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An oldie but a goodie — corneal tattooing
Please note the following is a description of a procedure that is not consistent with FDA labeling.
About once a year, I encounter a patient who helps me rediscover an old but great technology — keratopigmentation, or corneal tattooing. This procedure fell out of fashion for a number of years but has re-emerged among a few cornea specialists because it's a near-perfect solution for defects in the iris or for corneal leukomas.
One example is a patient referred to me with visual disturbances after previous cataract surgery. The patient had best corrected visual acuity of 20/30 with halos, even under photopic conditions. She had a peripheral iris defect caused by trauma during surgery. This allowed light to enter her eye without passing through her IOL. Several treatment options were possible: iridoplasty with a suture, placement of a Morcher artificial iris, placement of a therapeutic (peripherally opaque) contact lens and, of course, corneal tattooing. After discussing the options with the patient, I recommended corneal tattooing.
Tattoo dye for corneal use is an off-label procedure, as there are no approvals of tattoo inks for use on the eye. However, many surgeons have used commercially available tattoo dye, using a steam sterilizer to prepare it for surgery. Naturally, only a few cc's are necessary for the procedure.
In the procedure, I debride epithelium from the area of interest. I dip the tip of a 15° paracentesis knife into a small amount of sterilized dye and approach the corneal surface tangentially. This minimizes the chance of entering the anterior chamber while maximizing the visibility of the pigment when viewed externally.
It's important to intentionally "overdo it" or put about three times much more pigment spots than appear necessary at the time of surgery. That's because much of the dye accumulating on the surface of the stroma makes the cornea appear adequately pigmented. However, this will disappear within a few days, leaving behind only what was injected intrastromally.
One downside to this procedure: Some patients experience significant pain for a few days afterwards. To minimize this, I perform this procedure under a peribulbar anesthetic using bupivacaine because it keeps patients comfortable for at least 12 hours after surgery, by which time some of the corneal epithelial defect has healed. To further reduce pain, I use an NSAID drop — I typically use Xibrom (bromfenac, Ista) twice a day, but Acular (ketorolac, Allergan) four times a day or Nevanac (nepafenac, Alcon) three times a day work also — in addition to four times a day dosing of prednisolone acetate and a broad spectrum antibiotic. A bandage contact lens is also a must during healing.
This patient's BCVA improved to 20/25 after tattooing. Moreover, her complaints of halos disappeared, and she much appreciated having a noninvasive procedure with little risk to solve her problem.