Corneal tattooing (or keratopigmentation) is the practice of tattooing the cornea of the human eye. Reasons for this practice include improvement of cosmetic appearance and the improvement of sight. Many different methods and procedures exist today, and there are varying opinions concerning the safety or success of this practice.
Causes or reasons for corneal tattooing vary from patient to patient. Most patients receive treatment to alter the cosmetic appearance of their eyes following disease or accident. Others receive treatment for optical purposes, including decreasing circumstantial glare within the iris. Corneal opacities are the leading reason for undergoing cosmetic tattooing.
The leading reason for corneal tattooing is to alter the appearance of the eye cosmetically. Usually, the need for this alteration stems from corneal opacity. Corneal opacities (scarring of the cornea that creates an opaque or semi-transparent area on the eye) may be caused by leucoma, keratitis or cataracts. [1] Such opacities can be cosmetically disruptive for patients in their everyday lives. Tattooing the cornea can alter a discoloration, blending an opacity into the normal eye color. Most physicians agree that the procedure should be performed only on patients who have lost their vision or who do not expect to recover it.
Occasionally, corneal tattooing is performed when it might improve eyesight. [2] According to Dr. Samuel Lewis Ziegler, indications for treatment include albinism, aniridia, coloboma, iridodialysis, keratoconus, or diffused nebulae of the cornea. [1] Corneal tattooing is also performed on patients who still have vision to reduce symptomatic glare associated with large iridectomies or traumatic iris loss. [3]
Keratopigmentation for aesthetic purposes is an intervention performed in patients who want to change the color of their eyes. [4]
Corneal tattooing has been practiced for almost 2000 years, [5] first mentioned in history by Galen, a 2nd-century physician.
Galen of Pergamum, a Greek physician and philosopher, first described corneal tattooing in 150 AD, and the same procedure was later described by Aetius in 450 AD as an attempt to mask the leucomatous opacities of the eye. Both physicians would cauterize the corneal surface with a heated stilet. After the cauterization, they would apply the dye to the eye, using a variety of dyes, such as powdered nutgalls and iron (see iron gall ink) or pulverized pomegranate bark mixed with copper salt. This would then stain the cornea, correcting the cosmetic appearance for the patient. [1] Other sources have mentioned that Galen might have used copper sulphate. [6] This procedure was probably used only on those patients with an unsightly corneal leukoma. [7]
After Galen's reference to corneal tattooing in the 2nd century, the practice is not mentioned until 1869, when oculoplastic surgeon Louis de Wecker introduced a new method. De Wecker, as he was also known, was the first to use black India ink to tattoo a leukoma of the eye. He applied cocaine to the eye as a topical anesthetic, coated the cornea with a thick solution of ink, and inserted pigment into the corneal tissue obliquely with a grooved needle. [6] His method has influenced all subsequent methods.
Ziegler cites several physicians who contributed to the development of corneal tattooing. Some created new instruments to enhance the tattoo process. Taylor introduced one such method. He created a bundle of needles to tattoo the eye, instead of using a single needle; De Wecker found this method to be more practical. In 1901, Nieden introduced a method that used a tattooing needle based on the idea of a fountain pen, or something similar to the Edison electric pen. He found that this electrical needle operated more rapidly and reliably than traditional methods of tattooing. Another physician, Armaignac, used a small funnel that he fixed to the cornea by three small points. He would then put China ink into the instrument and tattoo with a needle. Armaignac claimed that his method produced a perfectly round pupil in one sitting. [1] Other physicians, such as Victor Morax, did not tattoo the cornea, but changed its appearance using other methods. Morax split the corneal tissue into two vertical layers, introducing the coloring substance under the pedicle flap and placing a compressive dressing over the eye. [6] Various methods have been introduced throughout history, collectively evolving into several mainstream methods that have proven to be the most effective to date.
Several different methods exist today. Generally in most procedures, the dyeing agent is applied directly to the cornea. The physician then inserts the needle into the eye to inject the dye into the cornea. [3] Physicians agree that the tattoo should be injected intramellarly or laterally, which provides an appearance of a uniform color and minimizes the chance of an irritable eye. [8]
The methods used to apply the ink to the cornea differ. In one such method, the physician applies the ink into the cornea stroma by multiple punctures, covering the needle with ink each time. [3] In another method, the physician would cover a three-edged spatula needle with ink before each puncture. He would then apply the ink into the anterior corneal stroma with each puncture. [5] Samuel Theobald would inject the eye first with a needle and then rub in the ink with a Daviel curet. This would prevent against the often obscure field of operation known to other physicians and also prevent against repetitive irrigation sometimes needed. [9]
Another method, introduced by Arif O. Khan and David Meyer in an article in the American Journal of Ophthalmology, suggests the removal of the corneal epithelium first. The physician would then place a piece of filter paper soaked in platinum chloride 2% onto the area for two minutes, followed by a second piece of filter paper soaked in hydrazine 2% applied for 25 seconds. [10] William Thomson practiced corneal tattooing in a method similar to Nieden. He used a small steel pen manufactured by Joseph Gillott, with the point converted into the cutting surface. The barrel would receive ink for the entire operation, avoiding the need to refill the ink or to recover the needle with ink. This method would avoid the disadvantages of other methods in which the ink impeded the physician's ability to control where the ink spread, which impeded the sight of the cornea to the physician. [11] A plethora of methods exist today with varying techniques and instruments.
Many different types of inks are used throughout history and today for the dyeing of the cornea. Today, India ink is the most commonly used, providing safe and long-lasting effects, [3] but other dyes include metallic colors in powder form, various organic dyes, and uveal pigment from animal eyes. [7] Two different methods exist: dyeing with gold or platinum chloride and carbon impregnation.
Walter Sekundo et al., in the British Journal of Ophthalmology, say that dyeing is easier and quicker than carbon impregnation, but it fades more rapidly than non-metallic tattooing. The West mainly uses dyeing. Some dyes that are commonly used are platinum or gold chloride, which provide a jet black stain. [12]
Carbon impregnation includes the use of India ink, Chinese ink, lamp black ink, and other organic dyes. [12] Snejina Vassileva and Evgeniya Hristakieva, both faculty members at universities in Bulgaria, say that India ink is safe and long lasting when properly diluted and is the most commonly used today. [3]
Some advantages of corneal tattooing include the success and minimum recovery process. Ji-Eun Lee et al., in an article from Acta Ophthalmologica Scandinavica, say, "Corneal tattooing by intrastromal injection of India ink into the amniotic membrane space may be a very useful method of achieving a good cosmetic report." [2] Often, the process is extremely successful and reduces the cosmetic disruption of any corneal opacity. Corneal tattooing may also reduce a glare within the eye due to iris loss and increase visual acuity. [12] J.N. Roy, a professor at the University of Montreal, wrote in the Canadian Medical Association Journal, "Placing a bandage over the tattooed eye is not indicated; ordinary coloured glasses are amply sufficient." Treatment after the procedure itself is limited, according to Roy, to colored glasses. [6]
Some of the disadvantages of corneal tattooing are the difficulty of performing the procedure and the risk of the procedure. Corneal tattooing is a procedure that is very difficult to perform precisely. Often, the area tattooed fades after time and rarely remains permanently. The size of the area tattooed also might reduce over time. [13] Sometimes, the results are not what were expected, and the eye might need to be re-tattooed. [14] Also, results may not last very long because of the multiple incisions, and the multiple lacerations might cause recurrent corneal erosions. [5] Finally, not all leucoma respond to the tattooing. J.N. Roy says, "All leucomas do not equally respond to intervention, which must be done only on those which present old, solid and flat corneal cicatrices." [6]
There are also some considerable dangers linked to corneal tattooing. Going blind from the attempt of the procedure is a possibility. Some patients complain of slight redness and that it feels like something is in their eye. [6] The ink might not remain in the cornea and could possibly cause keratitis. [14] Other complications include "toxic reaction, iridocyclitis, persistent corneal epithelial defects, and corneal ulceration." [15] Physicians may also run into problems such as fading, reduction in size, and short-term results.
Advances in technology have decreased the actual practice of corneal tattooing over the years. Instead, some of the following methods are used to disguise any corneal scarring: corneal grafting, keratoplasty techniques, and tinted contact lenses. [12] Also, advances in technology have decreased the probability of developing a dense corneal leucoma, such as chemotherapy, antibiotics, and the avoidance of "heroic measures of therapy." [14] Although such advances in technology have decreased the popularity of corneal tattooing, some still practice it. Sekundo et al. believe that the combination of new technology and old techniques might increase the popularity of tattooing in the future. [12] More recently Jorge Alió described a technique combining keratopigmentation and the use of a femtosecond laser in the treatment of essential iris atrophy. [16] This technique has also been used for cosmetic purposes on healthy eyes. [17]
An alternative way to permanently change the color of the eye is called BrightOcular, which is achieved by placing an artificial silicone lens on top of the original iris. The clients can choose from a variety of colors and different designs and images. The method also makes it possible to remove the implant later in life to get the original eye color back. [18] This implant technique frequently leads to serious complications. [19]
LASIK or Lasik, commonly referred to as laser eye surgery or laser vision correction, is a type of refractive surgery for the correction of myopia, hyperopia, and an actual cure for astigmatism, since it is in the cornea. LASIK surgery is performed by an ophthalmologist who uses a laser or microkeratome to reshape the eye's cornea in order to improve visual acuity.
Eye surgery, also known as ophthalmic surgery or ocular surgery, is surgery performed on the eye or its adnexa. Eye surgery is part of ophthalmology and is performed by an ophthalmologist or eye surgeon. The eye is a fragile organ, and requires due care before, during, and after a surgical procedure to minimize or prevent further damage. An eye surgeon is responsible for selecting the appropriate surgical procedure for the patient, and for taking the necessary safety precautions. Mentions of eye surgery can be found in several ancient texts dating back as early as 1800 BC, with cataract treatment starting in the fifth century BC. It continues to be a widely practiced class of surgery, with various techniques having been developed for treating eye problems.
Radial keratotomy (RK) is a refractive surgical procedure to correct myopia (nearsightedness). It was developed in 1974 by Svyatoslav Fyodorov, a Russian ophthalmologist. It has been largely supplanted by newer, more accurate operations, such as photorefractive keratectomy, LASIK, Epi-LASIK and the phakic intraocular lens.
Refractive surgery is optional eye surgery used to improve the refractive state of the eye and decrease or eliminate dependency on glasses or contact lenses. This can include various methods of surgical remodeling of the cornea (keratomileusis), lens implantation or lens replacement. The most common methods today use excimer lasers to reshape the curvature of the cornea. Refractive eye surgeries are used to treat common vision disorders such as myopia, hyperopia, presbyopia and astigmatism.
A phakic intraocular lens (PIOL) is a special kind of intraocular lens that is implanted surgically into the eye to correct myopia (nearsightedness). It is called "phakic" because the eye's natural lens is left untouched. Intraocular lenses that are implanted into eyes after the eye's natural lens has been removed during cataract surgery are known as pseudophakic.
Thygeson's superficial punctate keratopathy (TSPK) is a disease of the eyes. The causes of TSPK are not currently known, but details of the disease were first published in the Journal of the American Medical Association in 1950 by renowned American ophthalmologist Phillips Thygeson (1903–2002), after whom it is named.
A red eye is an eye that appears red due to illness or injury. It is usually injection and prominence of the superficial blood vessels of the conjunctiva, which may be caused by disorders of these or adjacent structures. Conjunctivitis and subconjunctival hemorrhage are two of the less serious but more common causes.
Corneal transplantation, also known as corneal grafting, is a surgical procedure where a damaged or diseased cornea is replaced by donated corneal tissue. When the entire cornea is replaced it is known as penetrating keratoplasty and when only part of the cornea is replaced it is known as lamellar keratoplasty. Keratoplasty simply means surgery to the cornea. The graft is taken from a recently deceased individual with no known diseases or other factors that may affect the chance of survival of the donated tissue or the health of the recipient.
Corneal abrasion is a scratch to the surface of the cornea of the eye. Symptoms include pain, redness, light sensitivity, and a feeling like a foreign body is in the eye. Most people recover completely within three days.
Corneal cross-linking (CXL) with riboflavin (vitamin B2) and UV-A light is a surgical treatment for corneal ectasia such as keratoconus, PMD, and post-LASIK ectasia.
Acanthamoeba keratitis (AK) is a rare disease in which amoebae of the genus Acanthamoeba invade the clear portion of the front (cornea) of the eye. It affects roughly 100 people in the United States each year. Acanthamoeba are protozoa found nearly ubiquitously in soil and water and can cause infections of the skin, eyes, and central nervous system.
Corneal neovascularization (CNV) is the in-growth of new blood vessels from the pericorneal plexus into avascular corneal tissue as a result of oxygen deprivation. Maintaining avascularity of the corneal stroma is an important aspect of healthy corneal physiology as it is required for corneal transparency and optimal vision. A decrease in corneal transparency causes visual acuity deterioration. Corneal tissue is avascular in nature and the presence of vascularization, which can be deep or superficial, is always pathologically related.
Corneal ulcer, also called keratitis, is an inflammatory or, more seriously, infective condition of the cornea involving disruption of its epithelial layer with involvement of the corneal stroma. It is a common condition in humans particularly in the tropics and in farming. In developing countries, children afflicted by vitamin A deficiency are at high risk for corneal ulcer and may become blind in both eyes persisting throughout life. In ophthalmology, a corneal ulcer usually refers to having an infection, while the term corneal abrasion refers more to a scratch injury.
Keratoprosthesis is a surgical procedure where a diseased cornea is replaced with an artificial cornea. Traditionally, keratoprosthesis is recommended after a person has had a failure of one or more donor corneal transplants. More recently, a less invasive, non-penetrating artificial cornea has been developed which can be used in more routine cases of corneal blindness. While conventional cornea transplant uses donor tissue for transplant, an artificial cornea is used in the keratoprosthesis procedure. The surgery is performed to restore vision in patients with severely damaged cornea due to congenital birth defects, infections, injuries and burns.
Herpetic simplex keratitis is a form of keratitis caused by recurrent herpes simplex virus (HSV) infection in the cornea.
An artificial iris is an intraocular implant that is used as both a cosmetic and to treat those with aniridia or other eye trauma. People with this condition experience photophobia, or increased sensitivity to light. The artificial iris, made from silicone, acts as a replacement iris. The artificial iris is implanted in the eye using different surgery techniques depending on the patient's eye trauma. Most of the major artificial iris manufacturers are European and the treatment is used sparingly in the United States because of limited FDA approval, in part due to possibility of vision loss and other risks.
A corneal button is a replacement cornea to be transplanted in the place of a damaged, diseased or opacified cornea, normally approximately 8.5–9.0mm in diameter. It is used in a corneal transplantation procedure whereby the whole, or part, of a cornea is replaced. The donor tissue can now be held for days to even weeks of the donor's death and is normally a small, rounded shape. The main use of the corneal button is during procedures where the entirety of the cornea needs to be replaced, also known as penetrating keratoplasty.
Corneal opacification is a term used when the human cornea loses its transparency. The term corneal opacity is used particularly for the loss of transparency of cornea due to scarring. Transparency of the cornea is dependent on the uniform diameter and the regular spacing and arrangement of the collagen fibrils within the stroma. Alterations in the spacing of collagen fibrils in a variety of conditions including corneal edema, scars, and macular corneal dystrophy is clinically manifested as corneal opacity. The term corneal blindness is commonly used to describe blindness due to corneal opacity.
Exposure keratopathy is medical condition affecting the cornea of eyes. It can lead to corneal ulceration and permanent loss of vision due to corneal opacity.
Peripheral Ulcerative Keratitis (PUK) is a group of destructive inflammatory diseases involving the peripheral cornea in human eyes. The symptoms of PUK include pain, redness of the eyeball, photophobia, and decreased vision accompanied by distinctive signs of crescent-shaped damage of the cornea. The causes of this disease are broad, ranging from injuries, contamination of contact lenses, to association with other systemic conditions. PUK is associated with different ocular and systemic diseases. Mooren's ulcer is a common form of PUK. The majority of PUK is mediated by local or systemic immunological processes, which can lead to inflammation and eventually tissue damage. Standard PUK diagnostic test involves reviewing the medical history and a completing physical examinations. Two major treatments are the use of medications such as corticosteroids or other immunosuppressive agents and surgical resection of the conjunctiva. The prognosis of PUK is unclear with one study providing potential complications. PUK is a rare condition with an estimated incidence of 3 per million annually.