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Year : 2019  |  Volume : 57  |  Issue : 1  |  Page : 68-70

White to black: Keratopigmentation

Department of Cornea and Refractive Surgery, MN Eye Hospital Pvt. Ltd., Chennai, Tamil Nadu, India

Date of Web Publication10-Jun-2019

Correspondence Address:
Dr. P A P. Aysha
MN Eye Hospital Pvt. Ltd., 781, TH Road, Tondiarpet, Opp. Tondiarpet Police Station, Chennai - 600 021, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/tjosr.tjosr_106_18

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Here we report a case of 34 year old female who presented to our department with chief complaints of photophobia, glare and whitish colouration of cornea in the left eye since 5 months. She had a history of penetrating ocular injury at the age of 6. She underwent penetrating keratoplasty, followed by cataract extraction and Intraocular lens implantation in 2015. On examination, Visual Acuity of right eye was 6/6 and left eye hand movements with projection of light in all quadrants. Slit lamp examination of left eye showed graft failure with leucomatous corneal opacity. Keratopigmentation was done using tattooing gun and jet black dye. Patient became symptomatically better and cosmetically satisfied. We found there was no fading of colour after three months.

Keywords: Corneal tattooing, leucomatous corneal opacity, penetrating keratoplasty

How to cite this article:
Madhivanan N, P. Aysha P A, Nishanth S, Madhivanan N. White to black: Keratopigmentation. TNOA J Ophthalmic Sci Res 2019;57:68-70

How to cite this URL:
Madhivanan N, P. Aysha P A, Nishanth S, Madhivanan N. White to black: Keratopigmentation. TNOA J Ophthalmic Sci Res [serial online] 2019 [cited 2020 Jun 2];57:68-70. Available from: http://www.tnoajosr.com/text.asp?2019/57/1/68/259867

  Introduction Top

Corneal tattooing has been used for cosmetic treatment of corneal opacities for centuries.[1],[2] Galen (AD 131–120) is considered to be the first to pigment human cornea using a reduced copper sulfate to mask a corneal leucoma.[3],[4],[5] Later, some surgeons experimented with different combination of various chemical products such as Indian ink, organic colors, animal uveal pigment, metallic borders, Chinese ink, platinum, and gold chloride. The main limitations in previous studies were fading of colors over time.[5] The literature also mentions von Weckerin back in 1870 who used India ink into a scarred cornea.[6]

  Case Report Top

A 34-year-old female presented to our department with chief complaints of photophobia, glare, and whitish discoloration in the left eye for 5 months. Her ocular history revealed penetrating injury to the left eye with a stick 28 years back followed by decreased vision. She had undergone penetrating keratoplasty followed by cataract extraction and intraocular implantation 3 years back. One year back, she developed graft failure with leucomatous corneal opacity.

On ocular examination, uncorrected visual acuity in the right eye was 6/6 and N6 and left eye-hand movement with projection of light in all quadrants. On slit-lamp examination, right eye was normal and left eye had a graft failure with leucomatous opacity with no visual potential as she was densely amblyopic in that eye [Figure 1]. Fundus examination of the right eye was normal and left eye had hazy view.
Figure 1: Preoperative picture

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B scan of both eyes was normal.

Systemic examination was found to be in normal limits.

Routine blood investigations were normal.

On pachymetry, corneal thickness of the right eye was 520 μ and left eye 540 μ.

The patient was not willing for visual rehabilitation procedure but was interested in good cosmesis.

The patient was planned for corneal tattooing of the left eye under topical anesthesia.

The epithelium was scraped off using a number 15 blade. A drop of black tattoo ink was put on corneal surface using 26-gauge 1cc needle, and micropuncture was performed using the gun of the tattooing machine. The gun of the machine is kept perpendicular on the cornea and moved along the surface gently and softly [Figure 2]. This maneuver is repeated multiple times on the area in cornea to be tattooed until final cosmesis is achieved. Bandage contact lens is placed with routine postoperative medication such as low-dose steroids, antibiotics, and lubricants [Figure 3].
Figure 2: (a) Machine, (b) sterile needle, (c) needle length adjustment, (d) tattoo ink

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Figure 3: (a) Epithelium scraping, (b) ink application, (c) micropuncture with tattoo gun, (d) tattooing, (e) saline wash, (f) bandage contact lens placement

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Her postoperative period was uneventful with cosmetically better and no fading of color after 3 months [Figure 4] and [Figure 5].
Figure 4: Even distribution of ink picture

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Figure 5: (a) Preoperative picture, (b) postoperative picture

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  Discussion Top

The main indications for corneal tattoos are leucomas, aniridia, polycoria, and corneal scars. Although tattoos are often given to patients who have end-stage opaque corneas, the procedure can also be performed on patients who are more interested in cosmesis than visual rehabilitation for leucomatous cornea. The corneal tattoo procedure is also a viable alternative to a corneal transplant with no visual potential and a good adjunctive therapy that helps minimize the psychological impact of opaque corneas or cosmetically unacceptable scars.

The machine (PMT/MTS) is made by a Chinese manufacturer who is well known in the field of cosmetic tattooing. The package contains the machine and disposable sterile needles are purchased separately. The ink which used was presterilized by gamma irradiation and is approved for dermal pigmentation. The machine is rotary and easy to use. There is a small motor encased in each rotary tattoo machine that moves the attached tattoo needle up and down. Sterile precaution is followed while using the tattoo gun, i.e., a sterile cloth cover over the probe and a disposable sterile plastic sleeve over the wiring. Only needle cartridge is exposed over the surgical field. There is dial on tattoo pen with which we can adjust the depth from 0 to 3.5 mm, usually a depth setting around 0.5 mm or less suffices for the procedure. However, it can be adjusted depending on the pre-existing thinning or a thick, scarred cornea.

  Conclusion Top

Keratopigmentation has achieved good cosmetic and symptomatic results and is associated with high patient satisfaction. Corneal tattooing is a very safe, easy, and cost-effective method to achieve cosmetic results.

Future potential option

Femtoassisted cornea tattooing is a new technique that has been proposed for the treatment of an opaque cornea for cosmetic purposes.[7],[8]

Declaration of patient consent

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

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Mannis MJ, Eghbali K, Schwab IR. Keratopigmentation: A review of corneal tattooing. Cornea 1999;18:633-7.  Back to cited text no. 1
Leigh AG. Tattooing of the cornea. In: Duke-Elder S, editor. System of Ophthalmology. Part 2. Vol. 8. London: Henry Kimpton; 1965. p. 645-8.  Back to cited text no. 2
Holth S. Revival of Galen's corneal staining with copper sulfate and tannine should be abandoned. Am J Ophthalmol 1931;14:378-9.  Back to cited text no. 3
Ziegler SL. Multicolor tattooing of the cornea. Trans Am Ophthalmol Soc 1922;20:71-87.  Back to cited text no. 4
van der Velden-Samderubun EM, Kok JH. Dermatography as a modern treatment for coloring leucoma corneae. Cornea 1994;13:349-53.  Back to cited text no. 5
Roy JN. Tattooing of the cornea. Can Med Assoc J 1938;39:436-8.  Back to cited text no. 6
Kim JH, Lee D, Hahn TW, Choi SK. New surgical strategy for corneal tattooing using a femtosecond laser. Cornea 2009;28:80-4.  Back to cited text no. 7
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. 8


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]


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