Corneal melt following corneal tattooing with carbon-based i
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A 67-year-old woman presented with a chief complaint of a corneal opacity on the right eye. The past medical history is unremarkable. The patient sustained a hacking injury to the right eye when she was 3 years. However, due to financial constraints, she did not seek medical advice. The injured eye eventually lost useful vision, with note of a white opacity on the cornea. The patient consulted because she was desirous of cosmesis.

The eye had a visual acuity of no light perception. Slit lamp biomicroscopy showed no conjunctival inflammation, a dense scar with band keratopathy and lipid keratopathy occupying the entire cornea with some areas of corneal neovascularization, shown in Fig. 1A. The anterior chamber could not be assessed due to the corneal opacity. The intraocular pressure was 19 mmHg. Ocular ultrasound showed an unremarkable posterior segment. The patient underwent corneal tattooing of the right eye with a carbon-based ink. Standard aseptic technique which included lid scrubbing and instillation of 5% povidone iodine solution in the conjunctival cul-de-sac was done preoperatively. Multiple intrastromal injections of carbon-based ink was done with each injection creating small pockets of ink within the stroma. The injections were repeated until most of the opacity was tattooed. A total of 0.23 mL of ink was injected. After the procedure, the patient was started on moxifloxacin and prednisolone acetate eye drops. On the first day postoperatively, examination showed a tattooed cornea with multiple areas of epithelial defects, consistent with the injection sites, as shown in Fig. 1B. There was minimal conjunctival congestion and no signs of infection. On the seventh day postoperatively, there was complete re-epithelialization of the cornea. The initial postoperative course was unremarkable.

On the eighth week postoperatively, the patient started noting eye pain on the tattooed eye described as a sharp needle-like sensation. Over the next few days, she noted protrusion of a brown-colored material from the area of the tattoo. Examination showed corneal melt with uveal prolapse, as shown in Fig. 1C. There were no signs of infection such as discharge, corneal infiltrates, or abscesses. Culture of tissue obtained from corneal scraping of the peripheral intact cornea showed no growth of organisms. The patient underwent evisceration of the right eye.

The excised cornea was sent for histopathologic examination. The specimen consisted of a hyperpigmented corneal button measuring 8.5 × 10 × 3.0 mm in size. Microscopic examination showed no identifiable epithelium and Bowman layer. The stroma was edematous with infiltration of polymorphonuclear leukocytes, lymphocytes, and macrophages. The Descemet membrane and endothelium were disorganized and infolded posteriorly with some adherent uveal tissue posteriorly. The culture of the corneal button showed no growth of bacterial nor fungal elements.