Corneal Tattooing and Anterior Stromal Puncture for Treating Symptomatic Bullous Keratopathy

CLINICAL SCIENCE

Hsin-Chiung Lin, MD,*† Yi-Lun Wang, MD,† Guang-Wu Chen, PhD,‡ and Chieh-Hung Yen, MD*

5-year survival rate of grafts is approximately 73%, but Purpose: fi To investigate the ef cacy of corneal tattooing, through endothelial cell counts progressively decline over the first 10 anterior stromal puncture (ASP), for managing painful bullous years after surgery.1,2 For patients who are not expected to keratopathy (BK). gain vision after a corneal transplant, alternative, nonsurgical Methods: This retrospective, case-controlled, consecutive case interventions may be able to provide temporary pain relief. series study was performed at a university-based referral clinic. These procedures include therapeutic contact lens (TSCL) use and anterior stromal puncture (ASP). Patients with painful BK who underwent corneal tattooing with fi Chinese ink between 2007 and 2013 were included in analyses. The rst use of a corneal tattoo dates back to 1859, when the procedure was performed to repair pigmentary Patients diagnosed with symptomatic BK who only underwent ASP 3 during the same period were included as a control group. defects related to leucoma. However, the use of corneal tattooing has been limited because of advancements in Results: A total of 40 patients (27 men, 13 women) with a mean keratoplasty, TSCL fitting, and ocular prostheses.4–8 In age of 57.5 6 15.3 years were included in analyses. The clinical general, corneal tattooing is performed for cosmetic purposes diagnosis was pseudophakic BK in 5 subjects (12.5%), failed graft in on eyes that have a corneal scar.9–11 Here, we compare BK 11 subjects (27.5%), BK secondary to perforating corneal injury recurrence rates after ASP and corneal tattooing. repair in 19 subjects (47.5%), and end-stage glaucoma in 5 subjects (12.5%). Subjects were followed for a mean period of 26.4 6 7.5 months (range: 6–55 months). Recurrent bullae formation occurred MATERIALS AND METHODS in 3 of 31 patients (9.68%) who had undergone corneal tattooing and in all 9 patients (100%) who had undergone ASP (P , 0.001). This study protocol was approved by the Human Research Ethics Committee at Chang Gung Memorial Conclusions: Corneal tattooing with Chinese ink is a simple, Hospital in Taiwan (No. 103-3480B) and all study conduct effective outpatient procedure for treating painful BK in eyes with no adhered to the tenets of the Declaration of Helsinki. Patient visual potential. information obtained from medical records was deidentified before analyses. Key Words: cornea tattoos, bullous keratopathy The medical records of patients with painful BK who (Cornea 2016;35:355–357) underwent ASP or corneal tattooing between 2007 and 2013 were examined. Painful BK was defined as corneal edema and bullae formation secondary to traumatic, inflammatory, or orneal edema resulting from endothelial decompensation iatrogenic damage. All patients had documented endothelial Cis a major cause of pain and decreased vision in patients cell dysfunction or had undergone at least 2 failed penetrating with bullous keratopathy (BK), which is manifested by keratoplasty (PK) procedures. Patients with neurotrophic stromal edema and small vesicle (bullae) formation. Corneal keratopathy, Stevens–Johnson syndrome, or chemical burns transplantation, where the nonfunctioning endothelium is that might impede corneal reepithelialization were excluded replaced, is most commonly used to treat BK. Successful from analyses. The presence of a systemic disease known to surgeries can restore vision and alleviate ocular pain. The delay corneal healing (eg, diabetes mellitus) was noted. Chinese ink in solid form was sterilized using ethylene oxide gas sterilization, after which it was diluted and ground with Received for publication August 19, 2015; revision received October 1, 2015; distilled water into liquid form and introduced into the corneal accepted October 4, 2015. Published online ahead of print November 25, stroma with a bent 25- or 27-gauge needle with the same 2015. method used to perform ASP in the control group (no Chinese From the *Department of Ophthalmology, Chang Gung Memorial Hospital, ink in needle). The actual number of corneal tattoos placed Taoyuan, Taiwan; †School of Medicine, Chang Gung University, Taoyuan, Taiwan; and ‡Department of Computer Science and Engineering, College with ASP varied in each patient according to the location and of Engineering, Chang Gung University, Taoyuan, Taiwan. area affected by bullae formation. All procedures were Supported by Chang Gung Memorial Hospital (No. CMRPG3C1781). performed in the outpatient setting on eyes with no hope The authors have no conflicts of interest to disclose. for vision improvement. After the procedures, patients were Reprints: Hsin-Chiung Lin, MD, Department of Ophthalmology, Chang Gung Memorial Hospital, #5, Fu-Hsing St, Kweishan, Taoyuan 333, instructed to wear a TSCL for temporary pain relief and to Taiwan (e-mail: [email protected]). promote reepithelialization. Patients were also instructed to Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. use topical 0.25% chloramphenicol or fluoroquinolone 4

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RESULTS TABLE 1. Patient Demographic and Ocular Characteristics A total of 40 consecutive patients [13 women (32.5%), Tattoo 6 ASP Group Group P 27 men (67.5%)] with a mean age of 57.5 15.3 years (range: 25–82 years) were included in analyses. The ASP group No. eyes 9 31 consisted of 9 patients and the corneal tattoo group consisted of Age (yrs) 53.9 6 15.4 58.5 6 15.4 31 patients. Four patients had diabetes and 3 patients had Sex (male/female) 7/2 20/11 hypertension. All patients had disfiguring corneal edema and System disease (diabetes/hypertension) 1/1 3/2 opacities that had resulted from traumatic or surgery-related Eye (right/left) 3/6 21/10 endothelial dysfunction. The assigned clinical diagnosis was Visual acuity pseudophakic/aphakic BK in 5 patients (12.5%), graft failure in Before procedure (NLP/LP/HM/CF) 8/0/0/1 24/3/3/1 11 patients (27.5%), postperforating corneal injury repair After procedure (NLP/LP/HM/CF) 8/1/0/0 24/3/3/1 edema/opacity in 19 patients (47.5%), and end-stage glaucoma Diagnoses* in 5 patients (12.5%). Patients were followed for an average Perforating injury 4 10 period of 26.4 6 7.5 months (range: 6–55 months). There were Ocular siderosis 1 0 no significant differences between the ASP and tattoo groups in Retinal detachment repair 2 1 patient age, sex, affected eye distribution (right, left), diabetes PK 3 14 or hypertension incidence, preoperative primary diagnosis, or Perforating keratitis 1 5 follow-up period duration (Table 1). Second glaucoma 7 14 The tattoo group consisted of 31 patients (20 men, 11 End-stage glaucoma 0 3 women) with a mean age of 58.5 6 15.4 years (range: 25–82 Chronic angle closure glaucoma 0 1 years). There was more severe ciliary congestion in the first Neovascular glaucoma 0 1 week after procedures in the tattoo group than in the control Pseudophakic BK 2 8 group. One month after undergoing corneal tattooing, 10 of Follow-up period (mo) 31.3 6 13.2 25.0 6 13.3 31 patients (32.6%) had complete epithelial bullae regression Bullae recurrence 9 (100%) 3 (9.7%) ,0.001 and most patients had at least partial regression of bullae. Treatment for recurrence Three months after tattooing, 28 of 31 patients (90.3%) were Corneal tattoo 5 1 symptom free and had no recurrence of bullae. Unfortunately, Conjunctival flap 2 1 3 patients (9.7%) had recurrent bullae formation and received Bandage contact lens 2 1 conjunctival flaps or a TSCL to relieve symptoms. Data presented as mean 6 standard deviation, where applicable. The ASP group (control group) consisted of 9 patients *Indicates that many patients also had glaucoma, which was the secondary (2 women, 7 men) with a mean age of 53.9 6 30.2 years diagnosis. – CF, counting fingers; HM, hand motion; LP, light perception; NLP, no light (range: 25 76 years). One patient had diabetes and 1 patient perception. had hypertension. All 9 patients (100%) had varying degrees of painful bullae recurrence by 3 months that required treatment with alternative procedures (eg, corneal tattooing times a day until the epithelium had healed. After healing, the or conjunctival flap creation). The difference between bullae TSCL was removed, chloramphenicol or fluoroquinolone use recurrence rates in the ASP (100%) and tattoo (7.5%) groups was discontinued, and Tobradex ointment use (twice a day was statistically significant (P , 0.001, Table 1). application; Alcon, Belgium) was initiated. Patients were examined at 1 day, 7 days, and 1 month after ASP or tattooing and every 3 months after that. Patient DISCUSSION symptoms, corneal findings, and visual acuity at the last Corneal tattooing has been used to improve the follow-up visit were noted. Procedural failure was defined as cosmetic appearance of eyes with corneal opacities and iris bullae recurrence 3 months or more after the procedure. defects for more than a century. Alio et al recently renamed A Fisher exact test was used to examine the difference the technique as “keratopigmentation” and used a new between groups in bullae recurrence. P-value examined was material, applied using a femtosecond laser, for both cosmetic 2-tailed and statistical significance was defined as P , 0.05. and optical function improvement.10,12–15

FIGURE 1. A, Ocular photograph of a 39-year-old man with sustained corneal perforating injury and BK with recurrence of pain. B, Corneal inﬂammation with ciliary congestion 1 week after treatment with corneal tattooing.

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This retrospective, consecutive case series investigated conjunctival flap and TSCL) do not offer. Therefore, we the efficacy of corneal tattooing through ASP in eyes with no suggest that corneal tattooing should be considered for visual potential but that had persistent painful bullous corneal treating painful recurrent BK, particularly in eyes with erosion. Kim et al16 reported good success rates for treating a disfigured appearance. Success with this minimally invasive BK with corneal tattooing in conjunction with amniotic procedure could prevent some patients from needing more membrane transplantation. We speculate that the presence aggressive surgery. of a foreign body (in this case, the tattoo ink) in the cornea induces higher levels of inflammation, promoting epithelial REFERENCES adhesion. 1. Ing JJ, Ing HH, Nelson LR, et al. Ten-year postoperative results of Several treatments have been proposed for eyes with penetrating keratoplasty. 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