case report Spektrum Augenheilkd DOI 10.1007/s00717-015-0250-0

Corneal tattoo with dysphotopsia after iridotomy: worth a chance! Christoph Wolfgang Faschinger

Received: 11 December 2014 / Accepted: 8 February 2015 © Springer-Verlag Wien 2015

Summary  We report a 32-year-old, functionally monocular male patient with a plateau-iris configuration with pupillary block on his healthy eye. He developed disturbing dysphotopsia after uneventful superior neodymium:yttrium-aluminium-garnet (Nd:YAG) laser iridotomies. After having discussed several options, we surgically closed that iridotomy that was closer to the lid margin. His dysphotopsia did not improve substantially, so we created a small corneal pocket in front of the other unclosed iridotomy and filled it with black tottoo ink. This immediately relieved the patient’s complaints. Corneal tattooing seems to be a simple, safe, inexpensive, and effective procedure distressing visual side effects after iridotomy.

Möglichkeiten wurde eine der beiden Iridotomien vernäht, die Beschwerden wurden dadurch aber kaum besser. Deshalb entschlossen wir uns zu einer Tätowierung der Hornhaut genau über der offenen Iridotomie. Sofort postoperativ verschwanden die Dysphotopsien und sind bis dato nicht mehr aufgetreten. Die Tätowierung der Hornhaut ist einfach, sicher, kostengünstig, sehr effektiv und sollte bei nicht aufgehörenden Beschwerden auf jeden Fall in Betracht gezogen warden.

Keywords  Dysphotopsia · Iridotomies · Corneal tattoo

Introduction

Schlüsselwörter  Dysphotopsie  · Iridotomien  · Hornhauttattoo

Zusammenfassung  Es wird über einen 32-jährigen Patienten berichtet, der aufgrund einer zentralen, kongenitalen Toxoplasmosenarbe funktionell einäugig war und am einzigen Auge eine Plateauiriskonfiguration mit Pupillarblock zeigte. Nach unkomplizierten Nd:YAG Iridotomien klagte er über sehr störende photische Phänomene. Nach ausgiebiger Diskussion der therapeutischen

Laser peripheral iridotomy is the treatment for pupillary blocks accompanying angle-closure diseases. Besides immediate complications like hyphema or lesions of the corneal endothelium, there can be a postoperative increase in intraocular pressure due to overload of the trabecular meshwork or posterior synechiae can form. In exceptional cases, patients complain of photic phenomena after iridotomy such as halos, glare, ghost images, or lines [1]. The following case describes how a patient could be relieved of his dysphotopsias by a corneal tattoo.

This paper was presented at the meeting organized by AMO “visus & visionen 2014”, Salzburg, Austria, February 8, 2014.

Case report

Mut zum Tattoo der Hornhaut bei Dysphotopsien nach Nd:YAG Iridotomien

Univ.-Prof. Dr. C. W. Faschinger, MD, PhD () Universitäts-Augenklinik der Medizinischen Universität, Auenbruggerplatz 4, 8036 Graz, Austria e-mail: [email protected] Univ.-Prof. Dr. C. W. Faschinger, MD, PhD Eye Department, Medical University Graz, Graz, Austria

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A male patient, born in 1968, was referred to us and complained of pressure pain, haziness, and rainbow effects in his right, and only functional, eye. For 2 years, these symptoms had recurred frequently, especially in the morning. To correct a refraction error of − 3.0  sph with + 4.5 zyl/95, he had worn glasses until he was 17 years old, then for many years a contact lens. From 2008 onward, he

Corneal tattoo with dysphotopsia after iridotomy: worth a chance!  

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had gone back to glasses when he could no longer tolerate the contact lens. He was born with a central toxoplasmosis scar on his left eye. This caused convergent strabismus, which was corrected with two surgeries that left the eyes reasonably parallel. The visual acuity of this eye was limited to hand movements. On the right eye, the cornea (pachymetry 610  mm) and lens were clear. With the aforementioned correction, visual acuity was 20/25. The papilla was well colored with intact neuroretinal tissue without a substantial excavation, but the vascular distribution was somewhat distorted and the macula ectopic. The intraocular pressure was 33  mmHg on the right side and 12 mmHg on the left. Due to the macular ectopia, the blind spot was shifted slightly downward, otherwise there were no abnormalities in the visual field examination. Treatment with latanoprost and timolol (fixed combination, once daily) was begun and achieved pressures below 20 mmHg. Gonioscopy showed an iris with a steep basis. Details like the trabecular meshwork and scleral spur were only visible with indentation. Indentation gonioscopy elicited a double hump sign. The diagnosis was a right-sided plateau iris configuration. The subjective complaints were presumed to be due to intermittent pressure increases with partial obstruction of the chamber angle causing epithelial edema. After receiving appropriate information, the patient consented to Nd:YAG laser iridotomies; these were performed without incident at 10 and 12 o’clock. The next day, the patient complained of scintillation, and a week later, of five vertical bars and one horizontal one that, however, disappeared when the upper lid was drawn down. With certainty, these complaints had not been present before the laser treatment. We explained the reasons for these light phenomena to the patient. On the one hand, the light beam is refracted by the upper prismatic tear meniscus and on the other, the two small openings cause further light-bending or diffraction phenomena. When the patient pulls the upper lid down, the tear meniscus is simply pushed downward and the refracted light beam again falls on intact iris tissue, where it is blocked. We hoped that the patient would suppress these symptoms with time, but, perhaps since he was functionally one-eyed, this did not happen. In spite of a number of consultations, in July 2011, the patient went to court seeking damages. We discussed the following options to solve the problem: 1. Further explanation of the pathophysiology of the pupillary and angular block and the necessity of an iridotomy, whereby the patient should be reassured that the dysphotopsias guarantee that the iridotomy is open. A plateau iris configuration is an exception: in that case, even with an open iridotomy, there can be a pressure increase after mydriasis requiring a subsequent argon laser iridoplasty. This was not the case.

2   Corneal tattoo with dysphotopsia after iridotomy: worth a chance!

Fig. 1  Patient’s own imposition on a standardized drawing of an eye of horizontal and vertical bars he saw when viewing a soccer field and facing a floodlight

2. Lowering of the lid with botulinum toxin. This would, however, have to be repeated and performed on both sides for the sake of symmetry. The patient refused this. 3. Application of the alpha-1 antagonist dapiprazole to partially weaken the sympathetic innervation of the tarsal muscle; this would also slightly narrow the pupil. However, this medication is not on the market in Austria. Once again, for the sake of symmetry, this would have to be applied on both sides. The patient refused this. 4. Surgical lowering of the conjunctiva over both iridotomies. The patient refused this for cosmetic reasons. 5. Enlarging the iridotomies to minimize the diffraction effects. The patient refused this as being too risky. 6. Using an argon laser to shrink the iridotomies. The resulting coagulates could shrink the openings and draw them further to the periphery. But, the patient found this as well to be too risky and refused the treatment. 7. Wearing a colored contact lens [2]. This was tried briefly, but the patient did not tolerate these lenses and had not worn contacts since 2008. But with the contact lens, the dysphotopsias almost disappeared. 8. Suturing one of the two iridotomies. The patient was agreeable to this. He absolutely wanted to have both of them sutured, but we could not agree to this on medical reasons, due to the renewed danger of a pupillary block. In November 2010, after limbal incision, the iridotomy at 11 o’clock was sutured with Prolene 10-0. Postoperatively, the patient complained that his problems were worse in sunlight; the vertical stripes were broader and more intensive but the lower crossbar had become shorter. One month after surgery, it was somewhat better; the stripes were less distinct but still bothersome (Figs.  1 and 2). As there was no further improvement after 1 year, further treatment concepts were discussed.

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case report

Fig. 3  Patient’s right eye 6 months after the peripheral corneal tattoo. Black pigment was applied in a pocket at 12 o’clock. Some pigment forms a sickle shape in the limbal epithelium

Fig. 2  Patient’s own imposition on a standardized drawing of an eye of horizontal and vertical bars he saw indoors when looking toward a window

9. Clear lens extraction with implantation of a capsular ring with iris segment that would be rotated exactly into the area of the coloboma. This was not an option for the patient, who was functionally one-eyed and has no cataract. 10. Tattooing the cornea over the iridotomy. This was acceptable to the patient. We purchased sterilely packaged black ink (Eternal Ink, 3830A Lining Black; Body Cult Tattoo Supply, D-89312 Günzburg, 30  ml for 15.00 €; similar to Gupta D and Broadway D [3]). We applied anesthetic eye drops and beginning limbally used a crescent knife to create a small intrastromal pocket in the middle of the thickness of the cornea (as in Remky et al. [4]), then applied two drops of ink with a cannula. Excess was rinsed off. Immediately after surgery, the patient was free of symptoms. He saw neither horizontal nor vertical bars and was grateful, happy, and relieved. Two years after the iridotomies, he was enjoying his former quality of life. At his last visit (18 months after the tattoo), the artificial pigmentation was unchanged. (Fig. 3).

Discussion In the eighteenth century, iridectomies were usually performed—e.g., by Albrecht von Graefe—for optical reasons in cases of iritis and pupillary occlusion. Soon after Hermann von Helmholtz’s invention of the ophthalmoscope and with the new understanding of glaucoma, Graefe undertook the first iridectomies on eyes that showed no symptoms of iritis, but, unfortunately, were not always successful [5]. What, however, is always corrected by iridectomy is any pupillary block. Since 1920, it has been recognized that the aqueous humor can flow

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through this fistula from the posterior into the anterior chamber [6]. This prevents the peripheral parts of the iris from bulging outward and forming an irido-trabecular contact or synechiae in the area of the chamber angle with subsequent development of angle-closure disease. Surgical iridectomy has generally been replaced by the laser iridotomy (usually with an Nd:YAG laser, seldom with an argon laser) due to the lower incidence of complications with the latter. The technique for the Nd:YAG iridectomy is well known. According to the recommendations of the American Academy of Ophthalmology [7], the site in one of the upper quadrants should be positioned so that the iridotomy is covered by the upper lid. If there is doubt as to the patency of the opening, the iridotomy should be enlarged, or a second one created. Complications include uveitis with posterior synechiae, pressure increase, focal opacity of the cornea and/or lens, and bleeding, along with glare, double vision, halos, and blurred vision. How are the latter visual disorders explained? Phillips et al. [8] mentioned that with exposed iridotomies that are not covered by the upper lid, there can be both spherical aberrations and simultaneous chromatic and diffraction phenomena caused by the small hole, the edge of the lid, and the eyelashes. The tear meniscus along the upper lid also plays a role as a prism [9]. The horizontal line is thought to be due to the interaction of light with the eyelashes [1], but above all to the length of the tear film meniscus along the upper lid [10]. Weintraub and Berke [11] had four patients who all had an iridotomy covered by the eyelid and saw lines that were found to disappear when the lid was drawn away from the eye; this small maneuver disrupted the tear film meniscus. How often do these latter undesired side effects occur? In the first major review of postoperative monocular visual problems, Murphy and Trope [1] found such complications in 11 out of 480 iridotomies (2 %). All of these patients were asymptomatic before the laser treatment but after surgery complained of blurred vision

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and a dark line that was usually horizontal. These symptoms disappeared when the iridotomy was either fully covered or fully exposed. Spaeth et al. [12] compared a group of glaucoma patients after iridotomy (172 eyes) with an age-matched comparison group (178 eyes). Postoperatively, 85 % had no symptoms but the remaining 15 % did. They found, however, that in both groups there were ghost images (11 vs. 3 %), halos (31 vs. 27 %), crescent moons (3 vs. 1 %), blurred vision (17 vs. 30 %), and glare (31 vs. 41 %), but shadows (7 %) and lines (3 %) were only seen after iridotomy. A total of 53 % of the iridotomies were fully covered by the upper lid (8.9 % symptomatic), 24 % were partially covered (26 % symptomatic), and 23 % were fully exposed (17.5 % symptomatic). Chung and Guan [13] described a single case in which a white line appeared in the lower visual field 1 week after an iridotomy at 11 o’clock. The woman managed the problem with dark glasses. Congdon et al. [14] compared 217 patients with upper iridotomies with 250 control patients with respect to glare and visual disturbances. After 18 months later, it was seen that there was no difference with regard to these problems between the control group and patients with completely covered iridotomies (121 patients of whom 6.6 % suffered from glare), partially covered iridotomies (43 patients, 11.6 % glare), and completely exposed iridotomies (53 patients, 9.4 % glare). There was, however, a difference between the extent of the cataract in the two groups that had an influence on these results. Does the position of the iridotomy play a role? Weintraub and Berke [11] published a study on four patients whose iridotomies were completely covered by the upper lid but still caused troublesome dysphotopsias. Vera et al. [10] prospectively studied 167 patients who were randomized to have iridotomies located either at 12 o’clock or temporally. Before the laser treatment, 94 patients (55.6 %) already had dysphotopsias. Linear dysphotopsias, which are relatively specific after iridotomies, occurred in 6.8 % of the eyes, with 10.7 % in the upper and only 2.4 % in the temporal position. The upper, symptomatic iridotomies were either partially or completely covered by the upper lid. The probability of developing linear dysphotopsias was 3.6 times greater with the iridotomy in the upper rather than the temporal position. With partially or completely covered iridotomies, the probability of linear dysphotopsias was four times greater than for those that were completely exposed. This led the authors to conclude that the temporal position is ideal for an iridotomy. This is because the light entering through this opening falls on the area of the posterior pole and owing to the longer path (in comparison with the shorter path from an upper iridotomy to the upper periphery of the fundus) is diffuse and so is not found to be disturbing. As enumerated earlier in the text, one of the many ways to correct dysphotopsias is tattooing of the cornea. For hundreds of years, artificial pigmentation of the cornea has been used to create a “pupil” for blind eyes for cosmetic reasons, as well as to treat traumatic and dysgenetic iris defects or after peripheral iridectomy [15]. Islam et al.

4   Corneal tattoo with dysphotopsia after iridotomy: worth a chance!

[9] used platinum chloride and hydrazine hydrate, and Segal et al. [16] successfully used black pigment mixed with balanced salt solution to treat symptomatic iridotomies in a few patients. Tattooing was found to be effective with artificial iris defects in eyes of cornea banks [17]. In summary, the prevalence of dysphotopsias after iridotomy is unknown and the number of unreported cases is probably high; the incidence of linear dysphotopsias is 6.8 %. All in all, tattooing of the cornea in the area of the iris coloboma is a safe, very simple, inexpensive, and effective procedure to relieve these unpleasant symptoms. What we have learned from this case: ●● Basically, a single iridotomy suffices. A second one should be created only when the first one is not definitely open and cannot be opened with certainty or expanded. ●● If an upper iridotomy is planned, it should be in the 12 o’clock position. In any case, the area should be avoided where the edge of the lid cuts the periphery of the cornea as a secant (usually at 10 and 2 o’clock). When a patient has a larger lid fissure, a temporal iridotomy might be better. Vera et al. [10] showed in a prospective comparison with superior iridotomies that new-onset linear dysphotopsia was reported in only 4 (2.4 %) out of 169 patients in temporal iridotomies vs. in 18 (10.7 %) with superior iridotomies. Conflict of interest  The author did not receive any financial support from any public or private sources. The author has no financial or proprietary interest in a product, method, or material described herein.

References   1. Murphy PH, Trope GE. Monocular blurring. A complication of YAG Laser iridotomy. Ophthalmology. 1991;98:1539–42.   2. Fresco BB, Trope GR. Opaque contact lenses for YAG Laser iridotomy occlusion. Optom Vis Sci. 1992;69:656–7.   3. Gupta D, Broadway D. Cost-effective tattooing: the use of sterile ink for corneal tattooing after complicated peripheral iridotomies: an alternative to expensive salts. J Glaucoma. 2010;19:566–7.   4. Remky A, Redbrake C, Wenzel M. Intrastromal corneal tattooing for iris defects. J Cat Refract Surg. 1998;24:1285–6.   5. Remky H. Albrecht von Graefe. Facets of his work. On the occasion of the 125th anniversary of his death (20 July 1870). Graefe’s Arch Clin Exp Ophthalmol. 1995;233:537–48.   6. Curran EJ. A new operation for glaucoma involving a new principle in the etiology and treatment of chronic primary glaucoma. Arch Ophthalmol. 1920;49:695–716.  7. American Academy of Ophthalmology. Laser peripheral iridotomy for pupillary-block glaucoma. Ophthalmology. 1994;101:1749–58.   8. Phillips RL, Campbell MCW, Flanagan JG, Trope GE. Optical explanation of visual blur with partially exposed iridotomies. Invest Ophthalmol Vis Res. 1991;32(Suppl):1210 (Abstract).

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case report   9. Islam N, Franks WA. Therapeutic corneal tattoo following peripheral iridotomy complication. Eye. 2006;20:389–90. 10. Vera V, Naqi A, Belovay GW, et al. Dysphotopsia after temporal versus superior Laser peripheral iridotomy: a prospective randomized paired eye trial. Am J Ophthalmol. 2014;157:929–35. 11. Weintraub J, Berke SJ. Blurring after iridotomy (letter). Ophthalmol. 1992;99:479–80. 12. Spaeth GL, Idowu O, Seligsohn A, et al. The effects of iridotomy size and position on symptoms following laser peripheral iridotomy. J Glaucoma. 2005;14:364–7. 13. Chung RSH, Guan AEK. Unusual visual disturbance following laser peripheral iridotomy for intermittent angle closure glaucoma. Graefe’s Arch Clin Exp Ophthalmol. 2006;244:532–3.

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14. Congdon N, Yan X, Friedman DS, et al. Visual symptoms and retinal straylight after laser peripheral iridotomy: the Zhongshan Angle-Closure Prevention Trial. Ophthalmol. 2012;119:1375–82. 15. Mannis MJ, Eghbali K, Schwab IR. Keratopigmentation: a review of corneal tattooing. Cornea. 1999;18:633–7. 16. Segal L, Choremis J, Mabon M. Intrastromal corneal tattooing for symptomatic iridotomies. Br J Ophthalmol. 2012;96:464–5. 17. Burris TE, Holmes-Higgin DK, Silvestrini TA. Lamellar intrastromal corneal tattoo for treating iris defects (Artificial iris). Cornea. 1998;17:169–73.

Corneal tattoo with dysphotopsia after iridotomy: worth a chance!  

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