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 Table of Contents  
Year : 2021  |  Volume : 59  |  Issue : 4  |  Page : 382-384

Corneal tattooing in a case of keratoconus with posthydrops scarring

Department of Cornea and Refractive Surgery, Sankara Eye Hospital, Guntur, Andhra Pradesh, India

Date of Submission15-May-2021
Date of Decision11-Jul-2021
Date of Acceptance24-Jul-2021
Date of Web Publication21-Dec-2021

Correspondence Address:
Dr. V Nishant Janardhana Raju
Department of Cornea and Refractive Surgery, Sankara Eye Hospital, Vijayawada- Guntur Expressway, Pedakakani, Guntur - 522 509, Andhra Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/tjosr.tjosr_65_21

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We report a case of bilateral keratoconus with posthydrops scarring in a 40-year-old female denying perception of light (PL) in both eyes. She underwent corneal tattooing in the left eye for cosmetic purpose. Preoperative corneal thickness at the site of scar was 374 μ. Corneal tattooing was carried out using stromal puncture technique with microneedling device and triple black dye (Dynamic color co, USA). One-month postoperatively cosmetic results were promising. Cases with corneal thinning carry a risk of corneal perforation with dye diffusion into the anterior chamber causing hypotony and severe uveitis. With well-adjusted needle length and technical expertise, we can give excellent cosmetic results even in cases with minimal corneal thickness.

Keywords: Corneal tattooing, keratoconus, posthydrops scarring

How to cite this article:
Janardhana Raju V N, Potti S. Corneal tattooing in a case of keratoconus with posthydrops scarring. TNOA J Ophthalmic Sci Res 2021;59:382-4

How to cite this URL:
Janardhana Raju V N, Potti S. Corneal tattooing in a case of keratoconus with posthydrops scarring. TNOA J Ophthalmic Sci Res [serial online] 2021 [cited 2022 Dec 10];59:382-4. Available from: https://www.tnoajosr.com/text.asp?2021/59/4/382/333178

  Introduction Top

The practice of staining opacities and scars on the cornea dates back 2000 years. The first practitioners of corneal tattooing were Galen in 150 AD and Aetius in 240 AD.[1] Corneal tattoos were used for eye diseases in the second half of the 19th century, and in the early 20th century for esthetic purposes.[2]

Initially derived to improve cosmesis in blind eyes with disfiguring corneal opacification, the indications for corneal tattooing have been expanding. It has been used to cosmetically improve leukocoria, reduce glare from iris defects, and reduce light scatter from eccentric semitranslucent corneal scars.[3],[4],[5],[6] More recently, it has been used to address visual obscuration in a case of strabismus with intractable diplopia.[7]

Two methods are used predominantly for tattooing the cornea.

  1. Chemical method: this involves using metallic salts which react with each other chemically to produce a brown–black precipitate that is taken up by keratocytes and stain the cornea. The chemicals used are gold chloride, platinum chloride, and silver nitrate reduced by hydrazine hydrate to a black pigment. The reacting chemicals are applied over the stroma directly after peeling the corneal epithelium. This technique is reportedly easier and quicker but fades more rapidly
  2. Coloring method: this technique involves the direct introduction/impregnation of colored pigments into the corneal stroma. To obtain a uniform color, the dyeing agent is injected through multiple micro-punctures by a needle inserted into the corneal stroma or by topical application to the stromal bed after constructing an anterior stromal flap. Various colored dyes and inks such as Indian ink, organic colors, animal uveal pigment, Chinese ink, and soot have been used. This technique provides more uniform dyeing and better durability. According to a study by Kim et al., 5-year results in corneal tattooing are promising with only 12% of patients experiencing color fading or increased corneal opacity.

The new advances in technology include using femtosecond laser and excimer laser for tattooing, but they are associated with drawbacks like being expensive, not suitable for thin corneas and laser system failing with scarred corneas.[8]

Complications such as infectious and granulomatous keratitis, persistent corneal epithelial defects, corneal perforation, corneal ulceration, iridocyclitis, and toxic reactions have been reported in patients who underwent corneal tattooing.[9]

Here, we discuss the cosmetic outcome and safety profile of stromal puncture technique employing microneedling device in case of posthydrops scarring with minimal corneal thickness.

  Case Report Top

A 40-year-old female presented with defective vision since childhood with cosmetically awkward whitening of both eyes. The patient denied perception of light (PL) in both eyes. On slit-lamp examination, both corneas appeared ectatic having central epithelial hypertrophy with underneath stromal scarring suggestive of keratoconus with posthydrops scarring [Figure 1]. Anterior segment optical coherence tomographic revealed the corneal thickness of 350 and 374 μ in right and left eyes, respectively, at site of scarring. In the left eye, barring epithelium corneal thickness was just 322 μ at the site of scarring [Figure 2]. B scan was normal in both eyes with no cupping. As the patient's family members were bothered about the cosmetic appearance of eyes, cosmetic contact lens was tried but could not fit because of the extreme corneal curvatures. Left with no option, the patient was advised corneal tattooing in the left eye followed by the right eye. Corneal tattooing was planned using stromal puncture technique with microneedling device [Figure 3] and triple black dye (Dynamic color co, USA). The main ingredients of the dye were titanium dioxide and isopropyl alcohol.
Figure 1: Both eyes appear ectatic with epithelial hypertrophy and stromal scarring

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Figure 2: Anterior segment optical coherence tomographic of the left eye measuring thickness of cornea barring epithelium (322 μ) at the site of scarring

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Figure 3: Microneedling device with console and probe

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Surgical technique: Initially, the hypertrophied epithelium is scraped off at the site of scar with a crescent blade. Two drops of triple black dye (dynamic colors co, USA) were instilled on the cornea. Using micropuncture needling device with probe adjusted to needle length of 0.5 mark on gauge (minimal length), stromal puncture is carried out in linear fashion with lines parallel to each other encompassing whole of the scar area. Excess dye is washed off with saline and cotton swabs. The same procedure is repeated for four times and made sure that the scarred area is stained uniformly and completely. Bandage contact lens (BCL) was placed and the patient was put on eye drops loteprednol 0.5% 4 times a day, moxifloxacin 0.5% six times a day, and HPMC 0.7% six times a day.

One week postoperative, the patient appeared comfortable and tattooed eye (left) appeared cosmetically promising, anterior chamber was well-formed with no signs of inflammation. BCL was removed and the patient was advised to taper loteprednol eye drops in a weekly manner. Six months postoperative, the operated eye (left) appeared uniformly dyed without any fading [Figure 4]. Backed by the promising left eye postoperative result, the patient was advised corneal tattooing in the right eye.
Figure 4: Clinical photograph of the left eye with uniform dye distribution at 6-month postoperative period

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  Discussion Top

Corneal tattooing has had a favorable safety profile in many prior studies, complications from corneal tattooing do exist. For this reason, corneal tattooing is generally reserved for patients who have failed noninvasive alternatives such as colored contact lenses or scleral shells.[10]

Among the potential complications of corneal tattooing, corneal perforation is a particularly important consideration in scarred, irregular, and/or thin corneas.

Doganay et al. in a study performed on outcomes of various corneal tattooing techniques stated that stromal puncture technique can cause corneal perforation in very thin areas of the cornea during the procedure, in addition to a lack of full (homogeneous) dye distribution. Further concluded that femtosecond laser-assisted corneal tattooing is an effective, practical, and fast technique for homogenous dye staining technique.[11] Contradicting that we would like to add that femtosecond laser-assisted corneal tattooing is a far expensive technique, which cannot be afforded by everyone, and opacities anterior to the flap cannot be stained by the dye even if the flap is dissected manually, making it less expensive.

Pitz et al. documented corneal perforation while tattooing using micropuncture technique and cited fragile scarred tissue as a reason.[10] Contrary to that, we have successfully tattooed a thin fragile scarred cornea without perforation.

Panda et al. stated that damaging basement membrane while scrapping off the epithelium would predispose to recurrent corneal erosions.[12] But in our case, we performed tattooing after scrapping epithelium without causing any recurrent corneal erosions postoperatively.

There is limited literature available on safety profile of corneal tattooing on thin, fragile, and scarred corneas. There is no documented case of successfully performed corneal tattooing on extremely thin cornea. Our case will be one of its kinds as we have performed corneal tattooing in an extremely thin cornea using stromal puncture technique with microneedling device after scraping of hypertrophied epithelium, making it further thin (322 μ) and susceptible to perforation. Contrary to the literature, we were able to perform the procedure without any perforation and were able to deliver excellent cosmetic results. On the flip side, the durability of the dye could not be tested here as only 6-month postoperative period has been studied. Long-term and large case series on corneal tattooing of thin corneas would be of more help.

  Conclusion Top

We would like to conclude that corneal tattooing employing stromal puncture technique in extremely thin corneas is safe and cosmetically promising, but it requires proper preoperative assessment and intraoperative graded stromal puncturing, making it an affordable but technically demanding option.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Ziegler SL. Multicolor tattooing of the cornea. Trans Am Ophthalmol Soc 1922;20:71-87.  Back to cited text no. 1
Pitz S, Jahn R, Frisch L, Duis A, Pfeiffer N. Corneal tattooing: An alternative treatment for disfiguring corneal scars. Br J Ophthalmol 2002;86:397-9.  Back to cited text no. 2
Kymionis GD, Ide T, Galor A, Yoo SH. Femtosecond-assisted anterior lamellar corneal staining-tattooing in a blind eye with leukocoria. Cornea 2009;28:211-3.  Back to cited text no. 3
Ahn SJ, Han YK, Kwon JW. A case of superficial corneal tattooing for glare after trabeculectomy. Can J Ophthalmol 2009;44:e63.  Back to cited text no. 4
Reed JW. Corneal tattooing to reduce glare in cases of traumatic iris loss. Cornea 1994;13:401-5.  Back to cited text no. 5
Sekundo W, Seifert P, Seitz B, Loeffler KU. Longterm ultrastructural changes in human corneas after tattooing with non-metallic substances. Br J Ophthalmol 1999;83:219-4.  Back to cited text no. 6
Laria C, Alió JL, Piñero DN. Intrastromal corneal tattooing as treatment in a case of intractable strabismic diplopia (double binocular vision). Binocul Vis Strabismus Q 2010;25:238-42.  Back to cited text no. 7
Irfan S, Rashid F, shahzad I, To assess the efficacy of chemical corneal tattooing for unsightly corneal scars. Pak J Ophthalmol 2014;30:151-5.  Back to cited text no. 8
Park JH, Um T, Kim MJ, Tchah H, Kim JY. A new multiple noncontinuous puncture (pointage) technique for corneal tattooing. Int J Ophthalmol 2015;8:928-32.  Back to cited text no. 9
Pitz S, Jahn R, Frisch L, Duis A, Pfeiffer N. Corneal tattooing: An alternative treatment for disfiguring corneal scars. Br J Ophthalmol 2002;86:397-9.  Back to cited text no. 10
Doganay D, Doganay S, Cankaya C. Corneal tattooing for esthetic purposes in patients with corneal opacities. Indian J Ophthalmol 2020;68:1033-6.  Back to cited text no. 11
[PUBMED]  [Full text]  
Panda A, Mohan M, Chawdhary S. Corneal tattooing--Experiences with “lamellar pocket procedure”. Indian J Ophthalmol 1984;32:408-11.  Back to cited text no. 12
[PUBMED]  [Full text]  


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