Corneal and Scleral Problems Caused by Skin-Lightening Creams.

PURPOSE: To present a case series of patients with corneal and scleral changes associated with the use of skin-lightening creams. This is the first report of corneal changes with these widely available creams. METHODS: Three patients of West African origin presented with strikingly similar skin, corneal, and scleral changes and were found to have all been using skin-lightening creams containing hydroquinone. Histopathology was obtained for 1 patient. RESULTS: Three patients were referred to the corneal clinics of 2 hospitals with corneal changes and a history of blurred vision for 1 to 3 years. There was a 60-year-old woman from Nigeria and a 68-year-old woman and a 73-year-old man both from Ghana. All 3 had been using skin-lightening lotions containing hydroquinone on their faces for between 3 and 15 years and had black-blue facial pigmentation of exogenous ochronosis, a recognized complication of these creams. Their corneas all had horizontal striae radiating across the posterior corneas with scleral thinning and plaques. Linear brown epithelial pigmentation was observed within the lower third of the corneas. Biopsy of the sclera in 1 patient showed ochronosis. CONCLUSIONS: We present previously unreported eye changes associated with the use of skin-lightening creams containing hydroquinone, with a triad of signs: posterior corneal striae radiating from 3 o'clock to 9 o'clock, thinning and plaques in the sclera, and a normal endothelial cell count. Similar pathological changes are seen in exogenous ochronosis, a recognized skin complication of hydroquinone, are seen in the sclera.

Body dysmorphia, self-mutilation and the reconstructive surgeon.

Body dysmorphic disorder (BDD) is a disabling preoccupation with a slight or an imagined defect in appearance. It is recognised in some patients who present to the plastic surgeon requesting multiple cosmetic procedures. Very rarely, BDD patients may wish for amputation of a healthy limb and may even mutilate themselves deliberately in order to necessitate amputation. These patients pose a diagnostic challenge as BDD is uncommon and they are often uncooperative whilst appearing mentally sound. Furthermore, they raise difficult ethical and legal issues for the surgeon. Although there is some guidance for the management of BDD patients seeking elective amputation, there is currently none for the management of those who present in the emergency setting. Illustrated by the case of a man who, having failed to find a complicit surgeon, attempted self-amputation of the hand, we review the relevant ethical, legal and management issues with advice by the British Medical Association and General Medical Council.

Amniotic membrane transplantation in children with symblepharon and massive pannus.

OBJECTIVE: To report our pediatric experience with amniotic membrane transplantation for ocular surface and forniceal reconstruction. METHODS: Retrospective case review of children who underwent superficial keratectomy, symblepharon lysis, and forniceal reconstruction using amniotic membrane transplantation. The underlying diagnosis, visual acuity, level of discomfort at first and last visits, and surgical details were noted. RESULTS: Four patients (5 eyes) were included. Two patients had epidermolysis bullosa (1 recessive dystrophic and 1 junctional), 1 had laryngo-onychocutaneous syndrome, and 1 had measles-related keratitis and was positive for human immunodeficiency virus. Their mean age when initially seen was 8.7 years (age range, 4-16 years), and mean follow-up was 18.25 months (range, 12-29 months). The mean visual acuity preoperatively was 1.1 logMAR (logarithm of the minimum angle of resolution) (range, 1-1.3), and postoperatively was 0.7 (range, 0.2-1.2). All patients experienced increased ocular comfort with anatomical restoration of corneal and conjunctival surfaces. Visual acuity improved in 3 eyes. Only the patient with laryngo-onychocutaneous syndrome had recurrence of granuloma, at 9 months after surgery. CONCLUSION: Amniotic membrane transplantation with symblepharon lysis is effective for ocular surface reconstruction in the management of epidermolysis bullosa and other conditions that cause corneal scarring and symblepharon in children. In this small series, children with epidermolysis bullosa fared better and the effects of surgery lasted longer compared with patients with other causes of symblepharon and massive pannus.