TATTOOING OF PENETRATING KERATOPLASTY

While penetrating keratoplasty (PK) remains the gold standard for corneal replacement, it may not always restore adequate cosmetic appearance when combined with residual corneal scarring or iris abnormalities. This video demonstrates a novel combined surgical approach of performing corneal tattooing (keratopigmentation) simultaneously in a 30-year-old penetrating keratoplasty with some scars due to previous herpetic keratitis to achieve optimal cosmetic rehabilitation in eyes with disfiguring corneal pathology.

Tertiary referral center and University Hospital, Sussex Eye Hospital, University Hospitals Sussex NHS Foundation Trust, Brighton, UK

An 85-year-old patient with a chronic history of herpetic keratitis and a penetrating keratoplasty (PK) had ongoing symptoms of disconcerting binocular visual disturbance with or without glasses due to scarred PK in the right eye. His right eye had pseudophakia with a previous YAG laser capsulotomy. His unaided vision in the right eye was 6/24 which improved to 6/18 with pinhole. His left eye,which was pseudophakic had a vision of 6/6 with glasses. He was not willing to try rigid gas permeable contact lens or undergo a repeat penetrating keratoplasty. A 2-week right eye patching exercise relieved his symptoms. Therefore, he was listed for tattooing of the PK under local anesthesia. The video presents a stepwise approach to combining penetrating keratoplasty with corneal tattooing using a modified lamellar pocket technique. Postoperative management included topical antibiotics, corticosteroids, and careful monitoring for complications, including infection, inflammation, pigment migration, or corneal epithelial defects. Follow-up examinations assessed cosmetic outcome, patient satisfaction, and structural integrity of the graft.​

Therapeutic corneal tattooing in old scarred PK represents a safe and effective approach for occluding vision and providing symptomatic relief from disconcerting visual disturbances binocularly. The lamellar pocket technique provides several advantages, including more homogeneous pigment distribution, reduced risk of recurrent corneal erosions compared to superficial techniques, and longer-lasting cosmetic results. 

Key surgical pearls include meticulous lamellar pocket dissection to appropriate depth in old scarred PK without disrupting the graft-host junction, careful painting in the lamellar pocket, and comprehensive patient counseling regarding realistic expectations, including potential pigment fading over time. This technique offers a cost-effective alternative to more complex reconstructive procedures or ocular prostheses, particularly valuable in resource-limited settings. The combined procedure significantly improved patient self-esteem, social functioning, and overall quality of life while preserving globe integrity.​