INTRODUCTION
Bimatoprost is a prostamide – a synthetic analog of fatty
acid amides – rather than a true prostaglandin, but
it is typically referred to as a prostaglandin analog
(PGA). PGAs have been used by ophthalmologists to treat
glaucoma for many years. As with any drug, there are the intended
therapeutic effects as well as unintended side effects
and complications. Some of the side effects may be deleterious
while others may eventuate in a new indication for the
drug. Such was the case with bimatoprost. There was a serendipitous
finding that glaucoma patients developed longer,
darker eyelashes while instilling drops of bimatoprost into
the eyes for the treatment of glaucoma.
Latisse® (topical bimatoprost solution, 0.03%; Allergan, Inc.,
Irvine, CA) was FDA-cleared for the purpose of eyelash enhancement
in December, 2008; although not placed on the globe, as
in the treatment of glaucoma, the cosmetic formulation of bimatoprost,
applied topically to the upper eyelid ciliary margin,
is exactly the same as Lumigan® (Allergan, Inc., Irvine, CA), the
drug used in the treatment of glaucoma. With the appropriate
application of the solution, the eyelashes become both longer
and darker – an enhancement of the aesthetic appearance.
In addition to the lengthening and darkening of the eyelid
cilia, other side effects associated with the ocular instillation
of bimatoprost for the treatment of glaucoma have been
noted by some ophthalmologists for over 10 years. The first
case report was published in an optometry journal in 2004;
three patients treated with unilateral bimatoprost developed ipsilateral deepening of the upper eyelid sulcus and involution
of dermatochalasis. These findings were reversed when
the drops were discontinued.1
The next publication of case reports was from the glaucoma
service at the Massachusetts Eye and Ear Infirmary in 2008.
They noted periorbital fat atrophy, deepening of the upper eyelid
sulcus, relative enophthalmos, loss of lower eyelid fullness,
and involution of dermatochalasis in five non-consecutive patients
treated unilaterally for glaucoma with bimatoprost 0.03%.
Imaging studies in two of the patients revealed the absence of
primary orbital pathology and, like the 2004 report, there was
partial reversal of these changes with discontinuance of the
medication.2 The authors postulated that PGA-mediated fat atrophy
was responsible for the loss of preaponeurotic fat in the
upper eyelid with resulting deepening of the upper eyelid sulcus
and involution of dermatochalasis. Atrophy of the deeper
periorbital fat resulted in the enophthalmos noted and diminished
pseudoherniation of periorbital fat in the lower eyelids.
Subsequent publications began to emerge in the ophthalmologic
literature with similar descriptions. Names such as
“deep superior sulcus syndrome†or “DUES†– Deepening of
the Upper Eyelid Sulcus – were used, but these names failed
to recognize the entire constellation of findings that were
noted with bimatoprost 0.03% used in treating glaucoma.
It was not until 2011, however, in an ongoing collaboration
between two glaucoma specialists, Dr. Stanley Berke and
Dr. Louis Pasquale, that the name, “Prostaglandin-Associat
