melanosis (PAM) associated with melanocytic atypia. The patient was treated by incisional conjunctival biopsy followed by two cycles of mitomycin C 0.04% eye drops and supplemental double-freeze thaw cryotherapy to residual foci of PAM. By 1 year following this treatment, there was no clinically apparent residual conjunctival melanosis, and visual acuity remained stable at 20/30.

Objective: To characterize histopathologic features of leaking mitomycin C-treated blebs and aberrant wound healing that may lead to persistent conjunctival thinning and leakage., Methods: Forty mitomycin C-treated filtering blebs excised for persistent leaks from 40 patients were examined histopathologically using hematoxylin-eosin, periodic acid-Schiff, Masson trichrome, and Alcian blue histochemical stains., Results: Ninety percent of the leaking blebs contained epithelial-stromal domes with areas of acellular stroma covered by attenuated epithelium. Seventy-five percent of the blebs demonstrated varying degrees of fibrovascular repair growing from the bleb margin, either beneath or interdigitating with the acellular zone. A novel observation in 65% of specimens was Alcian blue-positive myxoid stroma at the interface between the fibrovascular proliferation and the epithelial-stromal dome. The association between the presence of fibrovascular proliferation and Alcian blue-staining myxoid stroma was significant by Fisher exact test (P = .002)., Conclusions: A desirable filtration bleb requires a sufficient reparative fibrovascular response to maintain an epithelial-stromal barrier to prevent leakage. Fibroblasts must lay down a continuous collagen-rich fibrous layer, rather than merely myxoid stroma, beneath the conjunctival epithelium to promote bleb stability. Surgical techniques and postsurgical care should aim to attain this desired outcome.

Purpose: To investigate whether intraoperative application of mitomycin C may enhance the success of amniotic membrane transplantation in symblepharon lysis and fornix reconstruction in severe cicatricial ocular surface diseases., Design: Noncomparative interventional case series., Participants: Sixteen patients (8 female, 8 male; 18 eyes) with a mean age of 41+/-23.4 years (range, 3-79) and suffering from severe chemical/thermal burns (7 eyes), multiple recurrent pterygia and pseudopterygia (5 eyes), Stevens-Johnson syndrome (4 eyes), and ocular cicatricial pemphigoid (2 eyes) were consecutively enrolled. All except for 2 eyes had had prior surgical attempts of surgical reconstruction, including 6 eyes with a mucous membrane graft (MMG), but still presented with symblepharon and persistent ocular surface inflammation., Intervention: After excision of subconjunctival fibrovascular tissues, 0.04% mitomycin C was applied for 5 minutes in the deep fornix before amniotic membrane transplantation., Main Outcome Measures: Deeper fornix, noninflamed ocular surface, and full motility., Results: The mean epithelial healing time was 4.2+/-1.9 weeks. During the follow-up of 14.16+/-5.2 months, all eyes showed a marked reduction of conjunctival inflammation, a deep fornix, and a continuous tear meniscus. Of 12 eyes with motility restriction, 2 eyes with multiple recurrent pterygia and 1 eye with severe thermal burn showed recurrence of partial motility restriction 2 months after surgery. The vision of 9 eyes was successfully restored by an additional keratolimbal allograft with subsequent penetrating keratoplasty (6 eyes)., Conclusion: Intraoperative application of mitomycin C is an effective means to reduce chronic and deep-seated conjunctival inflammation, and helps amniotic membrane restore a deep fornix after symblepharon lysis, even in eyes that had a failed MMG. Restoration of deep fornix and tear meniscus is an important prerequisite to achieve successful reconstruction by subsequent limbal stem cell transplantation.

Purpose: To report our results of 12 consecutive patients with conjunctival primary acquired melanosis (PAM) with atypia who were treated by topical Mitomycin C (MMC)., Design: Retrospective interventional consecutive case series., Methods: Twelve patients with PAM with atypia in one of their eyes who were treated by topical chemotherapy with MMC were included in this case study. Eyes with histologically proven PAM with atypia were treated by two to five courses of 0.04% (0.4 mg/ml) MMC four times a day. Each course lasted 2 continuous weeks. Follow-up was conducted on patients for control of local disease, side effects, and visual acuity in the treated eye., Results: In all patients, there was complete or partial response to treatment. In four patients, the pigmentation disappeared, whereas in eight patients, some remnants of the pigmentation remained. In seven of these eight patients, the remnants of the pigmentation were stable during the follow-up period of 4 months to 9 years, whereas one in whom re-growth of the PAM was noticed was successfully treated again by topical MMC. No patients lost visual acuity at the end of the follow-up. All side effects of the local chemotherapy were resolved after cessation of the treatment., Conclusions: Topical MMC chemotherapy is a good alternative to surgical excision and cryotherapy in treating conjunctival PAM with atypia.

A case of primary acquired melanosis of the conjunctiva primarily treated with topical mitomycin chemotherapy is presented. The patient underwent treatment with one 2-week course of topical mitomycin 0.02% four times daily, followed 4 weeks later by a 2-week course of topical mitomycin 0.04% four times daily, followed by a 3-month course of topical mitomycin 0.02% twice daily. Map biopsies were performed after the initial two courses of mitomycin therapy and 12 months after all courses of mitomycin treatment had been completed. Complete resolution of the conjunctival pigmentation was noted after the final course of treatment. Map biopsies performed at 12 months following completion of treatment showed normal conjunctiva histopathologically. No recurrence of pigmentation was noted in follow-up 26 months after completion of treatment. Topical mitomycin chemotherapy may be a successful primary treatment for primary acquired melanosis of the conjunctiva.

Purpose: To assess the clinical efficacy of topical mitomycin C (MMC) 0.04% for the treatment of patients with pigmented conjunctival lesions. Clinical efficacy was evaluated on the basis of reduction in lesion size and degree of pigmentation and histologic study., Methods: Two patients, one with primary acquired conjunctival melanosis with atypia and another with conjunctival melanoma, were treated with topical MMC 0.04%. Before treatment, a biopsy was performed that confirmed the diagnosis and the absence of atypical melanocytes beyond the basal layer. In both patients, MMC was administered with sponges, while one patient additionally received MMC 0.04% drops. Each treatment cycle lasted 14 days, with repetition after 3 months when necessary. Follow-up was weekly, then monthly, and then every 6 months up to 3 years., Results: Treatment with topical MMC 0.04% not only reduced the size and degree of pigmentation clinical lesions in both patients but also eradicated atypical conjunctival melanocytes as observed in histologic studies. In the patient with primary acquired conjunctival melanosis, adjunct cryotherapy was required, along with various cycles of MMC, to reduce the pigmented areas of skin of the internal canthus and caruncle. In the second case, only MMC was used. No severe adverse reactions to the treatment were observed. After 3 years of follow-up, no clinical relapse has been detected., Conclusion: Topical MMC 0.04% is an option worth considering for the treatment of pigmented conjunctival lesions, particularly as an adjunct to other forms of treatment.

Purpose: The authors performed a prospective evaluation of the efficacy of treating ocular cicatricial pemphigoid (OCP) with subconjunctival mitomycin C., Design: Unmasked, prospective, internally controlled case series., Methods: Patients were eligible for treatment with subconjunctival mitomycin C under three criteria: (1) significant complications of systemic immunosuppressant therapy; (2) markedly asymmetric conjunctival disease; and (3) end-stage OCP. All patients received monocular subconjunctival injections of 0.25 ml of 0.2 mg/ml mitomycin C to both the superior and inferior bulbar conjunctivae in the eye with the more severe disease., Results: Nine eyes of nine patients (mean age, 74 years) were treated with subconjunctival mitomycin C to the more-involved eye and were followed for a mean of 23.5 months (range, 12-40 months). Eight of nine patients showed quiescence of their OCP in the treated eye based on serial evaluation of conjunctival cicatrization and grading of conjunctival erythema. Five of the nine untreated eyes showed progression of the conjunctival disease. One patient required concomitant systemic immunosuppressive therapy after subconjunctival mitomycin C. Two patients underwent successful visual rehabilitative surgery in the mitomycin C-treated eye., Conclusion: The use of subconjunctival mitomycin C may be effective in preventing progression of conjunctival cicatrization and erythema in patients with OCP. No complications of mitomycin C treatment were noted. Long-term follow-up and further investigation into the efficacy of subconjunctival mitomycin C in the management of OCP is warranted.

A patient who had primary acquired melanosis with marked atypia shown on histological studies received topical 0.02% mitomycin C for 2 weeks and 0.04% mitomycin C for an additional 2 weeks. Conjunctival biopsy specimens were obtained to evaluate the efficacy of the treatment. After the first course of mitomycin C administration, some decrease of conjunctival pigmentation was seen, and histological studies disclosed a lower degree of atypia. After the second application of mitomycin C, the pigmentation disappeared except for one small spot that contained only a few typical melanocytes on histological study. The clinical findings did not change during 7 months of follow-up. No adverse reactions to topical mitomycin C occurred except for mild conjunctival hyperemia at the end of the courses of treatment. Administration of topical mitomycin C may be an effective medical treatment for primary acquired melanosis with atypia.