Corneal tattooing (or keratopigmentation) is the practice of

tattooing A tattoo is a form of body modification made by inserting tattoo ink, dyes, and/or pigments, either indelible or temporary, into the dermis layer of the skin to form a design. Tattoo artists create these designs using several tattooing p ...

the

cornea The cornea is the transparent front part of the eye that covers the iris, pupil, and anterior chamber. Along with the anterior chamber and lens, the cornea refracts light, accounting for approximately two-thirds of the eye's total optical ...

of the

human eye The human eye is a sensory organ, part of the sensory nervous system, that reacts to visible light and allows humans to use visual information for various purposes including seeing things, keeping balance, and maintaining circadian rhythm. ...

. 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.

Reasons for corneal tattooing

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.

Reconstructive cosmetic purposes

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 The human cornea is a transparent membrane which allows light to pass through it. The word corneal opacification literally means loss of normal transparency of cornea. The term corneal opacity is used particularly for the loss of transparency of c ...

. Corneal opacities (scarring of the cornea that creates an opaque or semi-transparent area on the eye) may be caused by leucoma,

keratitis Keratitis is a condition in which the eye's cornea, the clear dome on the front surface of the eye, becomes inflamed. The condition is often marked by moderate to intense pain and usually involves any of the following symptoms: pain, impaired e ...

cataracts A cataract is a cloudy area in the lens of the eye that leads to a decrease in vision. Cataracts often develop slowly and can affect one or both eyes. Symptoms may include faded colors, blurry or double vision, halos around light, trouble ...

. 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.

Optical purposes

Occasionally, corneal tattooing is performed when it might improve eyesight.Lee, Ji-Eun. "Corneal tattooing to mask subsequent opacification after amniotic membrane grafting for stromal corneal ulcer." Acta Ophthalmologica Scandinavica 2006; 84: 696-698. According to Dr. Samuel Lewis Ziegler, indications for treatment include

albinism Albinism is the congenital absence of melanin in an animal or plant resulting in white hair, feathers, scales and skin and pink or blue eyes. Individuals with the condition are referred to as albino. Varied use and interpretation of the term ...

aniridia Aniridia is the absence of the iris, a muscular structure that opens and closes the pupil to allow light into the eye. It is also responsible for eye color. Without it, the central eye appears all black. It can be congenital, in which both ey ...

coloboma A coloboma (from the Greek , meaning defect) is a hole in one of the structures of the eye, such as the iris, retina, choroid, or optic disc. The hole is present from birth and can be caused when a gap called the choroid fissure, which is presen ...

iridodialysis Iridodialysis is a localized separation or tearing away of the iris from its attachment to the ciliary body.Cline D; Hofstetter HW; Griffin JR. ''Dictionary of Visual Science''. 4th ed. Butterworth-Heinemann, Boston 1997. Cassin, B. and Solomon, ...

keratoconus Keratoconus (KC) is a disorder of the eye that results in progressive thinning of the cornea. This may result in blurry vision, double vision, nearsightedness, irregular astigmatism, and light sensitivity leading to poor quality-of-life. ...

, or diffused nebulae of the cornea. Corneal tattooing is also performed on patients who still have vision to reduce symptomatic glare associated with large iridectomies or traumatic

iris Iris most often refers to: *Iris (anatomy), part of the eye *Iris (mythology), a Greek goddess * ''Iris'' (plant), a genus of flowering plants * Iris (color), an ambiguous color term Iris or IRIS may also refer to: Arts and media Fictional ent ...

loss.

Aesthetic purposes

Keratopigmentation for aesthetic purposes is an intervention performed in patients who want to change the color of their eyes.

History

Corneal tattooing has been practiced for almost 2000 years, first mentioned in history by

Galen Aelius Galenus or Claudius Galenus ( el, Κλαύδιος Γαληνός; September 129 – c. AD 216), often Anglicized as Galen () or Galen of Pergamon, was a Greek physician, surgeon and philosopher in the Roman Empire. Considered to be o ...

, a 2nd-century physician.

Ancient practice

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

nutgall Galls (from the Latin , 'oak-apple') or ''cecidia'' (from the Greek , anything gushing out) are a kind of swelling growth on the external tissues of plants, fungi, or animals. Plant galls are abnormal outgrowths of plant tissues, similar to ...

s and iron (see

iron gall ink Iron gall ink (also known as common ink, standard ink, oak gall ink or iron gall nut ink) is a purple-black or brown-black ink made from iron salts and tannic acids from vegetable sources. It was the standard ink formulation used in Europe for ...

) or pulverized pomegranate bark mixed with copper salt. This would then stain the cornea, correcting the cosmetic appearance for the patient. Other sources have mentioned that Galen might have used

copper sulphate Copper sulfate may refer to: * Copper(II) sulfate, CuSO4, a common compound used as a fungicide and herbicide * Copper(I) sulfate Copper(I) sulfate, also known as cuprous sulfate, is an inorganic compound with the chemical formula Cu2 SO4. I ...

.Roy, J.N. "Tattooing of the Cornea." ''The Canadian Medical Association Journal'' 1938. 436-438. This procedure was probably used only on those patients with an unsightly corneal leukoma.Kobayashi, Akira and Kazuhisa Sugiyama. "In Vivo Confocal Microscopy in a Patient with Keratopigmentation (Corneal Tattooing)." ''Cornea'' 2005; 24:2:238-240.

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 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 Cocaine (from , from , ultimately from Quechua: ''kúka'') is a central nervous system (CNS) stimulant mainly used recreationally for its euphoric effects. It is primarily obtained from the leaves of two Coca species native to South Am ...

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. 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. Other physicians, such as

Victor Morax Victor Morax, Paris, 1920 Victor Morax (16 March 1866 – 14 May 1935) was an ophthalmologist born in Morges, Switzerland. He studied in Freiburg (Germany) and Paris, and from 1891 to 1903, he worked at the Pasteur Institute in Paris. Fro ...

, 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. Various methods have been introduced throughout history, collectively evolving into several mainstream methods that have proven to be the most effective to date.

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. 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. 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. 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. 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. 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. William Thomson practiced corneal tattooing in a method similar to Nieden. He used a small steel pen manufactured by

Joseph Gillott Joseph Gillott (11 October 1799 – 5 January 1872) was an English pen-manufacturer and patron of the arts based in Birmingham. Pen manufacturing After a brief period of schooling, Gillott began working in the cutlery trade in his home t ...

, 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. A plethora of methods exist today with varying techniques and instruments.

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, but other dyes include metallic colors in powder form, various organic dyes, and uveal pigment from animal eyes. 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.Sekundo, Walter et al. "Long term ultrastructural changes in human corneas after tattooing with nonmetallic substances." ''British Journal of Ophthalmology'' 1990; 83:219-224. Carbon impregnation includes the use of India ink, Chinese ink, lamp black ink, and other organic dyes. 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.

Advantages and disadvantages

Advantages

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." 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. 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.

Disadvantages

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. Sometimes, the results are not what were expected, and the eye might need to be re-tattooed.Doggart, James H. "Significance of Colour Change in the Cornea." ''British Journal of Ophthalmology'' 1959; 43:13-20. Also, results may not last very long because of the multiple incisions, and the multiple lacerations might cause

recurrent corneal erosion Recurrent corneal erosion is a disorder of the eyes characterized by the failure of the cornea's outermost layer of epithelial cells to attach to the underlying basement membrane (Bowman's layer). The condition is excruciatingly painful because t ...

s. 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." 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. The ink might not remain in the cornea and could possibly cause

. Other complications include "toxic reaction,

iridocyclitis Uveitis () is inflammation of the uvea, the pigmented layer of the eye between the inner retina and the outer fibrous layer composed of the sclera and cornea. The uvea consists of the middle layer of pigmented vascular structures of the eye and ...

, persistent corneal epithelial defects, and

corneal ulcer Corneal ulcer 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 the a ...

ation." Physicians may also run into problems such as fading, reduction in size, and short-term results.

Advances in technology

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. 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." 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. More recently Jorge Alió described a technique combining keratopigmentation and the use of a femtosecond laser in the treatment of essential iris atrophy. This technique has also been used for cosmetic purposes on healthy eyes.

Alternative methods

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. This implant technique frequently leads to serious complications.

References

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