Cosmetic Wide Conjunctivectomy
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Surgical Therapy
Background
Cosmetic wide conjunctivectomy, commonly known as cosmetic eye whitening, was a non-therapeutic surgical procedure aimed at reducing conjunctival hyperemia for aesthetic purposes. The technique involved excision of the bulbar conjunctiva, typically followed by application of mitomycin C (MMC).[1][2] The procedure was first developed in South Korea in the early 2000s as a treatment option for patients with persistent conjunctival hyperemia unresponsive to topical medications.[1] It quickly gained popularity among cosmetic surgery clinics, with early reports citing high patient satisfaction and minimal complication rates, leading to widespread adoption across South Korea and some other parts of Asia.[1][2]
With expanding use, further research was performed, and its safety profile came under increased scrutiny. In 2012, a landmark study reported that 91.7% of patients experienced at least one postoperative complication, including scleral thinning, calcified plaques, chronic conjunctival defects, diplopia, and most concerningly, necrotizing scleritis.[3] Subsequent investigation revealed delayed presentation of these complications, often emerging years after surgery, and identified MMC-induced ischemia and impaired wound healing as likely contributors.[3][4][5][6]
In response to these new findings, the Korean Ministry of Health and Welfare formally banned the procedure, citing the high rate of complications and lack of therapeutic necessity.[7] Despite this decision, cosmetic eye whitening was introduced into the United States under the trademarked name I-BRITE™, where it was marketed as a safe and effective cosmetic option.[8]
U.S. adoption remained relatively limited, but reports of serious complications, mirroring those seen in South Korea, quickly emerged.[6][8] Although the procedure is rarely performed and has received increasing scrutiny in the ophthalmic community, there is currently no formal ban in the US.
Patient Selection
Indications
There are no established, evidence-based guidelines for the use of cosmetic wide conjunctivectomy. The procedure was originally developed for patients experiencing chronic conjunctival hyperemia that was refractory to conventional treatments, including topical vasoconstrictors, lubricants, and anti-inflammatory agents.[1] Ideal candidates were those with no underlying ocular surface disease who desired cosmetic improvement.[2] The procedure was also proposed for patients with subconjunctival fibrosis, conjunctivochalasis, or excessive conjunctival pigmentation; however, these indications were not widely adopted and remain poorly studied.[2]
Contraindications
There are currently no formal guidelines outlining contraindications to cosmetic wide conjunctivectomy. However, based on observed complication patterns in the literature, several risk factors were proposed as absolute or relative contraindications by clinicians involved in managing adverse outcomes.
Absolute contraindications include:
- Active ocular surface inflammation or infection[4][8]
- History of autoimmune scleritis or connective tissue disease[4]
- History of scleral thinning, previous conjunctival surgery, or ocular trauma[4][6][9]
- Prior ocular radiation or MMC exposure[4][5]
Relative contraindications include:
- Contact lens dependence[8]
- History of dry eye disease[4][8]
- History of delayed epithelial healing or keratopathy[3][8]
- Any condition impairing ocular surface regeneration or vascular supply[4][5]
Studies from both South Korea and the U.S. have highlighted that even patients without known risk factors may develop delayed complications, particularly when mitomycin C is used perioperatively.[3][8]
Surgical Technique
Cosmetic wide conjunctivectomy was typically performed in an outpatient setting using topical or subconjunctival anesthesia, consistent with practices for anterior segment surgery.[1][2] The procedure involved resection of the bulbar conjunctiva and Tenon’s capsule, most commonly in the nasal and temporal quadrants, extending from the limbus to the fornix.[1][2] The underlying sclera was intentionally left bare, and no conjunctival closure or grafting was performed during the primary procedure.[1]
After excision, adjunctive agents were applied to the exposed scleral surface. Mitomycin C was typically given postoperatively as topical drops, though some reports describe intraoperative sponge application.[1][2] Bevacizumab was also used in select cases to reduce postoperative vascularization.[2]
Most standard protocols did not involve wound closure, and no tissue was transplanted over the scleral bed during the initial surgery.[2] Postoperatively, the eye was typically treated with a fluoroquinolone antibiotic and topical corticosteroids, along with continued MMC drops in certain regimens.[2]
Despite variations in technique, there is no standardized surgical protocol and complication rates remained high across all approaches.
Complications
Intraoperative Complications
Intraoperative complications during cosmetic wide conjunctivectomy are infrequently reported, as most adverse events are delayed and occur in the postoperative period. However, potential intraoperative risks can be inferred based on the surgical anatomy and steps involved, as well as from published complication profiles of other conjunctival surgeries, such as pterygium excision.[10]
Potential intraoperative complications may include:
- Excessive bleeding from conjunctival and episcleral vessels[10]
- Thermal injury from cautery used for hemostasis[1]
- Mechanical trauma during dissection[10]
While not directly identified intraoperatively, disruption of limbal vasculature and excessive resection of Tenon’s capsule are believed to predispose patients to limbal stem cell deficiency and persistent epithelial defects.[3][5][8]
Postoperative Complications
Cosmetic wide conjunctivectomy has been associated with a high rate of postoperative complications, many of which present weeks to months after the initial procedure. In the largest published series, over 90% of patients experienced at least one complication, with more than half considered severe and approximately one-third requiring surgical revision[3]
Reported postoperative complications include:
- Persistent conjunctival epithelial defects[3][4][5]
- Progressive scleral thinning and ischemia[1][4][5][6]
- Calcified plaque formation over the bare sclera[4][5]
- Diplopia resulting from scarring or restrictive ocular movement[3]
- Chronic conjunctival hyperemia and discomfort[2][3]
- Limbal stem cell deficiency with delayed epithelial healing and corneal vascularization[5][8]
- Necrotizing scleritis[4][5][6][8]
- Infectious scleritis[6][8]
Among these complications, necrotizing scleritis is the most devastating. Several studies have reported progressive, vision-threatening scleral necrosis, often delayed by months or years following the procedure. These cases have occurred even in immunocompetent patients without autoimmune disease, suggesting a localized ischemic and toxic mechanism rather than systemic predisposition.[3][4][5] In the United States, one patient developed bilateral infectious scleritis and scleromalacia with cystoid macular edema four years after surgery[8], and similar cases involving deep scleral ischemia and inflammation have also been reported.[6]
Mitomycin C (MMC) has been strongly implicated in these complications. Its anti-fibrotic and anti-angiogenic properties can impair wound healing, particularly when applied to large areas of bare sclera. MMC exposure has also been associated with avascular sclera and persistent epithelial breakdown.[5]
Despite various modifications to surgical technique and MMC dosing, no version has proven consistently safe, and the risk of irreversible vision loss remains significant.
Outcomes
Cosmetic wide conjunctivectomy was initially regarded as a safe and effective aesthetic procedure, with high patient satisfaction and minimal reported complications. However, long-term follow-up contradicted these early impressions, with later studies revealing a much higher risk profile, including cases of irreversible vision loss.
In the largest published series, only 8.3% of patients remained complication-free, while over one-third required additional surgical intervention. [3] Complications frequently emerged months to years after surgery, highlighting the delayed and progressive nature of tissue damage. Although most early data came from South Korea, similar findings, including necrotizing scleritis, have been documented in the United States.[6][8] While some patients achieved partial anatomical recovery, visual outcomes were often poor due to persistent inflammation, scarring, and ocular surface instability.[4][5]
Despite these concerns, no large-scale prospective trials exist, and the true incidence of late complications may be underestimated due to limited follow-up in cosmetic practice settings. Although South Korea formally banned the procedure in response to these risks[7], no comparable regulatory action has been taken in the United States.
The available evidence suggests that cosmetic wide conjunctivectomy carries an unacceptably high risk of delayed, and potentially irreversible, complications.
References
- ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 Kim BH. Regional conjunctivectomy with postoperative mitomycin C to treat chronic hyperemic conjunctiva. Cornea. 2012;31(3):236–244. doi:10.1097/ICO.0b013e318211467d
- ↑ 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 Lee S, Go J, Rhiu S, et al. Cosmetic regional conjunctivectomy with postoperative mitomycin C application with or without bevacizumab injection. Am J Ophthalmol. 2013;156(3):594–601. doi:10.1016/j.ajo.2013.01.035
- ↑ 3.00 3.01 3.02 3.03 3.04 3.05 3.06 3.07 3.08 3.09 3.10 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(3):245–252. doi:10.1097/ICO.0b013e3182343073
- ↑ 4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 4.09 4.10 4.11 4.12 Ji YW, Park SY, Jung JW, et al. Necrotizing scleritis after cosmetic conjunctivectomy with mitomycin C. Am J Ophthalmol. 2018;193:41–52. doi:10.1016/j.ajo.2018.07.008
- ↑ 5.00 5.01 5.02 5.03 5.04 5.05 5.06 5.07 5.08 5.09 5.10 5.11 Solomon A, Kaiserman I, Raiskup FD, Landau D, Frucht-Pery J. Long-term effects of mitomycin C in pterygium surgery on scleral thickness and the conjunctival epithelium. Ophthalmology. 2004 Aug;111(8):1522-7. doi: 10.1016/j.ophtha.2004.02.007. PMID: 15288982.
- ↑ 6.0 6.1 6.2 6.3 6.4 6.5 6.6 6.7 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(1):39. doi:10.1186/1869-5760-3-39
- ↑ 7.0 7.1 Yoon SC, Seo KY. The safety and effectiveness of cosmetic wide conjunctivectomy with postsurgical mitomycin C to treat chronic hyperemic conjunctiva. Cornea. 2013;32(3):379. doi:10.1097/ICO.0b013e3182621608
- ↑ 8.00 8.01 8.02 8.03 8.04 8.05 8.06 8.07 8.08 8.09 8.10 8.11 8.12 Vo RC, Van Gelder RN. Severe complications following cosmetic ocular whitening procedures. Ophthalmic Surg Lasers Imaging Retina. 2014;45(3):251–255.
- ↑ Kwon HJ, Nam SM, Lee SY, Ahn JM, Seo KY. Conjunctival flap surgery for calcified scleromalacia after cosmetic conjunctivectomy. Cornea. 2013;32(6):821–825. doi:10.1097/ICO.0b013e318277ac92
- ↑ 10.0 10.1 10.2 Kodavoor, Shreesha K., V. Preethi, and Ramamurthy Dandapani. "Profile of complications in pterygium surgery-A retrospective analysis." Indian Journal of Ophthalmology 69.7 (2021): 1697-1701.
