Keratopigmentation technique provides permanent cosmetic results in severely damaged eyes

The intralamellar and superficial corneal staining techniques offered lasting results in eyes with corneal opacity, severe leukoma or total aniridia.

Thomas John

A normal ocular appearance is cosmetically essential from both a social and professional standpoint. Any compromise in the ocular appearance by way of corneal opacities such as scars, leukoma or total absence of the iris can be very disturbing to the individual, and correction to a more normal appearance may be required even in a non-seeing eye. Although cosmetic contact lenses, corneal prostheses and full-thickness keratoplasty procedures have been performed to improve the ocular appearance, these may not always be the preferred approach. Other procedures, such as corneal tattooing or keratopigmentation, may be more suitable in some cases.

Various techniques have been used for keratopigmentation, including manual techniques, microkeratome-assisted corneal tattooing and, more recently, femtosecond laser-assisted anterior lamellar corneal tattooing. Corneal tattooing has also been used for visual benefits in sighted eyes with intractable diplopia and in cases following trabeculectomy with iris defects that may cause glare and light scatter. Classic corneal staining agents include metallic salts or cost-effective sterile ink.

In this column, Dr. Jorge Alió describes both superficial and deeper intracorneal keratopigmentation techniques using micronized mineral pigments and a manual surgical technique.

– Thomas John, MD
OSN Surgical Maneuvers Editor

Jorge L. Alió

Corneal tattooing using micronized mineral pigments is a safe and effective procedure for permanent correction of cosmetically disabling corneal opacities, according to a surgeon at the Vissum Institute in Alicante, Spain.

Cosmetic contact lenses, corneal prostheses and penetrating keratoplasty are currently the most frequently used methods for treating blind, cosmetically impaired eyes. However, these eyes often do not tolerate contact lenses, and corneal prostheses and PK have high rates of severe complications.

Keratopigmentation, or corneal tattooing, has gained limited popularity as an alternate treatment due to the fading of colors over time.

“We have resumed this ancient practice, using a new set of mineral micronized pigments and innovative surgical techniques that allow permanent tissue staining. Different pigment combinations can be used to obtain different shades of colors,” Jorge L. Alió, MD, PhD, said.

Intralamellar corneal staining and superficial corneal staining are two methods of keratopigmentation that can be used. In more severe cases, the two approaches are sometimes combined.

In the intralamellar technique, the center of the cornea is marked with a caliper and the pupil diameter is determined by an RK optical zone marker. Three to four radial incisions are then made from the limbus to the edge of the pupil mark using a diamond knife. The corneal segments are dissected intralamellarly with a crescent knife.

“The dye is then injected under the lamellar flaps using a 30-gauge cannula. No sutures are used,” Dr. Alió said.

Preoperative view of patient in top photo. Postoperative view on bottom. Images: Alió JL

The pupil is drawn at the center, using a similar technique. From a small arcuate incision along the pupil diameter, the central cornea is dissected circularly, and 1 cc of black pigment is injected.

Superficial corneal staining can be performed in cases of superficial opacities and scars. A drop of dye is applied on the corneal surface, then micropunctures are made with a 30-gauge needle to penetrate down to the superficial stromal layers. The maneuver is repeated until the desired result is achieved. Finally, the superficial cornea is washed to eliminate the stained epithelial debris.

Rewarding results

In a prospective study published in the British Journal of Ophthalmology, the results of corneal tattooing were evaluated in 40 eyes of 40 patients with disfiguring corneal opacities or severe leukoma and total aniridia.

The team of surgeons used intralamellar corneal staining in 28 cases, superficial corneal staining in eight cases and a combination of the two in four cases. Brownish-black pigment was used in 95% of the eyes and bluish-green in 5% of the eyes.

“To our knowledge, this is the largest modern report on [keratopigmentation] for cosmetic purposes, and our case series is broadening up almost daily,” Dr. Alió said.

An independent observer classified the cosmetic results and postoperative ocular symmetry as excellent in 27 cases, good in 10 cases and poor in three cases. The latter three patients reported being unhappy with results, while the remaining 37 patients reported being happy or very happy and said they would repeat surgery.

Dr. Alió noted that limited or insufficient results can be improved by performing keratopigmentation a second time.

There were no reported cases of inflammation or other side effects of the procedure, such as pain, foreign body sensation, corneal de-epithelialization or color loss.

“[Keratopigmentation] is a safe surgical procedure, has a short learning curve, is inexpensive and prevents more invasive approaches. Patient satisfaction is very high. If our new mineral micronized pigments prove to guarantee stable, permanent staining, all previous limitations of this simple method will be overcome,” he said.

Of the two approaches, he favors intralamellar staining.

“It provides a more homogeneous cosmetic effect, and both surgical time and recovery time are faster. In addition, it leaves an intact corneal surface, and the staining is not exposed to the tear film,” he said. – by Michela Cimberle

References:

• Ahn SJ, Han YK, Kwon JW. A case of superficial corneal tattooing for glare after trabeculectomy. Can J Ophthalmol. 2009;44:e63.
• Alio JL, Sirerol B, Walewska-Szafran A. Corneal Tattooing (keratopigmentation) to restore cosmetic appearance in severely impaired eyes with new mineral micronized pigments. Br J Ophthalmol. 2009 Aug. 12. [Epub ahead of print]
• Fogla R, Gupta A, Indumathy TR. Microkeratome-Assisted Corneal Tattooing: A Case Report. Cornea. 2010 Feb 15. [Epub ahead of print]
• Kobayashi A, Sugiyama K. In vivo confocal microscopy in a patient with keratopigmentation (corneal tattooing). Cornea. 2005;24:238-240.
• Kymionis GD, Ide T, Galor A, Yoo SH. Femtosecond-assisted anterior lamellar corneal staining-tattooing in a blind eye with leukocoria. Cornea. 2009;28:211-213.
• Mannis MJ, Eghbali K, Schwab IR. Kerato-pigmentation: a review of corneal tattooing. Cornea. 1999;18:633-637.
• Stone NM, Somner JE, Jay JL. Intractable diplopia: a new indication for corneal tattooing. Br J Ophthalmol. 2008;92:1445, 1561-1562.

• Thomas John, MD, is a clinical associate professor at Loyola University at Chicago, and is in private practice in Tinley Park and Oak Lawn, Illinois. He can be reached at 708-429-2223; fax: 708-429-2226; e-mail: tjcornea@gmail.com.
• Jorge L. Alió, MD, PhD, can be reached at Vissum, Instituto Oftalmológico de Alicante, Avenida de Denia, s/n, 03016 Alicante, Spain; 34-965-150-025; fax: 34-965-151-501; e-mail: jlalio@vissum.com.