Corneal tattooing

Corneal tattooing is the practice of tattooing the cornea of the human eye. Reasons for this practice include the 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.

Reasons for corneal tattooing

Causes or reasons for corneal tattooing vary from patient to patient, but most patients receive treatment to alter the cosmetic appearance of their eyes due to disease or accident. Some patients also receive treatment for optical purposes, including decreasing a circumstantial glare within the iris. Corneal opacities are the leading cause for cosmetic tattooing.

Reconstructive cosmetic purposes

The leading reason for corneal tattooing is to cosmetically alter the appearance of the eye. Usually, the need for this alteration stems from corneal opacities. Corneal opacities, the scarring of the cornea which creates an opaque or semi-transparent area on the eye, can be caused by leucoma, keratitis, and cataracts.^[1] These opacities can be cosmetically disruptive for patients in their everyday lives. Tattooing the cornea can cosmetically alter the discoloration and therefore blend the opacity to a normal eye color. Most physicians agree that the procedure is to be performed on patients that have already lost vision or do not expect visual recovery. Occasionally, corneal tattooing can be performed in cases where it might improve the sight of the eye.^[2]

Optical purposes

Occasionally, corneal tattooing can be performed in cases where it might improve the sight of the eye. According to Dr. Samuel Lewis Ziegler, indications for this purpose might include albinism, aniridia, coloboma, iridodialysis, keratoconus, or diffused nebulae of the cornea.^[1] Corneal tattooing is also occasionally performed on eyes that still have vision in order to reduce the symptomatic glare associated with large iridectomies or traumatic iris loss.^[3]

History of corneal tattooing

Corneal tattooing has been practiced for almost 2000 years,^[4] first mentioned in history by Galen, a 2nd century physician. Methods of corneal tattooing have at times been practiced often and at other times faded into obscurity, but overall the methods have evolved throughout history.

Ancient practice

Galen of Pergamum, a Roman 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 leukomatous 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.^[5] This procedure was probably only used on those patients with an unsightly corneal leucoma.^[6]

Development of procedures

After Galen’s reference to corneal tattooing in the 2nd century, the practice is not mentioned until 1869 when oculoplastic surgeon Louis Von Wecker introduces a new method. De Wecker, as he was also known, was the first to use black ink, India ink, or China ink to tattoo a leucoma of the eye. He would first apply cocaine to numb any sensation in the eye and then cover the cornea with a thick solution of ink. He would then insert the pigment into the corneal tissue with a grooved needle obliquely.^[5] This method has influenced all subsequent methods since then. Ziegler writes of several physicians that have contributed to the development of corneal tattooing. Some physicians created new instruments to enhance the tattoo process. Taylor introduced one such new method. He created a bundle of needles to tattoo the eye instead of a single needle, and De Wecker later found this method to be more practical. In 1901, Nieden introduced a method that used a tattooing needle based upon the idea of a fountain pen, or something similar to the Edison electric pen. He found that this electrical needle operated more rapidly and regularly than other traditional methods of tattooing. Another physician, Armaignac, used a small funnel that he fixed to the cornea by three small points. He would then place a portion of China ink into the instrument and proceed to tattoo with a needle. Armaignac claimed that this method produced a perfectly round pupil in one sitting.^[1] Other physicians, such as Victor Morax, did not actually tattoo the cornea but still changed the appearance of the cornea. Victor Morax would split the corneal tissue into two vertical layers, introducing the coloring substance under the pedicle flap. He would then apply a compressive dressing over the eye.^[5] Various methods have been introduced throughout history, evolving and often improving. They have collectively evolved into several main stream methods of today that have proved to be the most effective.

Different methods

Methods

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] All 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.^[7] 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.^[4] 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.^[8] Another fairly new method, introduced by Arif O. Khan and David Meyer in an article presented by 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.^[9] 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 recover the needle with ink. This method would avoid the disadvantages of other methods in which the ink impeded the physician’s inability to control where the ink spread to, which impeded the sight of the cornea to the physician.^[10] A plethora of methods exist today with varying techniques and instruments.

Different inks

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.^[6] Two different methods exist: chemical dyeing with gold or platinum chloride and carbon impregnation. Walter Sekundo et al, in the British Journal of Ophthalmology say that chemical dyeing is easier and quicker than carbon impregnation, but it fades more rapidly than non-metallic tattooing. The West mainly uses chemical dyeing. Some chemical dyes that are commonly used are platinum or gold chloride, which provide a jet black stain.^[11] Carbon impregnation includes the use of India ink, Chinese ink, lamp black ink, and other organic dyes.^[11] 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]

Advantages and disadvantages

Some advantages of corneal tattooing include the successfulness 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.^[11] 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.^[5]

Disadvantages

Some of the disadvantages of corneal tattooing are the difficulty of performing the procedure and the risk of the procedure. Many people have gone blind from the attempt of the procedure. Corneal tattooing is a difficult procedure and 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.^[12] Sometimes the results are not what were expected, and the eye might need to be re-tattooed.^[13] Also, results may not last very long because of the multiple incisions, and the multiple lacerations might cause recurrent corneal erosions.^[4] 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.”^[5] Also, there are some considerable dangers linked to corneal tattooing. Some patients complain that it feels like something is in their eye and slight redness.^[5] The ink might not remain in the cornea and could possibly cause keratitis.^[13] Other complications include “toxic reaction, iridocyclitis, persistent corneal epithelial defects, and corneal ulceration.”^[14] In summary, the corneal tattooing might not always work successfully, and physicians run into problems such as fading, reduction in size, complications, or short-term results.

Advances in technology

New 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.^[11] 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.”^[13] Although such advances in technology have decreased the popularity of corneal tattooing, some do practice it still. Sekundo et al even believe that the combination of new technology and old techniques might increase the popularity of tattooing in the future.^[11]

Tattooing of the sclera

Another practice that is similar to corneal tattooing is the tattooing of the sclera, which is the practice of injecting dye into the sclera, or the white part of the eye. This process is very new and is viewed as an extreme practice. Body Modification Ezine (BME) recently wrote an article concerning the first three procedures performed on sighted eyes. The tattoo artist tried two different procedures, the first covering the needle with ink and puncturing the eye. This method was deemed unsuccessful, and the second method was attempted. This procedure, in which the sclera was injected with blue dye, was successful. The procedures were “effectively painless because there aren’t nerve endings in the surface of the eye,” says the article's author Shannon Larratt. The aftereffects include “fairly minor” pain, bruising, and some discomfort. Also, the author, who had the procedure performed on himself, seems to have some blisters between the sclera and conjunctiva. The author twice indicates the risks and possible complications, the most important including blindness, of the procedure and warns that it should not be performed without a professional.^[15] The New York Post also wrote describing this procedure. The author of the article quotes Dr. Sandra Belmont, saying, “Cosmetic tattooing of the cornea can be extremely dangerous,” and complications may include infection, perforation, and hemorrhage.^[16] Scleral tattooing is extremely new and still experimental.

Oklahoma legislature

A local Oklahoma newspaper wrote about the Oklahoma Senate panel trying to make eye tattooing illegal. Senate Bill 844 was filed by Oklahoma Senator Cliff Branan and would make it illegal to tattoo the sclera of the eye. The Oklahoma Academy of Ophthalmology requested for this bill to pass because of the dangers of the procedure.^[17] It was eventually passed April 21, 2009.^[18]

References

1. ^ ^{a b c d} Ziegler, S. Lewis. "Multicolor Tattooing of the Cornea." 71-87.
2. ^ ^{a b} Lee, Ji-Eun. "Corneal tattooing to mask subsequent opacification after amniotic membrane grafting for stromal corneal ulcer." Acta Ophthalmologica Scandinavica 2006; 84: 696-698.
3. ^ ^{a b c d e} Vassileva, Snejina and Evgeniya Hristakieva. "Medical Applications of Tattooing." Clinics in Dermatology 2007; 25:367-374
4. ^ ^{a b c} Pitz, S. et al. "Corneal tattooing: an alternative treatment for disfiguring corneal scars." British Journal Ophthalmology 2003; 86:397-399.
5. ^ ^{a b c d e f} Roy, J.N. "Tattooing of the Cornea." The Canadian Medical Association Journal 1938. 436-438.
6. ^ ^{a b} Kobayashi, Akira and Kazuhisa Sugiyama. "In Vivo Confocal Microscopy in a Patient with Keratopigmentation (Corneal Tattooing)." Cornea 2005; 24:2:238-240.
7. ^ Panda, A. et al. "Corneal Tattooing." British Journal of Ophthalmology. 1461.
8. ^ Theobald, Samuel. "A Practical Point in the Technic of Corneal Tattooing, the Value of Which is Not Commonly Recognized." 225-226.
9. ^ Khan, Arif O. and David Meyer. "Corneal tattooing for the treatment of debilitating glare in a child with traumatic iris loss." American Journal of Ophthalmlogy 2005; 920-921.
10. ^ Thomson, William. "An Instrument for Tattooing the Cornea."
11. ^ ^{a b c d e} Sekundo, Walter et al. "Long term ultrastructural changes in human corneas after tattooing with nonmetallic substances." British Journal Ophthalmology 1990; 83:219-224.
12. ^ Duggan, Jamshedji N. and B.P. Nanavati. "Tattooing of Corneal Opacity with Gold and Platinum Chloride." British Journal of Ophthalmology. 419-425.
13. ^ ^{a b c} Doggart, James H. "Significance of Colour Change in the Cornea." British Journal of Ophthalmology 1959; 43:13-20.
14. ^ Sharma, A. et al. "Granulomatous Keratitis following Corneal Tattooing." Indian Journal of Ophthalmology 2003; 51.3:265-267.
15. ^ "Three Blind Mice." Shannon. BME NEWS. 2 Jul 2007. 31 Oct. 2009 <http://news.bmezine.com/2007/07/02/three-blind-mice>.
16. ^ Positano, Rock. "Don't Turn Blind Eye to Eye-Tattoo Risks." New York Post. July 2007. 31 Oct. 2009 <http://www.nypost.com/>.
17. ^ Bisbee, Julie. "Oklahoma Senate Panel wants us to make tattooing the eyeball illegal." NEWS OK. Feb. 2009. 31 Oct. 2009 <http://www.newsokcom/>.
18. ^ "Week in Review the Oklahoma Senate." 31 Oct. 2009 <http://www.oksenate.org/>.