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Year : 2020  |  Volume : 2  |  Issue : 1  |  Page : 25

Corneal tattooing on leukoma

Departament of Ophthalmology, Pontifical Catholic University of Campinas, São Paulo, Brazil

Date of Submission05-Jun-2020
Date of Decision06-Jun-2020
Date of Acceptance27-Jul-2020
Date of Web Publication18-Sep-2020

Correspondence Address:
Dr. Camila Sayuri Sawatani
Rua Itagyba Santiago, 360
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/PAJO.PAJO_27_20

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The objective is to report a case about corneal tattooing on leukoma in PUC Campinas Hospital. It is a retrospective case report, about 64-year-old patient with corneal opacity of the left eye without visual acuity. The patient was not satisfied with the esthetics of the leukoma and did not tolerate the use of a contact lens. For this reason, corneal tattooing with stromal micropuncture and pigment impregnation was indicated.

Keywords: Corneal tattoo, leukoma, stromal micropuncture

How to cite this article:
Sawatani CS, Teixeira Faria DA, Delloiagono HS, Andrade Sobrinho MV, Ferreira HS, De Almeida Filipe PH. Corneal tattooing on leukoma. Pan Am J Ophthalmol 2020;2:25

How to cite this URL:
Sawatani CS, Teixeira Faria DA, Delloiagono HS, Andrade Sobrinho MV, Ferreira HS, De Almeida Filipe PH. Corneal tattooing on leukoma. Pan Am J Ophthalmol [serial online] 2020 [cited 2021 Aug 1];2:25. Available from: https://www.thepajo.org/text.asp?2020/2/1/25/295336

  Introduction Top

Corneal tattooing is a little-known but useful technique in some clinical situations.

It was initially proposed for esthetic purposes to camouflage white corneal scars in the eye with no visual potential.

The main causes of corneal opacity with potential for treatment are eye trauma (50.6%), pathologies of the retina (15.5%), and congenital causes (5.5%). For the cosmetic treatment of leukoma, the presence or absence of the eyeball must be taken into account. In cases of Phtisis bulbi, the use of the prosthesis, evisceration, and enucleation may be options; while in cases without phtisis bulbi, options such as cosmetic contact lenses, penetrating keratoplasty, deep anterior lamellar keratoplasty and iris and pupil tattoo can be used.[1]

Introducing corneal tattooing to the cornea was carried out by several maneuvers, including simple corneal staining, anterior stromal needle puncture, or corneal stromal pigment insertion through lamellar intrastromal channels. Recently, cuts by femtolaser were used to excimer laser and lamellar corneal.[2],[3]


The aim of this study is to report an approach in cases of corneal opacity without potential for vision and esthetic discontent.

  Case Report Top

DJP, male, 64-year-old, professor, resident of Campinas-SP (Brazil). Patient with a history of long-standing diabetes and trauma of the left eye in childhood, evolving with loss of vision in the same eye.

In follow-up at the Ophthalmology service of PUC Campinas (Brazil), in the departments of retina, cornea and external diseases and contact lenses.

On examination, the patient presented the best-corrected visual acuity 20/200 in the right eye and without light perception in the left eye. Biomicroscopy of the right eye showed no abnormalities and the left eye showed: calm eye, central leukoma with keratinized areas [Figure 1] and [Figure 2]. Ultrasonography of the left eye showed an image compatible with retinal detachment.
Figure 1: Ectocospy showing a central leukoma

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Figure 2: Central leukoma with keratinized area

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The patient complains of intolerance to the use of cosmetic contact lenses and dissatisfaction with the esthetic appearance of leukoma, damaging his personal life. A surgical approach to corneal tattooing with stromal micropuncture and pigment impregnation was suggested. For the procedure, a crescent slide was used to de-epithelialize the cornea and remove keratinized plaques; a cystitimous produced with an insulin needle for stromal micropuncture. The pigment used was a tattoo ink in brown for iris and black for pupil and they were composed of deionized water, nonionic surfactant, vegetable glycerin, propylene glycol, and pigments. The result of the procedure is shown in [Figure 3]. The patient was discharged using topical antibiotic, third-generation fluoroquinolone, and therapeutic contact lens for 15 days until the corneal repithelization.
Figure 3: Immediate postoperative

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An anterior optical coherence tomography (OCT) was performed after 5 months of the procedure, but due to subepithelial fibrosis induced by micropuncture, no satisfactory image was captured [Figure 4]. Unfortunately, the preoperative OCT was not performed due to the patient's social condition.
Figure 4: Anterior OCT with subepithelial fibrosis

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In the postoperative, he had no complaints or any complications and most important, the patient was satisfied with the aesthetic result, maintaining the monitoring at the service [Figure 5] and [Figure 6].
Figure 5: Stromal pigment impregnation (day 1 of postoperative)

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Figure 6: Aesthetic final result

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  Discussion Top

Disfiguring corneal opacities may alter personal self-confidence and affect badly both social lives and quality of life. The corneal tattoo may be a valuable therapeutic alternative in a distinct group to improve both patient's self-confidence and social life and in patients that comprises reconstructive surgical procedures, either will not result in functional improvement or carry the risk of phthisis.[4]

The indications of corneal tattoo vary from an esthetic improvement to the remission of complaints of photophobia and diplopia, in the absence of adverse effects.

Regarding the pigments used, it is still a little debated topic. Sekundo et al. demonstrated, by optical and electronic microscopy and histological analysis, that keratocytes retain particles of nonmetallic pigment in their cell membranes for long periods (up to 60 years).[5] The acrylic pigment and china ink are the pigments that present less toxicity and longer durability. Our surgical technique corroborated with a study by Amesty et al.,[6] which concluded that the intrastromal keropigmentation technique reports good cosmetic results, with no adverse effects on the treated eyes, in addition to longer color durability.[7]

According to literature, this approach has two theoretical problems. The first one is due to the multiple incisions into the corneal stroma, and thereby activation of phagocytosis and consequently lead to a shorter duration of pigmentation. Second, it has been thought that the multiple lacerations of Bowman's layer might promote recurrent corneal erosions, on the other hand, stromal micropuncture is known to be a treatment in case of recurrent erosions.[8]

Other disadvantages can be cited as the surgical difficulty, with not insignificant risk of perforation, also the possibility of gradual loss of pigment, especially with corneal micropuncture with possible reintervention.[9] Besides that, the postoperative period can be painful, although it is usually a transient condition with remission in 7–10 days. In our case, the patient did not complain of pain; but it was preferable to use a therapeutic contact lens due to deepithelialization of the cornel epithelium in the intraoperative.

The risk of tattoo infection compared to using a cosmetic lens is lower, since the risk of infection is higher during the intraoperative period and during epithelialization of the cornea, also antibiotic prophylaxis may be used. While the incorrect use or lack of hygiene of the cosmetic lenses can cause recurrent infections.

  Conclusion Top

Corneal tattling currently represents a simple, low-risk therapeutic alternative which may be proposed for numerous indications for esthetic and functional reasons. The degree of patient satisfaction in this study was high, and the intervention was an important aspect of their social integration.

Declaration of patient consent

The author certify that they have obtained all appropriate patient consent forms. In the form the patient(s) 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

Chang KC, Kwon JW, Han YK, Wee WR, Lee JH. The epidemiology of cosmetic treatments for corneal opacities in a Korean population. Korean J Ophthalmol. 2010;24:148-154. doi:10.3341/kjo.2010.24.3.148.  Back to cited text no. 1
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. 2
Anastas CN, McGhee CN, Webber SK, Bryce IG. Corneal tattooing revisited: Excimer laser in the treatment of unsightly leucomata. Aust N Z J Ophthalmol 1995;23:227-30.  Back to cited text no. 3
Chang KC, Kwon JW, Han YK, Wee WR, Lee JH. The epidemiology of cosmetic treatments for corneal opacities in a Korean population. Korean J Ophthalmol 2010;24:148-54.  Back to cited text no. 4
Sekundo W, Seifert P, Seitz B, Loeffler KU. Long-term ultrastructural changes in human corneas after tattooing with non-metallic substances. Br J Ophthalmol 1999;83:219-24.  Back to cited text no. 5
Amesty MA, Rodriguez AE, Herna ndez E, DeMiguel MP, Alio JL. Tolerance of micronized mineral pigments for intrastromal keratopigmentation: A histopathology and immunopathology experimental study. Cornea 2016;35:1199-205.  Back to cited text no. 6
Alsmman AH, Mostafa EM, Mounir A, Farouk MM, Elghobaier MG, Radwan G. Outcomes of corneal tattooing by rotring painting ink in disfiguring corneal opacities. J Ophthalmol 2018;2018:1-6.  Back to cited text no. 7
Pitz S. Corneal tattooing: An alternative treatment for disfiguring corneal scars. Br J Ophthalmol 2002;86:397-9.  Back to cited text no. 8
Alio JL, AL-Shymali O, Amesty MA, Rodriguez A. Keratopigmentation with micronised mineral pigments: Complications and outcomes in a series of 234 eyes. Br J Ophthalmol 2017;102:742-7.  Back to cited text no. 9


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]


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