Phototherapeutic keratectomy for treatment of long-term dye migration after corneal tattooing.

T he history of corneal tattooing dates back to 129 AD, when Galen pioneered it as a technique to conceal leukomata. In modern times, keratoplasty and contact lenses (CLs) have largely replaced corneal tattooing as treatment for leukomata. However, newer techniques have helped corneal tattooing regain its popularity. In addition to concealing corneal opacities and iris defects for cosmesis, corneal tattooing may improve vision by reducing aberrant light that causes glare and light scattering. All methods of tattooing, however, suffer from long-term instability as the result of dye dispersion and fading. This process appears to occur by endocytosis of dye particles into cells and then subsequent migration. Various forms of lamellar dissection of the cornea have been attempted using specialized tools followed by intralamellar dyeing. Unfortunately, they all have difficulty accurately delineating the margin of the tattoo bed, resulting in an irregular tattoo border and irregular distribution of stain. Thus, researchers have been focused on accurately delineating the margin of the tattoo bed. Two studies have used the femtosecond laser to create a lamellar free flap. Kim et al lifted the corneal flap and injected dye into the lamellar stromal bed. Kymionis et al removed the flap and immersed it in dye. In both studies, the flap was then repositioned on the residual corneal bed. Report of a Case. A 45-year-old woman was referred for consideration of corneal tattooing of the left eye in 1983. Her ocular history was significant for a congenitally abnormal left eye with retinal atrophy and an inferior iris coloboma as well as secondary exotropia following surgery for esotropia as a child. She underwent an intracapsular cataract extraction on her left eye 12 years earlier; her left eye was aphakic and had a superior iris sectoral defect (Figure 1A). Baseline best-corrected visual acuity was counting fingers OS. She had been wearing a custom-designed aphakic/ cosmetic soft CL on the left eye for years to improve peripheral vision and minimize exotropia. This CL had built up protein deposits causing CL intolerance, and it was not possible to have a replacement made. Standard tinted CLs had been tried but did not disguise the iris defects to the patient’s satisfaction. For this reason, corneal tattooing of the left eye was performed in 1983 using a No. 75 Beaver blade (BeaverVisitec International) along with brown, gray, green, and white dyes in an attempt to match the color of the right iris while maintaining a central clear zone 4 mm in diameter (Figure 1B and C). Following the procedure, the patient was able to wear tinted CLs with satisfactory cosmetic and functional results. In 2010, the patient was referred back for consideration of revision of the corneal tattoo in the left eye due to slowly worsening cosmetic appearance and dimming of vision during the past 10 years. Examination showed significant lightening of corneal pigment compared with original postoperative photographs as well as migration of tattoo pigment into the central 4-mm clear zone (Figure 2A). Phototherapeutic keratectomy was performed in a 5-mm-diameter central zone to “reopen the pupil” by ablating the pig-