Norfolk and Norwich University Hospital, Norfolk, Norwich, United Kingdom
Financial Disclosures: None to disclose.
Reprints: Deepak Gupta, MRCOphth, Norfolk and Norwich University Hospital, Norfolk, Norwich, Nr4 7uu, United Kingdom (e-mail: firstname.lastname@example.org).
Received July 2, 2009
Accepted October 18, 2009
Corneal staining (tattooing) has been advocated in the management of patients with corneal leucomata, iris malformations or following iridotomies. Functional visual benefits can result from the reduction of aberrant light directed through iris defects that may cause glare and light scatter, in addition to cosmetic improvements for those with opacification. Inks, classified as stationery or cosmetic products, offer an economic alternative to currently available classical corneal staining agents (metallic salts). Furthermore, they may be used to good clinical effect with an intrastromal lamellar pocket technique.
Corneal tattooing has a history of more than 2000 years,1–4 its early use being to improve cosmesis for individuals with significant corneal opacification or scarring. Initially, salts were used, which were later replaced by inks.2,4 Agents were applied to the anterior stroma, initially after epithelial debridement4 and later by transepithelial needle puncture.3 Both techniques were associated with the disruption of the epithelial basement membrane and therefore predisposed to poor epithelial regeneration.5 Reported complications included corneal irritation, infection, perforation, anterior chamber inflammation, long-term fading of pigment, and dye dispersion and migration.4 More recently, placement of the dye within intrastromal lamellar pockets has been advocated.1,5
A 55-year-old woman presented to the ophthalmic emergency treatment room with bilateral linear photopsia. Her symptoms were worse at night and interfered with driving ability. Six months earlier, she had bilateral prophylactic laser peripheral iridotomies (LPIs) performed (206 mJ OD/286 mJ OS) in the 12-o'clock position to treat occludable angles, followed by further LPIs for enlargement to ensure patency (80 mJ OD/120 mJ OS).
On examination, her visual acuities were recorded at 20/20 (OU). Adnexal examination revealed slightly retracted eyelids, but no other abnormalities and no other signs of thyroid eye disease were observed. Thyroid function tests had been performed earlier by physicians confirming an euthyroid state. Fundoscopy was normal and she was referred back to the glaucoma clinic. By that stage she had determined that her symptoms varied with eyelid position, left more than right. Examination revealed that the left iridotomy was visible in the primary position of gaze (Fig. 1). Her symptoms resolved with downward distraction of the upper eyelid (downward pulling). It was hypothesized that the mild lid retraction resulted in the upper precorneal tear film meniscus being positioned immediately anterior to the LPI, the prismatic effect of the meniscus causing light to enter through the LPI from an apparently different angle to that passing through her pupil, with resultant symptoms. She was listed for a left corneal tattooing procedure, using sterile ink, to mask the iridotomy from incident light.
The procedure was performed under aseptic conditions with topical anesthesia (g. proxymetacaine 0.5%). Using a microscope, an intrastromal lamellar pocket was created with a standard 2.8-mm phacoemulsification keratome anterior to the LPI position, to a corneal depth of 50%. A black sterile marking ink was deposited into the pocket using a syringe and Rycroft cannula. Excess ink was washed away after a few minutes and topical antibiotic (g.chloramphenicol 0.5%) was instilled.
At 1-week follow-up, the patient reported that her symptoms had resolved almost immediately after the tattooing procedure and that she was able to resume driving at night (Fig. 2). No adverse effects have been reported. There was no postsurgical ptosis to account for the improvement in her symptoms. At 1-year follow-up, the intensity of the staining remains unaltered.
Corneal staining has been advocated in the management of patients with corneal leucomata or iris malformations.1,2 Advances in microsurgical reconstructive procedures have limited the indication for tattooing to a select few patients.3 Apart from the obvious cosmetic improvements for those with corneal opacification, functional visual benefits can result from the reduction of aberrant light directed through iris defects that can cause glare and light scatter. Monocular visual symptoms are a reported complication of laser iridotomies,6–8 as in this case.
The lamellar pocket technique was developed as an alternative to corneal epithelial debridement or puncture.5 The procedure is efficient and technically simple, requiring commonly used ophthalmic equipment. The use of a lamellar pocket minimizes the corneal basement membrane trauma and helps pigment retention by staining 2 surfaces instead of 1 (both the corneal bed and the inner surface of the stromal pocket), thus increasing the density and potential duration of staining.5
To our knowledge, the only reported use of intrastromal corneal staining with inks has been as a treatment for disfiguring corneal scars, using a transepithelial intrastromal needle puncture technique, with reported staining durations of up to 56 months (mean 27 mo in 10 patients).3 In the UK, chemically reduced metallic salts, such as platinum chloride (2%) and hydrazine hydrate (2%), are available for tattooing. Platinum chloride, however, is very expensive [£602 ($992) for 10×2 mL; ie, £30 ($50)/mL] and hydrazine hydrate has to be manufactured to order, which again is costly. In contrast, commercially available sterile inks (eg, Rotring Sterile Marking Ink, GmbH; Hamburg, Germany) are readily available and inexpensive [£30 ($49) for 10×0.5 mL; ie, £6 ($10)/mL].
Inks are classified as stationery or cosmetic products, rather than pharmaceutical agents, but they are an economic alternative to currently available, expensive, classic corneal staining agents. Furthermore, they may be used to good clinical effect, with an intrastromal lamellar pocket technique.
The authors thank Jill Bloom and Wendy Franks of Moorfields Eye Hospital for their assistance.
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corneal tattoo; corneal tatooing; iris defect; laser peripheral iridotomy
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