When Beauty Burns: Bilateral Thermal Keratopathy After Intense Pulsed Light Over Cosmetic Periocular Tattoos'

To report bilateral thermal keratopathy following intense pulsed light (IPL) therapy performed in the presence of periocular cosmetic tattoos, resulting in prolonged ocular surface dysfunction and significant symptomatic morbidity despite recovery of visual acuity.

Tertiary ophthalmology referral centre (Western Eye Hospital, London) managing severe ocular complications after IPL performed privately abroad for menopausal dry eye treatment.

A 48-year-old woman with blepharitis,   dry eyes and prior LASIK underwent IPL in June 2024 for menopausal dry eye symptoms. She had periocular cosmetic tattoos. Within days, she developed bilateral epithelial breakdown and marked ocular surface inflammation consistent with thermal keratopathy.

Tattoo pigment acts as a potent exogenous chromophore, absorbing IPL energy and converting it to heat. In the thin periocular tissues, this amplified thermal effect likely conducted to the cornea, precipitating epithelial failure in an already vulnerable ocular surface.

Initial management included oral acyclovir (for suspected HSK), topical dexamethasone 0.1%, and moxifloxacin 0.5%. Persistent epithelial defects necessitated emergency bilateral amniotic membrane grafting in August 2024. She subsequently developed prolonged epithelial defects (up to 2×3 mm), keratic precipitates, and anterior chamber inflammation; corneal scrapes were negative.

Treatment required intensive topical antibiotics, preservative-free steroids, ciclosporin, high-frequency autologous serum, topical losartan (sourced abroad), and aggressive lubrication. Epithelial healing was achieved by November 2024.

At presentation, visual acuity was 6/24 (PH) right eye and 6/12 (PH) left eye. At latest review, acuity improved to 6/7.5 (corrected) right eye and 6/5 (PH) left eye. Despite visual recovery, she continues to experience persistent dryness, ocular discomfort, glare, and a substantial long-term treatment burden.

Periocular tattoo pigment can amplify IPL energy through pigment-mediated thermal absorption, creating risk of corneal injury. Patients with pre-existing ocular surface disease or prior refractive surgery may be particularly susceptible. This case

demonstrates that even when vision recovers, prolonged symptomatic morbidity and intensive therapy may follow. Rigorous pre-treatment screening for cosmetic tattoos and appropriate ocular protection are essential to prevent avoidable sight-threatening complications.