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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 2  |  Issue : 1  |  Page : 128-130

Inadvertent globe penetration due to self-attempted eyeball tattooing


1 Department of Intraocular Lens and Cataract Services, Aravind Eye Hospital and Post-Graduate Institute of Ophthalmology, Tamil Nadu, India
2 Department of Cornea and Refractive Services, Aravind Eye Hospital and Post Graduate Institute of Ophthalmology, Tamil Nadu, India
3 Department of Retina and Vitreous Services, Aravind Eye Hospital and Post-Graduate Institute of Ophthalmology, Tamil Nadu, India

Date of Submission25-May-2021
Date of Acceptance16-Aug-2021
Date of Web Publication07-Jan-2022

Correspondence Address:
Dr. Bagavath Shalini
Aravind Eye Hospital and Post-Graduate Institute of Ophthalmology, Coimbatore, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_1402_21

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  Abstract 


Eyeball tattooing or scleral tattooing is a new form of body modification. A 27-year-old Indian male presented with defective vision in the left eye a day after self-attempted eyeball tattooing. The inadvertent penetration and ink injection led to the staining of the cornea, suspension of ink in the aqueous. The lens showed capsular staining and subsequent progression to the cataract. The posterior segment showed staining of vitreous with the red dye, retinal thickening at the macula. The optical coherence tomography showed inner retinal hyperreflectivity with retinal thickening. As these “Do it yourself” maneuvers are becoming trends influenced by social media, we report a case of self-attempted eyeball tattooing and its complications.

Keywords: Eyeball tattooing complications, inadvertent ocular globe penetration, pen ink, scleral tattooing


How to cite this article:
Shalini B, Velayudhan Nair A, Periasamy M, Kumarswamy K, Dsouza PN. Inadvertent globe penetration due to self-attempted eyeball tattooing. Indian J Ophthalmol Case Rep 2022;2:128-30

How to cite this URL:
Shalini B, Velayudhan Nair A, Periasamy M, Kumarswamy K, Dsouza PN. Inadvertent globe penetration due to self-attempted eyeball tattooing. Indian J Ophthalmol Case Rep [serial online] 2022 [cited 2022 Aug 14];2:128-30. Available from: https://www.ijoreports.in/text.asp?2022/2/1/128/334874



Eyeball tattooing also referred to as subconjunctival, episcleral, or scleral tattooing is an emerging trend in extreme body modification. Though similar case reports are common in the western literature, very few cases or hardly any have been reported from our population. This procedure involves injecting a colored dye or tattoo ink into the bulbar conjunctiva and sclera. This procedure is often done by tattoo artists with no formal medical training, surgical instruments, or microscope leading to grave complications including loss of sight.[1]


  Case Report Top


A 27-year-old male presented to us with complaints of defective vision in his left eye (LE) of one day duration. The patient is a tattoo artist who attempted scleral tattooing in both eyes (BE). The patient had attempted the same 6 months ago using red pen ink and a 26-gauge hypodermic needle. He developed a sudden onset of defective vision in the LE and pain in BE after injection.

On examination, the uncorrected visual acuity (UCVA) was 6/12 with no further improvement in the RE and hand movements (HM) in LE. Slit-lamp examination revealed lid edema, subconjunctival hemorrhage (SCH) with interspersed red ink. The cornea showed a greenish hue with an epithelial defect. The anterior chamber showed ink suspended in the aqueous with dilated non-reacting pupils [Figure 1]a and [Figure 1]b. The lens showed a red capsular hue with cataractous change [Figure 1]c, [Figure 1]d. The fundus examination showed red-tinged vitreous, retinal thickening at macula [Figure 2]a. The optical coherence tomography (Spectralis; HRA, Heidelberg, Germany) of the LE showed retinal hyperreflectivity with thickening [Figure 3]. An ultrasound B-scan showed a few vitreous opacities in the vitreous cavity. The RE showed patchy SCH and red ink in all the quadrants. The rest of the anterior and posterior segment was within normal limits (WNL) [Figure 4].
Figure 1: (a) Diffuse illumination anterior segment image of the left eye, subconjunctival red ink, greenish hue of the cornea, and anterior chamber. Eyebrow scar of piercing (arrowhead). Diffuse illumination nasal subconjunctival hemorrhage with adjacent red ink staining (b). Diffuse illumination (down gaze) superior bulbar subconjunctival red ink dye and hemorrhage (c). Slit-lamp view of the anterior segment showing greenish hue of aqueous, capsular staining, and cataractous change in the lens (d)

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Figure 2: (a) Normal fundus photograph of the right eye. Fundus photo of the left eye, dye within vitreous cavity and disc hazily visualized (b)

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Figure 3: Swept-source optical coherence tomography (SD-OCT) B-scan at presentation, showing inner retinal hyperreflectivity with the thickening of the macula in the left eye (a) Normal SSOCT of the right eye (b)

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Figure 4: (a and b) Diffuse illumination anterior segment image of the right eye showing patchy areas of subconjunctival red ink and hemorrhage in the temporal and nasal bulbar conjunctiva. Diffuse illumination (downgaze) patchy subconjunctival hemorrhage with adjacent red ink staining on the attempted tattooing of the superior subconjunctival space (c) Diffuse illumination (upgaze) inferior patchy subconjunctival hemorrhage, clear cornea, and anterior chamber (d)

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Fundus fluorescein angiography (FFA) was performed, which showed intense leak into the anterior segment. The dye was present within the anterior chamber. Due to a fluorescein leak into the vitreous, angiography was obscured in the LE. The angiography of the RE was WNL.

Oral prednisolone 60 mg once daily (Tab Wysolone, Wyeth Pharmaceuticals, India) was started along with topical 2% homatropine (Homide, Warren Pharmaceuticals Pvt. Ltd, India) in the LE and an antibiotic ointment (Ocupol, Centaur Pharmaceuticals, Mumbai) in both eyes and was advised close follow-up.

Upon review the next day, the LE corneal epithelial defect had healed. The deeper layers showed a greenish hue, and the rest of the anterior segment remained the same. The patient was recommended to have cataract surgery as well as a media clearing vitrectomy. The patient refused surgical intervention. Conservative management was continued after counseling possible poor visual outcome of delayed surgical intervention. LE topical prednisolone acetate 1% eye drops (Predmet Eye Drops, Sun Pharmaceuticals, India) 2-hourly added and a close follow-up was suggested.

On his next review a week later, BE showed resolving SCH. The LE cornea and anterior segment were clear with dilated pupil, lens red capsular hue resolved with progression to near mature cataract (NMC). The patient declined cataract surgery and a subsequent pars plana vitrectomy. His topical and systemic steroids were tapered.

On his final follow-up visit a week later, uncorrected visual acuity (UCVA) in RE was 6/9 and LE was HM. The LE showed resolving SCH, clear cornea. The anterior chamber was clear with a dilated pupil and NMC. The RE anterior and posterior segments were WNL. The intraocular pressure was 20 mm of Hg in BE. Despite medical advice and parental counseling, the patient was opposed to any surgical intervention. He refused further treatment and was lost to further follow-up.


  Discussion Top


Eyeball tattooing is a form of extreme body modification. Since it was first reported in 2007 in Body Modification Ezine, eyeball tattooing has gained popularity in several countries.[2] Only a few cases have been reported in the literature to date, with the majority occurring in North and Latin American countries. Tattoo ink, fabric paint, and gel pen ink are just a few of the compounds that have been used for eyeball tattooing.[3] The methods used range from an ink-coated oscillating needle to hypodermic insulin syringes. When inadvertent globe penetration occurs, serious complications occur in the majority of the cases. Less serious side effects occur because of hypersensitivity reactions and chemical toxicity toward the dye and solvents. Tubek et al.[4] classify eyeball tattoo complications into two types: procedure-related and ink-related.

When a tattoo needle or device penetrates the globe, a serious complication occurs. Traumatic cataract, vitreous and subretinal hemorrhage, retinal detachment, and endophthalmitis are all possible complications.

Complications from ink are caused by inflammatory reactions and the toxicity of the ink particle and chemicals. When exposed to these compounds, they can trigger an immediate response comparable to the toxic anterior segment syndrome. Endothelial and trabecular damage, pigmentation and atrophy of the iris, capsular staining, and cataract formation are all signs of ocular penetration and dye deposition within the anterior segment.

In the absence of globe penetration, a delayed response is also seen as granulomatous uveitis and secondary glaucoma.[5] Similar cases of iridocyclitis and panuveitis have been reported by Ostheimer et al.[6] after skin tattooing. A sarcoidosis-like reaction has also been reported as a systemic effect of dermal tattooing. Chronic inflammatory reactions to the dye can also result in scleromalacia and carcinoma. The previous case reports have also shown ink component migration into the eyelid, implying that dye migration through the intact sclera to the suprachoroidal space and aqueous outflow tract is possible.[7] The tattoo ink contains metal residue because metals such as copper can cause severe ocular inflammation. It is critical to remove intraocular ink residues promptly to avoid further complications. The tattoo ink analysis revealed a significant amount of titanium, copper, chromium, and cobalt in the inks white, blue-green, green, and blue.[8]

This case exemplifies the body modification ideology prevalent among the younger generation. The influence of social media and the ease with which information can be obtained from it encourage untrained individuals to attempt dangerous “do it yourself” procedures.[9] According to media reports, extreme body modification, such as eyeball tattooing, is gaining popularity in India.[10] In the United States, legislation restricting tattooing around the eye is in place in some states.[11]


  Conclusion Top


Scleral tattooing is a social media influenced trend being attempted by untrained individuals. We wish to draw the attention of ophthalmologist to the serious complications and long-term morbidity associated with ocular tattooing.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Brodie J, El Galhud H, Bates A. A case of episcleral tattooing--an emerging body modification trend. BMC Ophthalmol 2015;15:95.  Back to cited text no. 1
    
2.
Larratt S. Three blind mice. BME.com2007. Available from: https://news.bme.com/2007/07/02/three-blind-mice/. [Last accessed on 2021 May 20].  Back to cited text no. 2
    
3.
Rohl A, Christopher KL, Ifantides C. Two cases of pen ink scleral tattoos and a brief review of the literature. Am J Ophthalmol Case Rep 2021;21:101015. doi: 10.1016/j.ajoc. 2021.101015.  Back to cited text no. 3
    
4.
Tubek K, Berus T, Leszek R. The girl with the eyeball tattoo-what the ophthalmologist may expect? Case report and a review of literature. Eur J Ophthalmol 2019;29:NP1-4.  Back to cited text no. 4
    
5.
Haq Z, Pasricha N, Bever G, Seitzman G, Stewart JM. Delayed acute granulomatous anterior uveitis after inadvertent intraocular injection of tattoo ink from a scleral tattoo procedure. Ocular Immunol Inflamm 2020;1-3. doi: 10.1080/09273948.2020.1784439.  Back to cited text no. 5
    
6.
Ostheimer TA, Burkholder BM, Leung TG, Butler NJ, Dunn JP, Thorne JE. Tattoo-associated uveitis. Am J Ophthalmol 2014;158:637-43.e1.  Back to cited text no. 6
    
7.
Jenkins KS, Layton CJ. An eye for art? A challenge of ophthalmic body modification. Clin Exp Ophthalmol 2016;44:741.  Back to cited text no. 7
    
8.
Jalil A, Ivanova T, Bonshek R, Patton N. Unique case of eyeball tattooing leading to ocular penetration and intraocular tattoo pigment deposition. Clin Exp Ophthalmol 2015;43:594-6.  Back to cited text no. 8
    
9.
Ng JY, Ting DSJ, Vaideanu-Collins D, Mudhar HS, Wagner B, Goggin P, et al. Self-tattooing of eyeball with inadvertent corneoscleral perforation: The implication of social media. Eye 2019;33:1672-4.  Back to cited text no. 9
    
10.
Upadhyay N. For his eyes only: Delhi man with tattooed eyeballs on what makes him tick. Hindustan Times 2017. Available from: https://www.hindustantimes.com/india-news/for-his-eyes-only-delhi-man-with-tattooed-eyeballs-on-what-makes-him-tick/story-Z0lzpoaKVOYm7didRRieYL.html [Last accessed on 2021 May 20].  Back to cited text no. 10
    
11.
Cruz NFS da, Santos KS, Farah M de L, Felberg S. Conjunctival tattoo with inadvertent globe penetration and associated complications. Cornea 2017;36:625-7.  Back to cited text no. 11
    


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



 

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