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Year : 2003  |  Volume : 51  |  Issue : 3  |  Page : 265-267

Granulomatous Keratitis following Corneal Tattooing.

Grewal Eye Institute, SCO 168-169, Sector 9-C, Madhya Marg, Chandigarh-160 009, India

Correspondence Address:
A Sharma
Grewal Eye Institute, SCO 168-169, Sector 9-C, Madhya Marg, Chandigarh-160 009
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Source of Support: None, Conflict of Interest: None

PMID: 14601857

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We report a patient who developed granulomatous keratitis following corneal tattooing

Keywords: Cornea, tattooing, granulomatous keratitis

How to cite this article:
Sharma A, Gupta P, Dogra MR, Hidayat AA, Gupta A. Granulomatous Keratitis following Corneal Tattooing. Indian J Ophthalmol 2003;51:265-7

How to cite this URL:
Sharma A, Gupta P, Dogra MR, Hidayat AA, Gupta A. Granulomatous Keratitis following Corneal Tattooing. Indian J Ophthalmol [serial online] 2003 [cited 2021 Jan 24];51:265-7. Available from: https://www.ijo.in/text.asp?2003/51/3/265/14668

Corneal tattooing has been in use to mask the disfiguring leucomata corneae since ancient times. Galen was the first to mention the tattooing of the corneal opacity using copper sulphate. Taylor reported the first successful attempt to tattoo the corneal opacity a century ago.[1] This procedure is almost obsolete in modern ophthalmic practice. Cosmetic contact lenses offer a better alternative to tattooing of corneal scars. However, in developing countries, tattooing of corneal opacities is still performed in rare instances for cosmetic indications. The main problem with corneal tattooing is the fading of colour, ranging from mild to total loss over a period of time.[2] Complications such as toxic reaction, iridocyclitis, persistent corneal epithelial defects and corneal ulceration have been reported following corneal tattooing.[1],[2], A Medline search showed no reports of granulomatous keratitis following corneal tattooing. Here we report a case of granulomatous keratitis and review various other possible aetiologies.

  Case report Top

A 33-year-old male presented with complaints of redness, diminution of vision and white discolouration in his left eye of one week's duration. He had already been treated with topical gentamicin 1.4% one hourly, and atropine 1% eye drops three times daily for one week, but showed no improvement. He had undergone tattooing of the peripheral corneal opacity in the left eye three weeks prior to onset of symptoms. Corneal tattooing had been done by debridement of the corneal epithelium with 70% alcohol followed by application of 2% Gold chloride and 2% Hydrazine hydrate using a multiple stromal puncture technique. The patient developed symptoms two weeks after the corneal tattooing.

On examination, he had a visual acuity of 6/6 in the right eye and 6/36 in the left eye. Slitlamp biomicroscopy of the left eye showed a 4.5 mm x 7.0 mm black tattoo pigment in the inferonasal quadrant of the cornea. This area was surrounded by 2 mm, full thickness, stromal infiltrate with well defined round margin [Figure - 1]. The cornea surrounding the infiltrate showed mild oedema. There were multiple medium size keratic precipitates, aqueous flare 1+ and cells 1+. A presumptive diagnosis of mycotic keratitis was made. The patient was treated with topical natamycin 5% suspension one hourly, ciprofloxacin 0.3% four times a day, cyclopentolate 1% thrice daily and oral fluconazole 150 mg twice daily. Gram stain, wet mount of potassium hydroxide (KOH) and calcofluor staining of the smears from the corneal scrapings revealed no bacterial or fungal pathogen. Cultures from the corneal scrapings did not grow any microorganism. The patient showed no sign of improvement 72 hours after initiating anti-fungal treatment.

In an attempt to identify the pathogenic microrganism, we performed a corneal biopsy and debridement of the entire tattoo pigment. Histopathological examination of the corneal biopsy specimen revealed a dense lymphocytic aggregate, plasma cells and multinucleated giant cells in the corneal stroma surrounding the margin of the tattoo pigment. No fungal hyphae or gram positive/negative bacteria were seen [Figure - 2]

The corneal infiltrate showed resolution within a week of surgical debridement. Six weeks later, the patient developed a vascularised corneal opacity in the involved area. Anti-fungal treatment was gradually tapered. A penetrating keratoplasty was performed 18 months later. Histopathological examination of the recipient corneal button revealed that the epithelium was irregular in thickness and the Bowman's layer was extensively destroyed. The scarred and vascularised stroma was infiltrated by mononuclear inflammatory cells. [Figure - 2]. The inflammatory cells included lymphocytes, plasma cells, few epithelioid cells and multinucleated giant cells [Figures 3][Figure - 4] and were admixed and close to dark pigment granules. Special stains including Zeihl-Neelsen, Gommori methenamine silver, PAS, Brown-Hopps were negative for acid-fast bacilli, fungi and bacteria. Immunohistochemical studies and polymerase chain reaction (PCR) were negative for herpes simplex virus.

The patient maintained a clear corneal graft and a best corrected visual acuity of 6/9 in the left eye at the last follow-up six years after surgery [Figure - 5].

  Discussion Top

Corneal tattooing, though rarely performed these days, is considered a relatively safe procedure. The potential complications include toxic reaction, iridocyclitis and persistent epithelial defects.[1],[2] Infection and corneal ulceration following corneal tattooing are mentioned in the literature though the details are not available.[1] The commonly used technique of corneal tattooing includes the debridement of corneal epithelium with 70% alcohol followed by chemical treatment of the stroma with a metallic solutions such as gold or platinum chloride.[2] This technique can cause injury to the basement membrane which may regenerate poorly, thus producing a condition akin to recurrent erosions.[1] In one study, this complication was reported in 6 of 10 eyes and caused periodic attacks of pain, redness and watering up to one year after the procedure.[2] Recurrent erosions may predispose the patient to secondary infection. Corneal tattooing under a lamellar pocket decreases the incidence of recurrent erosions.

Recently several authors have reviewed the corneal tattooing procedure and safety of staining pigments.[3],[4] Lamellar keratectomy procedures give excellent results.[2] Multiple tangential stromal punctures using a spatula needle of 10.0 nylon suture avoids the problem of making lamellar cornea flaps in an irregular and thin cornea with calcified deposition.[4] Theoretically the technique has two disadvantages, including the multiple lacerations of Bowman's membrane and inciting of phagocytes, which may result in recurrent erosions.[4] However, stromal puncture is an established treatment for recurrent erosions. Safety of corneal tattooing using drawing ink in different shades have been reported as having satisfactory results.[3],[4] Non metallic staining agent has been reported safe and non-toxic on longterm, histological evaluation of specimens up to 61 years after corneal tattooing. Corneal tattooing is safe and gives satisfactory results in disfiguring corneal scars.

In our patient, the presence of corneal stromal infiltrate surrounding the tattoo pigment in a relatively quiet eye was suggestive of fungal keratitis. The results of wet mount KOH preparation, calcofluor staining and cultures were negative for fungal pathogen. Corneal biopsy and histopathological examination of the corneal button demonstrated granulomatous stromal reaction. Nauman et al[5] have reported granulomatous stromal reaction without involvement of endothelium in Mycotic keratitis. However, as we failed to demonstrate a fungal pathogen Mycotic keratitis is unlikely to be a cause of granulomatous keratitis in our patient

Granulomatous reaction in the corneal stroma in relation to Descemet,s membrane is considered pathognomic of Herpes simplex keratitis.[6],[7] A negative polymerase chain reaction (PCR) test excluded the possibility of reactivation of Herpes simplex virus causing granulomatous keratitis in our patient. Herpes simplex keratitis may be confirmed by demonstrating virus particles on electron microscopy, enzyme studies, co-cultures and herpes simplex virus DNA on PCR.[8] Granaulomatous reaction has also been reported in other infections, including fungi, Herpes zoster, syphilis and acanthamoeba.[7],[8] The absence of vesicular eruptions and interstitial keratitis excluded Herpes zoster and syphilis in our patient. The presence of stromal infiltrate and granulomatous reaction surrounding the pigment in the absence of bacterial, fungal and viral pathogens rather suggested the possibility of pigment induced granulomatous keratitis.

Granulomatous keratitis may rarely occur as a complication following corneal tattooing and should be entertained as a possibility in patients who present with ocular inflammation after this procedure.

  References Top

van der Velden, Samderubun EM, Kok JH. Dermatography as a modern treatment for coloring leucoma cornea. Cornea 1994;13:349-53.   Back to cited text no. 1
Panda A, Mohan M, Chaudhary S. Corneal tattooing: Experience with lamellar pocket procedure. Indian J Ophthalmol 1984;34:408-11.  Back to cited text no. 2
Sekundo W, Seifert P, Seitz B, Loeffler KU. Long-term ultrastructural changes in human corneas after tattooing with non-metallic substances. Br J Ophthalmol 1999;83:219-24.   Back to cited text no. 3
Pitz S, Jahn R, Frisch L, Duis A, Pfeiffer N. Corneal Tattooing: An alternative treatment for disfiguring corneal scars. Br J Ophthalmol 2002;86:397-99.  Back to cited text no. 4
Naumann G, Green WR, Zimmerman LE, Mycotic keratitis: A histopathologic study of 73 cases. Am J Ophthalmol 1967;64:366-82.  Back to cited text no. 5
Holbach LM, Font RL, Naumann GOH. Herpes simplex stromal and endothelial keratitis: granulomatous cell reactions at the level of Descemet's membrane, the stroma and Bowman's layer. Ophthalmology 1990;97:722-28.  Back to cited text no. 6
Mietz H, Font RL. Acanthamoeba keratitis with granulomatous reaction involving the stroma and anterior chamber. Arch Ophthalmol 1997;115:259-67.  Back to cited text no. 7
Leisegang TJ. Biology and molecular aspects of herpes simplex and varicella-zoster virus infections. Ophthalmology 1992;99:781-99.  Back to cited text no. 8


  [Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5]

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