Month: March 2015

Bulbar Conjunctival Tattooing

Q:

Dear KeraNet Members,

A 17 year old patient came into my office yesterday with her mother after having bulbar conjunctival tattooing done to both eyes four days ago with purple ink.  Pictures below.

There is one entry point in each quadrant where the “body sculpting artist” dipped a needle into ink and irrigated saline under the conjunctiva.  The left inferotemporal quadrant has 3 entry points.  There is no conjunctival defect presently.  The right cornea has a crystalline appearance in the epithelium and anterior to mid stroma.  Pannus 360 degrees OU with purple pigment up to the limbus.
Patient says it was previously very chemotic but is getting better now.  However, she regrets her decision and wants it reversed.  Any tips and recommendations?  Many thanks.
Tenley
A by Doctor Chynn:
man some people are totally nuts!:)

fortunately, he didn’t really tattoo anything, just injected colored saline between the conj and sclera
i guess you could try irrigating saline into that space, but after 4 days i doubt you would be able to get much pigment out
i would try that as you probably should at least try something, but consent her that the utility might be pretty low by now, if she came to you a day afterwards that would probably help
and then just reassure her that the body’s immune cells will chew up the pigment over time, but that will probably take months to fade out (hopefully not years like would be necessary if he actually went into the sclera)
you could also give her some mild topical steroid (eg lotemax) to help reduce the allergic reaction to the dye
good luck, and please give me follow-up in a month as to what transpires, as i am doing corneal tatooing myself, so would like to know how long it takes for the dye to resorb
thanks for sharing

 

Rx of Granular Corneal Dystrophy in the USA in 2015

Q by Doctor Randy:

Dear All, 

I have not seen the patient yet, but was called by a colleague who wanted to refer a 55 year old patient with the above to me for “corneal laser treatment”. I asked of the patient had any ocular surface disease/recurrent erosions, and was told that the only problem was decreased acuity form the opacities themselves. No irregular astigmatism, no cataracts. 

How would those of you advise those of us who only have access to “USA technology” to proceed to treat such a patient? 

Thanks,
Randy
A by doctor Will:
Randy, 
    I have performed PTK on a handful of Granular Dystrophy patients who were experiencing reduced vision  The problem in Granular Dystrophy is that the opacities are breaking through the anterior stromal surface.  Removing the epithelium reveals a highly irregular surface 
    The goal with PTK is to just smooth out the surface, not eliminate opacities. 
    After smoothing out the stromal surface with PTK – patients will note  improved vision – both on Snellen testing as well as report improved quality of vision 
    Following the PTK – There will be plenty of opacities remaining.   
    Overall – the PTK procedure should be a very superficial treatment.  I have had one patient require a repeat PTK 6-7 years after the first treatment – and I expect that the PTK lasts for 5-10 years, depending on the patient.  So focusing as much on corneal smoothing while preserving as much corneal tissue is key, in my opinion. 

I hope this helps
Bill
Answer by Emil Chynn, MD:
When we treat granular dystrophy or scars, as long as there’s a significant refractive error, we try to treat that, too. Then the issue always arises re if abnormal tissue ablates at a faster or slower rate than normal cornea stroma
We (meaning myself and the various doctors who’ve worked with me) have concluded this is impossible to predict. So then we just shoot our normal nomogram. And have been pleasantly surprised that our refractive outcomes have come out close to plano
Regarding differential ablation rates and leaving bumps and lumps, if you employ a PRK nomogram and ablation profile, as long as your scars are mostly central and superficial, you wind up shaving off a substantial amount of the opacities. I’ve used many different agents to mask, and now there are dozens of tears out with varying viscosities. Unfortunately the predictability of outcomes when using any masking agent is lower than if you don’t use one.
Luckily as many of us have pointed out the epithelium can cover and mask a huge amount of surface irregularity. Therefore after myopic ablation, since you’re creating a “top hat” profile afterwards, it seems like the epithelium is more able to cover up the residual pathology than the original pathology, because the epithelium is going to try to recreate a more normal “dome” shape. There’s also epithelial hyperplasia, which can be encouraged with topical NSAIDs. So these are two often-ignored factors that contribute significantly to a smoother front refractive surface after PRK of opacities, even without using a masking agent in an attempt to differentially and preferably ablate scars or dystrophic deposits over normal stroma

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