Text and Atlas on Corneal Pigmentation Jorge L Alio, María Alejandra Amesty, Alejandra Rodríguez, Mohamed El Bahrawy
INDEX
ABCDEFKIKLMNOPSTVWZ
Page numbers followed by f refer to figure
A
Agnew’s needle 4f
set 20f
Alcian blue staining 12f
Ancient Ziegler’s surgical protocol 26
Armaignae’s pupillary ring 5f
B
Biocompatibility to micronized mineral pigments 10
Blue eye of
in experimental 59f
patient, normal 59f
Blue, gray and light brown colors intralamellarly on left half 60f
C
Cataract extraction surgery, complicated 73
Cataract surgery, underwent 101
Cells or neovascularization changes in stroma 11f
Celluloid epicorneal dressing 28f
Chamber phakic intraocular lens, posterior 37f
Cobalt blue 52f
Cobalt blue + light gray + dark gray 52f
Cobalt, stannate of 4
Color tattooing 4
Colors for keratopigmentation in rabbits with MIK technique 53f
Conjunctival chemosis 82
Conjunctival hyperemia 89
Cornea in pigmentation 53f
Cornea on right eye 67f
Cornea stained, section of 50
Corneal and pupillary trephines 21
Corneal calcification of left eye 67f
Corneal micropigmentation, central 56f
Corneal neovascularized opacity 101
Corneal opacity
bilateral 81, 81f
diffuse 71
left 65f
neovascularized 95
Corneal pigmentation 34
Corneal sak, central 56f
Corneal staining, final results after superficial 66f
Corneal stroma, predominant in 13f
Corneal tattoo 28, 34, 65
Corneal tattooing
history of 3
instruments currently used for 21
instruments used for 22f, 30f
Corneal tolerance 10
Cosmetic appearance of both eyes 63f, 65f, 67f, 69f
Cosmetic keratopigmentation 34
Cosmetic of both eyes 85f, 89f
Cosmetic result 100f
final 72f, 80f, 88f, 92f
one month after surgery 64f, 84f
three months after surgery 70f, 76f, 94f, 96f, 98f
Cosmetic therapeutic keratopigmentation 63
Cyclodiode photocoagulation 73, 74
Cytomegalovirus endophthalmitis, bilateral 81
D
Dark granules 8
Dense clusters dominate 12f
Discoloration 70
E
Electric tattooing needle 20
Endophthalmitis 89
Epithelial pupil in different sizes and curve 49f
Eye and band keratopathy of right eye, normal left 63f
Eye and corneal calcification on right eye, normal left 69f
Eye and right eye corneal opacity, slit-lamp examination of left normal 71f
Eye endophthalmitis, left 83
Eye of patient, reproduction of 59
Eye retinal detachment, right 63
Eye spike injury, right 99
Eye trauma, right 71
Eye traumatic cataract, left 75
F
Fading of color 68
Fading of previous pigmentation 65
Femtosecond-assisted intrastromal keratopigmentation 32
Femtosecond-assisted keratopigmentation 22, 30, 91, 101
technique 93, 95, 99
K
Helicoidal corneal dissectors 49f
Hematoxylin-eosin staining 41, 42f, 58f
in sample pigmented with blue 42f
I
Immunohistochemical staining with anticollagen 13f
Inferotemporal grayish black trace 70
Inks sterilization 26
Intralamellar corneal staining 14f, 21
technique 32f
Intralamellar keratopigmentation, manual 50, 50f, 59, 77, 79
Intralamellar, protocol for 28
Intralase for FAK 23f
femtosecond-assisted keratopigmentation 23f
Intraocular lens (IOL) 101
Intrastromal keratopigmentation 28
manual 84
technique 29f, 31
manual 77
Intrastromal micropigmentation 58f
Intrastromal technique of corneal dissector 57f
Intrastromal tunnel 29
Iris 64
appearance reconstruction and pupil simulation 15f
atrophy, partial 15f
blue color of simulated 75
color tones and required pigments 8
defect secondary to epithelial iris cyst in right eye 36f
defect with manual intralamellar keratopigmentation, restoration of 37
simulation, helicoidal corneal dissector for 49f
simulation, sectoral 15f
K
Keratocyte with several intracellular tattoo particles 40f
Keratocytes with larger nuclei 11f
Keratopathy, band 63, 67
Keratopigmentation 1, 11f, 26, 36, 47, 49
examination after second 74f
final results after 102f
for functional 35
history of 3
in rabbits physiological colors 57
in rabbits, manual intralamellar 53
instruments required for 20
instruments tray for 49f
instruments used for 20
on right eye, and normal examination on left eye 70f
surgery, postoperative result after third 74f
surgery, second 80, 101
surgical 26
instruments for 49
techniques 30
therapeutic 34
tools and materials used for 5
L
Left eye
and opacified right eye, normal 89f
preoperative appearance of 15f
Leukocyte common antigen 44
immunostaining 43, 44f
Light absorbing layer 33f
Light granules 8
Light-colored layer matches color of contralateral eye, superficial 23
Light-colored to match color of other eye 33f
Limbal pigmentation, lack of adequate 73
M
Magnification 400x, original 56f
Manual intralamellar keratopigmentation
in cadaver pig eyes 50
technique in rabbits 54f
with black pigment in
central simulating pupil 53f
peripheral simulating half inferior iris 53f
Manual intrastromal keratopigmentation 30, 31
Masson’s trichrome stain 12f, 13f, 41, 43f
Megalophthalmos 69
Metallic and nonmetallic pigments 7
Metallic tattoo 8
Micronized mineral pigments 10
in rabbits 17
Midstromal tattoo pigment particles hematoxylin and eosin staining 39f
Mild lymphocytic infiltrate present in stroma 11f
Mineral pigments 13
micronized 8
Monocular diplopia at night 37f
Morphometric analysis 42
Multicolor tattooing of the cornea 4
Myopia, high 63
N
Needles in experimental cadaver eyes, depth test with different 51f
Needles used for tattooing, ancient 20
New Zealand albino rabbit eye before keratopigmentation 57f
O
Ocular examination 65f, 67f, 69f
Optic reasons: our experience 35
Optical coherence tomography high-resolution corneal image of eye 36f
P
Palette of colors 5
Paralimbal pigmentation 86
Peripheral corneal SAK (iris simulation) 56f
Pigment composition 8
Pigment deposits on IOL on left 102f
Pigment granules of different electronic densities, middle stromal keratocyte with 41f
Pigment injection 29
Pigment, color of 7
Pigment, localization of 7
Pigmented rabbit eyes after
enucleation 54f
three months 58f
Pigments palette 5f
Pigments selection 7
color 26
Pigments to avoid 7
Pigments, chemical composition of 7
Porcelain mortar 26f
Postoperative results clear cornea on
left eye after superficial keratopigmentation 68f
right eye after superficial keratopigmentation 68f
Postoperative results cosmetic
appearance eyes of both eyes 72f
appearance of both eyes 70f, 98f
of both eyes 64f, 76f, 80f, 86f, 88f, 92f, 94f, 100f, 102f
and keratopigmentation pattern detailed 73f
of right eye 77f
Postoperative results slit-lamp
biomicroscopy after keratopigmentation 88f
biomicroscopy of keratopigmentation pattern 77f
examination 80f
after keratopigmentation 10f, 76f, 92f, 100f
of pigmented eye 72f
view after keratopigmentation 67
Prophylaxis, antibiotics 29
Pseudophakic 67
Ptosis surgery simultaneously 79
Pupil 64
Pupil + corneal limbus 52f
Pupil + corneal limbus + iris 52f
Pupil corneal dissectors 49f
for pupil simulation, curve 49f
Pupil simulation 56f
Pupillary distortion, two years after first keratopigmentation 74f
Retinal detachment 75
Retroillumination indicates atrophic iris 85
S
Slit-lamp biomicroscope of essential iris atrophy 35f
Slit-lamp biomicroscopy 85f, 89f
cosmetic appearance of both eyes 81f
Slit-lamp examination, pre- and postoperative 17f
Speculums 49f
Squint surgery, history of 77
Sterilization 7
Strabismus surgery 98
Subepithelial keratocyte with pigment particles agglomerations 40f
Superficial and femtosecond-assisted keratopigmentation techniques 97
Superficial automated keratopigmentation 24, 24f, 30, 59, 63
in pig cadaver eyes 51
Superficial corneal staining 22, 30
Superficial keratopigmentation 68, 85
technique 31, 64, 75
Superficial pigmentation 71
T
Tattooing pupil 27f
Taylor’s bundle of needles 20f
Taylor’s needle 4f
Toothed curets 21
Trauma, history of 65
V
Visual disability symptoms 77
Visual function symptoms 23
W
Wecker’s needle 3f
Wecker’s single-grooved needle 20f
Z
Ziegler’s fixation ring and Nieden’s fountain pen 5f, 21f, 27f
Ziegler’s limbal fixation ring 21
Ziegler’s operative technique
fourth stage 28
second stage 27
third stage 28
×
Chapter Notes

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1TEXT AND ATLAS ON CORNEAL PIGMENTATION2
3TEXT AND ATLAS ON CORNEAL PIGMENTATION
Editor Jorge L Alió MD PhD Professor and Chairman Department of Ophthalmology Miguel Hernandez University, Medical School President, Vissum Corporation Alicante Spain Associate Editors María Alejandra Amesty MD Adnexal Fellow Moorfields Eye Hospital City Road London UK Alejandra Rodríguez MSc Senior Biologist/Microbiologist Research, Development and Innovation (RDI) Department VISSUM Corporation Alicante Spain Mohamed El Bahrawy MD Senior Clinical Research Fellow Vissum-Instituto Oftalmologico Miguel Hernandez University Alicante Spain
This work has been supported in part by a grant from the Spanish Ministry of Science and Innovation, Centro para el Desarrollo Tecnológico Industrial (CDTI), CENIT: “Customized Eye Care”, CeyeC (CEN-20091021)
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Text and Atlas on Corneal Pigmentation
First Edition: 2015
9789351529064
Printed at
5Dedicated to
Our patients, who gave us the motive
to develop and innovate in the art and science of keratopigmentation.
Knowing that, we may contribute even in a small way to improve their quality of life
through giving them a better cosmetic appearance, a higher quality of vision or
simply increasing their self-esteem with a desired eye color.
6
7
Contributors
8
Preface
9 Even though it is true that since Galen’s time pigmentation has been known, it is not until recently that keratopigmentation has become feasible with new tools, new pigments, and especially new knowledge about corneal behavior and tolerance to these pigments. The book tries to gather together all the scientific information available on this topic to offer ophthalmologists and in particular corneal surgeons, the possibility of using this technique for many patients who will benefit from its cosmetic therapeutic applications (leukomas and blind eyes, phthisical eyes with deformations as an alternative to evisceration and prosthesis), functional therapeutic applications (aniridic patients, colobomas, traumatic iris losses) or even purely cosmetic applications (changing the color of the eye on a voluntary basis). All these applications are possible and are presented in the book in a scientific way.
We have now 10 years of experience in keratopigmentation since we did the first case. We have always been attracted by the idea of avoiding losing the anatomies of young people affected by trauma and with cosmetically unacceptable appearances. Cosmetics is important today, just as it has always been, but in our modern environment, a cosmetic defect in the eye is unacceptable and limits the quality of life of many patients. Based on this idea, we have developed a systematic approach over the last 10 years in the field, creating and building up science on a topic that has always been empirical. So far, nobody has reported such a systematic approach, and we hope that we have done so adequately for the purpose of dissemination of this technique.
The clinical atlas will show clearly the evolution of this technique in our hands over the years and how perfect the outcomes are today with the adequate techniques and selected pigments. In the experimental atlas, we describe the methods that we have been using for the purpose of these investigations and indeed the outstanding knowledge that is obtained from the experimental model that we have used.
The reader will find in experimental atlas the evolution of the technique and also the very important changes that happen with very different or similar pigments when they are used at the surface or intrastromally inside the cornea.
The experimental use of pigments has taught us a lot about the performance and the optimal use of the pigments and also how the quality and character of their composition should be. It is the experimental model, where we have learnt and tested the secondary effects and the potential toxicity of the pigments as demonstrated in the reports that we have published.
We are sure that the readers will find the experimental part a tremendously interesting topic as from the experimental animal model to the human use keratopigmentation has reached maturity nowadays by using the adequate pigments and the adequate techniques.
Clinical atlas of keratopigmentation cases offer the readers the real facts and possibilities that corneal pigmentation may give our patients for therapeutic, cosmetic functional or purely cosmetic purposes. The cases have been selected from the many ones we have to indicate the evolution of the procedure. The initial cases performed by us show more variability in colors, while all cases have proven to be effective and stable depending on the quality of the colors used.
Corneal pigmentation is to be approached by adequate pigments and instruments. The pigments are essential as some metals and micronized pigments might induce chemical reactions with opacities and neovascularization. Adequately selected pigments do behave excellently over time and are stable.
10The readers will enjoy these clinical cases as most of them have been selected for therapeutic purposes while some of them are really truly cosmetic and open a new perspective on the use of pigments to change the apparent color of the eye.
In Appendices, we demonstrate the presentations about keratopigmentation in different congresses and conferences since 2008, also some of the papers, we published about the methodology and outcomes of our keratopigmentation experience in world class peer-reviewed journals, such as Journal of Cataract and Refractive Surgery and Cornea journal.
Also, a screenshot of our updated website: www.coloreyetattoo.com, is a great tool for both patient and professional education.
Keratopigmentation was an art and is now an art and a science. We hope that all our colleagues who read the book will find useful advice and convenient descriptions of this technique for the benefit of their patients.
Instructive surgical videos are available on our official website: www.coloreyetattoo.com .
Jorge L Alió
María Alejandra Amesty
Alejandra Rodríguez
Mohamed El Bahrawy
11 Acknowledgments
In more than a decade of developments in the field of keratopigmentation, our team has cooperated with many scientists and enterprises, to ensure that highest levels of quality and safety in terms of surgical techniques and pigments, we would like to acknowledge the efforts of Dr Bader Toffaha; former Clinical Research Fellow, VISSUM-Instituto Oftalmologico de Alicante, for his investigative contributions through our team, which was utilized through a number of publications and congress presentations. We acknowledge the clinical efforts and expertise of Dr Sabat K Abu-Mostafa, Ahmadi Hospital, Kuwait. Finally, due thanks to the team of Epsilon, Irvine, California, as their professional and state-of-the-art technology was the reason for the development of the successive generation of surgical tools used in keratopigmentation procedures.
Cover art is inspired as inspired by Secuencia—By Javier Montalt, Miradas Collection 2010, Fundacion Jorge Alió and La mirada al interior—By Cristina Ferrández Box, Miradas Collection 2004, Fundacion Jorge Alió.