Introduction

Amniotic membrane transplantation(AMT) has been successfully intro-duced for the treatment of persistentepithelial defects in deep corneal ulcers(Tseng et al. 1997; Azuara-Blanco et al.1999). The amniotic membrane (AM)promotes the epithelialization and sta-

bilization of the corneal surface (Lee &Tseng 1997), but is frequently preser-ved under the regenerated epitheliumof the cornea and may result in avariable amount of corneal opacity orscarring. Subsequently, this corneal scar-ring can cause cosmetic problems, albeitthat the wound caused by the cornealstromal ulcer has completely healed.

Corneal tattooing has been used forcenturies to improve the cosmeticappearance of blind eyes that havecorneal leukomas (Pickrell & Clark1947). To the best of our knowledge,there have been no reported cases ofcorneal tattooing used for healed stro-mal corneal ulcer scars in patientstreated with AMT. In this study, wedescribe the cosmetic utility of cornealtattooing for patients with blind eyeswho have corneal scars followingAMT for stromal corneal ulcers.

Case reports

Case 1

A 59-year-old man was referred to uswith a persistent epithelial defect thatwas combined with a stromal cornealulcer in his right eye. Best correctedvision in the right eye was light per-ception only; vision in the left eye wasnormal. Under the diagnosis of herpeszoster ophthalmicus, a antiherpeticophthalmic ointment (Samil, Seoul,Korea) and tobramycin 0.3% eye-drops (Dae Woong, Seoul, Korea)were instilled. However, the epithelialdefect and stromal ulcer persisted.Having confirmed that there was noevidence or sign of any microbiologi-cal infection, AMT was performedand the patient was given disposablecontact lenses. The corneal woundsurface totally healed over the grafted

Case Series

Corneal tattooing to masksubsequent opacification afteramniotic membrane grafting forstromal corneal ulcer

Ji-Eun Lee, Jong Bae Jun, Hee Young Choi, Boo Sup Oum andJong Soo Lee

Department of Ophthalmology, College of Medicine, Pusan National University,Pusan, Korea

ABSTRACT.

Purpose: We aimed to report on the cosmetic efficacy of corneal tattooing

using India ink for resolving corneal opacities resulting from amniotic mem-

brane grafting carried out to promote corneal wound healing in stromal cor-

neal ulcers.

Methods: Amniotic membrane grafting of corneal ulcers was carried out in

three patients. After corneal re-epithelialization, a 30-gauge needle filled with

India ink was placed into the amniotic membrane space located between the

regenerated corneal epithelium and the stromal bed. The ink was then care-

fully injected.

Results: The cornea was successfully stained with India ink in all cases. There

were no significant complications during the mean follow-up period of

17 months. All the patients were satisfied with the corneal staining.

Conclusion: When a corneal opacity occurs after an amniotic membrane graft

for stromal corneal ulcer, corneal tattooing by intrastromal injection of India

ink into the amniotic membrane space may be a very useful method of achiev-

ing a good cosmetic result.

Key words: amniotic membrane transplantation – corneal opacity – corneal tattooing – stromal

corneal ulcer

Acta Ophthalmol. Scand. 2006: 84: 696–698ª 2006 The Authors.

Journal compilation ª 2006 Acta Ophthalmol Scand.

doi: 10.1111/j.1600-0420.2006.00680.x

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AM within 3 weeks, but a cornealopacity occurred due to preservedAM and stromal opacity (Fig. 1A).

Tattooing was performed on the cor-neal opacity at 3 months followingAMT. First, topical 0.5% proparacaine(Alcaine; Alcon, Fort Worth, TX,USA) was administered in the righteye. Using an operating microscope,the India ink (India Ink Reagent Drop-per; Fisher Scientific International,Inc., Cedex, France) was then injected

into the AM space located between theregenerated corneal epithelium and thecorneal stroma by a bevelled downpuncture using a 30-gauge needle witha 1-ml disposable syringe (Fig. 2).

Tangential punctures into the AMspace were carried out; this easily cre-ated a puncture canal and we wereable to observe the portion of the nee-dle under the corneal epithelium. Itwas also easier to inject the dye intothe AM space through the puncture

site compared with a traditional cor-neal stromal injection. Postoperativetreatment consisted of 0.3% topicaltobramycin (Tobra; Dae Woong,Seoul, Korea) four times a day andofloxacine ointment given at night.The patient was well satisfied with thecosmetic result and no complicationswere observed during the follow-up of15 months (Fig. 1B).

Case 2

A 63-year-old man was referred to uswith a corneal ulcer that showed cen-tral corneal stromal melting in the lefteye. Visual acuity in the left eye waslight perception only. The ulcer provedto have a staphylococcal infection andwas treated with fortified tobramycin1.5% and cefazolin 0.5% eyedrops(Yuhan, Seoul, Korea). After confirm-ing there were no further clinical signsof acute infection, AMT was per-formed due to persistent corneal epi-thelial defect. The corneal wound re-epithelialization over the AM occurredwithin 5 weeks (Fig. 1C). The patientthen tried to wear an iris contact lensfor cosmetic purposes, but this failedbecause of the difficulties involved inwearing and caring for the lens. Tenmonths after the AMT we decided toperform corneal tattooing with Indiaink using the method described above.The tattooing resulted in a satisfactorypostoperative appearance for thepatient and no significant complica-tions such as microbial infection, poorwound healing or uveitis were seen dur-ing the 17-month follow-up (Fig. 1D).

Case 3

A 56-year-old man was referred to uswith a corneal ulcer in the right eyecaused by a foreign body. The initialexamination revealed VA of light per-ception only, with central corneal stro-mal melting with hypopyon. Stain andculture examinations indicated a fusa-rium infection. The patient was treatedwith topical natamycin eyedrops (Al-con) and systemic fluconazole (PfizerPharmaceuticals, Seoul, Korea) medi-cation and the hypopyon fortunatelysubsided. However, the corneal epithe-lial defect did not recover. The patientpresented no clinical or microbiologi-cal signs of acute corneal infection andso underwent AMT.

The corneal wound re-epithelializa-tion was completed within 5 weeks of

Fig. 1. Case 1: at 2 months after the AM graft, corneal re-epithelialization had already

occurred (A); 15 months after intrastromal corneal tattooing, the central corneal opacity was

obscured by India ink (B). Case 2: at 5 weeks after the AM graft, corneal re-epithelialization

over the AM had occurred (C); 17 months after intrastromal corneal tattooing, the black col-

our of the India ink was clearly visible in the central portion of the cornea (D). Case 3: at

5 weeks after the AM graft, corneal re-epithelialization had occurred (E); corneal staining

18 months after corneal tattooing (F).

Fig. 2. Schematic figure showing that India ink can be injected into the interspace (AM space)

between the regenerated corneal epithelium and the stromal bed.

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the AMT (Fig. 1E). This corneal opa-city was tattooed with India ink usingthe method described above at12 months after AMT. The processwas later repeated because of under-pigmentation. The result was satisfac-tory and no further complicationswere observed during the 20-monthfollow-up (Fig. 1F).

Discussion

In recent years, AMT has been intro-duced for the treatment of stromal cor-neal ulcer with persistent epithelialdefect (Chen et al. 2000). Amnioticmembrane acts as a basement mem-brane in that it supports epithelialadhesion, growth and differentiation,prevents epithelial apoptosis, and indu-ces re-epithelialization via the epithe-lial progenitor cells (Meller & Tseng1999). We performed AMT in cornealstromal ulcer patients who had persis-tent epithelial defects. These patientshad no prospect of visual recovery andwere intolerant to contact lenses.

The mean time required for epithe-lialization has been reported to varyfrom 2 to 5 weeks depending on theulcer (Rodriguez-Ares et al. 2004). Wewere able to observe complete re-epi-thelialization over the grafted AM3)5 weeks after AMT. Although AMpromotes epithelialization over itself,AM tissue is frequently preservedbetween the regenerated epitheliumand the stroma and may remain as acorneal opacity or scar. Thus, patientsfrequently describe the subsequentscar as a cosmetic problem.

Two methods of corneal tattooingare used to treat corneal scars. One ischemical dyeing performed with anyof several metallic solutions such asgold chloride, silver nitrate or plat-inum chloride (Leigh 1965; Olanderet al. 1983). The results of this are fre-quently unsatisfactory due to inflam-mation, variable staining and fading(Olander et al. 1983). The othermethod involves imbedding insolublepigments such as India ink in the cor-neal stroma (Pickrell & Clark 1947),where they are actively digested bykeratocytes and where they persist forlengthy periods of time (Olander et al.1983). One of the most useful methodsfor corneal tattooing involves a tech-nique similar to dermatography, butthis has two theoretical problems: the

activation of phagocytosis and thepromotion of recurrent corneal ero-sions (Mannis et al. 1999; Sekundoet al. 1999). In this study, we applied amethod similar to dermatography withthe use of a 30-gauge needle such as isreadily available in any ophthalmicsurgical department. The insolublepigment or dye can be easily injectedinto the interspace between the regen-erated epithelium and the stroma, andany phagocytic activation of the stro-mal layer can be prevented due to thereduced inflammation caused by theAM. Furthermore, this technique isrelatively simple to perform comparedwith the traditional intrastromal tat-tooing procedure and the results inour patients have been satisfactoryuntil now (with an average follow-upof 17 months). However, it is vital toensure that the dye is injected gentlyand slowly because forceful or rapidinjection may cause the dye to leakfrom the injection site or may damagethe corneal epithelium.

We experienced underpigmentationin one case and retreated the patient2 weeks later. If the physician orpatient is unsatisfied with the resultsof corneal tattooing or there isdecreased staining with time, the pro-cedure can be performed again untilsatisfactory results are obtained. Bac-terial infection or corneal perforationis a rare but serious potential compli-cation, so all patients should be trea-ted with prophylactic topicalmedications. We did not observe anyrelevant complications, although long-term follow-up is necessary to fullyevaluate the postoperative results. Fur-ther, we found we were able to obtaingood results from both the surgeon’sand the patient’s points of view.

To summarize, our experienceshows that for patients who do notexpect visual recovery, the cosmeticproblem of corneal opacities or scarsafter stromal corneal ulcers have beentreated with AMT can be resolved bycorneal tattooing with India ink in theAM space between the regeneratedcorneal epithelium and the stroma.

Acknowledgements

This study was supported by a Med-ical Research Institute grant (no.2003–36), Pusan National UniversityHospital, Pusan, Korea.

This material was presented at theAssociation for Research in Visionand Ophthalmology (ARVO) AnnualMeeting, Fort Lauderdale, Florida, inMay 2005.

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Received on May 25th, 2005.

Accepted on January 17th, 2006.

Correspondence:

Jong Soo Lee MD

Department of Ophthalmology College

of Medicine Pusan

National University 1–10,

Ami-Dong Seo-Ku

Pusan 602-739

Korea

Tel: + 82 51 240 7326

Fax: + 82 51 242 7341

Email: jongsool@pusan.ac.kr

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