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New pigment for cosmetic corneal tattooing

Tattooing was known & practiced long before the Christian era. In primitive civilizations, tattooing distinguished men of rank & status. Tattooing of the cornea for unsightly leucomas is of ancient lineage..

In the practice of Ophthalmology it is not always that you can give vision to a patient. There are occasions when you have to add a cosmetic value to the patients’ life, like in blind eye with corneal opacity. Simple answer is tattooing. Then why tattooing is not done by general ophthalmologists? There are two main reasons. Firstly there is non-availability of chemical pigment & secondly whatever pigments are used for tattooing are irritants for eye. Eye doesn’t remain quiet after the procedure & corneal epithelium doesn’t remain stable on the pigment. The ideal pigment or dye used for tattooing should be inert and easily available. On this background, I wish to draw your attention to a new pigment for tattooing. It is not water-soluble nor lipid soluble. I tried it initially on blind eyes and that too, in those patients who were prepared to get their eyes enucleated afterwards. Next, I tried the pigment in-patients of corneal opacity. The results are satisfactory beyond expectations.

For different types of opacities different surgical techniques are used.

    • Multiple needle puncture: This technique is used for superficial opacities which are not dense (nebular to macular grade). This procedure involves spreading the pigment which is in the in the powder form over the opacity. Multiple needle punctures are done in such a way that the pigment will go inside but there will not be any corneal perforation. In brief, strokes should be oblique, made into different directions, and should not penetrate deeper to superficial one third of stroma. Wash the pigment with saline. See extent of opacity, which is still remaining. If some part of opacity is still visible then spread the pigment and repeat the procedure till you are satisfied. Please keep it in mind that under microscope the opacity may be visible but in daylight it may be acceptable cosmetically.
    • Lamellar resection: If opacity is dense and superficial cornea is transparent or translucent, this method is used. Make an incision 3mm in width and nearly one-third thickness of cornea at one of the edges of opacity. A lamellar resection was done separating superficial cornea from the deep cornea with the help of crescent blade. Inj. Hyaluronidase 150 I.U. in 2ml is injected. This helps to create a proper plane of cleavage, as it is difficult to create plane of cleavage in the scarred tissue. Once the hyaluronidase is injected then separation is easy with blunt instrument like curved iris repositor. After this the pigment is spread between the superficial and deep corneal lamellae. The incision can be sutured with 9 zero nylon..
    • Lamellar graft: When the opacity is dense and superficial then following procedure is adopted. Scrape off the corneal epithelium over the opacity. If the corneal opacity is involving full diameter of cornea, make a partial thickness incision in circular fashion so as to separate the stem cells and conjunctiva. Then take the lamellar graft of one-third of the corneal thickness from glycerol preserved cornea. Tuck this graft below the stem cells and conjunctiva. If the opacity is small size but dense and superficial then tuck the graft like in epikeratophakia. Once this is done suture the graft with continuous 9 zero nylon. But before tying the knot the pigment is spread below the graft and then suture is tied.
    • Procedure for opacity of mixed variety: For example central dense deep opacity with peripheral nebular superficial, then combination of procedures can be adopted. Central area is done by lamellar resection while the peripheral faint opacity is done by multiple needle punctures.

Advantages of this process are, it’s easily available & no irritation.