Complications of ocular tattooing: a Canadian case series

Abstract

Body modification is the practice of deliberate alterations to the human body, such as tattoos, piercings, and scarification, to achieve self-expression or control over one's body. 1 The "body modification movement" has seen an increasingly popular practice of tattooing the eye. Typically, ink is injected into the subconjunctival space with pigmentation of the episclera and/or sclera. This has resulted in complications ranging from conjunctival edema and nodules 2 to more serious complications such as orbital cellulitis, 3 scleritis, panuveitis, 4 and secondary glaucoma. 5 Here we present 3 Canadian cases of ocular tattooing resulting in complications ranging from scleral laceration and serious corneal and anterior segment injury to endophthalmitis requiring enucleation. These cases reinforce the need for specific legislature surrounding ocular tattooing in Canadian provinces. A 39-year-old female (case 1) presented with severe left eye pain after allowing her partner (case 2) to attempt scleral tattooing at home using tattoo ink ordered from an online source (StarBrite, Somers, Conn). They did not have access to topical anaesthetics and used a 31-gauge insulin needle to perform the tattoo. She was otherwise healthy and did not take any ocular or systemic medications. On examination, her visual acuity was 6/6 in both eyes, with intraocular pressures of 18 mm Hg in the right eye and 13 mm Hg in the left eye. Slit-lamp examination revealed a shallow left anterior chamber and a Seidel-positive puncture wound temporally, where there was blue tattoo dye staining. Dilated fundoscopic examination findings were within normal limits bilaterally without any obvious evidence of intraocular penetration of tattoo dye in the left eye. To allow a complete examination and closure of the apparent wound, she was taken to the operating room. Despite an extensive exploration, a leaking scleral puncture wound was not found. The conjunctiva was closed in a watertight closure technique with 9-0 Vicryl. Postoperatively, her anterior chamber deepened, and her temporal sclera was Seidel-negative. An epithelial defect required a temporary bandage contact lens. She recovered well in the next week but was subsequently lost to follow-up. A 41-year-old male (case 2) presented with vision loss in his right eye after inadvertent globe penetration and intraocular injection of blue tattoo ink (StarBrite) during selfadministration of the dye. After watching a YouTube video, the patient attempted to tattoo his lateral right sclera. Increased force had been applied to the plunger to clear an obstruction, which resulted in the needle penetrating his eye. He injected approximately 1 mL of blue tattoo ink into his eye. On examination, his uncorrected visual acuity was light perception in the right eye and 6/6 in the left eye. Intraocular pressures were 44 and 12 mm Hg in the right and left eyes, respectively. Slit-lamp examination of the right eye revealed blue tattoo dye filling the anterior chamber (Fig. 1A) and evidence of inferotemporal needle penet...

Two cases of pen ink scleral tattoos and a brief review of the literature

“…Traditional tattoo inks, when inadvertently injected inside the anterior chamber or vitreous, can cause devastating injury to the eye and its structures including uveitis, corneal endothelial failure, secondary glaucoma, retinal detachments, infection, and loss of eye. 9 , 11 , 13 , 14 , 15 , 17 , 18 , 19 From our literature review, 10/14 (71%) cases previously reported were complicated by inadvertent globe puncture, and these cases had more serious visual consequences, especially if ink was injected while inside the eye. In cases without globe puncture, less serious side effects tend to occur and are likely related to hypersensitivity of the conjunctiva to the ink itself and include irritation and conjunctival chemosis as in our cases and others, as well as episcleral nodules.…”

“…These range from the less serious surface irritation and conjunctivitis to the more serious uveitis, glaucoma, and endophthalmitis requiring enucleation. 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 A literature review summary of all the previously reported cases of scleral tattooing and their complications are presented in Table 1 . Although this is a relatively new procedure, the dangerous nature of scleral tattooing has already been recognized and specific legislation preventing the procedure is now in place in at least four states including Oklahoma, Nebraska, Indiana, and Georgia (Okla. Stat.…”

“… Loss of eye? Final visual acuity Other Comments Chan et al 9 3 39 F Canada Blue Tattoo Ink (Starbrite) Inadvertent puncture wound without injection of ink Yes - globe exploration No Unknown Recovered well, lost to follow up after 1 week. 41 M Canada Blue Tattoo Ink (Starbrite) Inadvertent puncture and injection of 1 cc of ink into anterior chamber Yes - Anterior chamber washout, tap and inject, pars plana vitrectomy, then pars plana lensectomy and insertion of sulcus lens.…”

Episcleral mass secondary to ocular surface tattooing

“…Ocular tattooing has prompted clinician awareness in recent years due to severe complications resulting in loss of vision 1 . Such cases have been widely publicized in mainstream media due to sensational images and the expected visceral responses of the public.…”

“…Tattooing of the sclera or episclera is a form of body modification performed by tattoo artists, which involve injection of tattoo pigment beneath the bulbar conjunctiva. Complications include episcleral nodules, uveitis, orbital cellulitis and inadvertent globe penetration potentially leading to corneal endothelial decompensation, retinal detachment, glaucoma and endophthalmitis requiring enucleation 1‐4 …”