A brand new sort of surgical procedure

A brand new sort of surgical procedure

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A brand new sort of surgical procedure

Over the previous 10 years, an rising variety of research have been carried out on the subject of keratopigmentation, that’s, the induced beauty pigmentation change within the cornea.

This beauty change could be completed for therapeutic functions (eg, for corneal leukomas and blind and disfigured eyes, in addition to instances with traumatic aniridia or different issues that have an effect on the attention’s high quality of imaginative and prescient).

The subject has been extensively studied and lined in a sequence of papers which have demonstrated that such methods are efficient, possible, and really helpful for sufferers.1-16

Following this, the purely beauty software of this method has provided the likelihood to vary the obvious shade of the attention on a voluntary foundation. That is purely an aesthetic software that has been clearly disruptive and controversial. My colleagues and I first described this method,7 and it has been practiced in Europe by a number of surgeons on a continuous however selective foundation. The biotolerance and native toxicity of the pigments utilized in keratopigmentation have been the topic of intensive experimental research.2,6,8 In Determine 1, we show the devices used within the trendy keratopigmentation surgical approach.

FIGURE 1. Devices Utilized in Keratopigmentation

FIGURE 2. Femtosecond-Assisted Intrastromal Keratopigmentation

FIGURE 3. Superficial Keratopigmentation (Photos courtesy of Jorge L. Alió, MD, PhD, FEBOphth)

Therapeutic keratopigmentation is certainly a brand new and related sort of corneal surgical procedure; nevertheless, it’s nonetheless not on the whole use, basically due to the inadequate improvement of pigments particularly for corneal use. Sufferers with disfigured corneas and blind eyes, and sufferers preferring to not undergo the trauma related to evisceration and enucleation and their potential issues, discover this new sort of surgical procedure can show to be a really precious different that may efficiently restore their look in a much less invasive method.1,10

The pigment could also be positioned contained in the corneal stroma when the superficial cornea is clear (intrastromal keratopigmentation); (Determine 2). With completely opaque corneas, the approach must be carried out by making use of the pigment on the corneal floor (superficialkeratopigmentation)9,11; (Determine 3), both manually or utilizing an computerized gadget (Determine 4). In superficial keratopigmentation, the pigment is injected into the superficial corneal stroma as much as the extent of 140 mm, after denuding the corneal epithelium (Determine 3).

Superficial leucomas are handled with superficial methods, whereas deep opacities, aniridias, and different issues that occur in a affected person’s eye are higher handled by intralamellar methods.4,5 Surgical devices and methods have additionally been described intimately in different publications.15 (Figures 1 and 4).

When the superficial corneal stroma is clear, the intrastromal pigmentation approach could be higher used. For this goal, corneal stromal tunnels are created, assisted by femtosecond laser on the satisfactory corneal depth,4,5 which additionally creates a dissection to simulate the pupil at an satisfactory diameter (Determine 2).

FIGURE 4. Superficial Automated Keratopigmentation Machine

Such corneal tunnels might also be created manually utilizing adequately designed devices (Figures 1 and a couple of).

The pigment is matched to the colour of the contralateral regular eye, whereas the pupil is simulated with black pigment (Determine 5).

The principle limitation of this method is the supply of pigments, that are, as of the writing of this text, restricted to some colours and labeled for corneal use with the CE mark. Using dermatological pigments most likely may very well be acceptable, however the lack of detrimental results has not but been demonstrated on the traditional or diseased cornea, because the pigments are product of compounds which are typically reactive when involved with mild; thus, oxidation could happen. This could result in a change within the shade over time and would possibly make outcomes of this surgical procedure unpredictable.

Continuously, severely compromised and blind eyes are related to different disfiguring options resembling squint and ptosis, which will also be efficiently corrected concurrently the keratopigmentation process is carried out. A excessive stage of affected person satisfaction has been reported with the usage of such mixed surgical methods12 (Determine 6).

FIGURE 5. Guide Intrastromal Keratopigmentation and Pupil Simulation With Superficial Automated Keratopigmentation. Complete corneal leucoma (left) and consequence after therapy with femtosecond- assisted intrastromal keratopigmentation and superficial automated keratopigmentation for the pupil (proper).

FIGURE 6. Keratopigmentation With Strabismus Surgical procedure. Preoperative look earlier than keratopigmentation and squint surgical procedure (high) and postoperative consequence (proper). (Photos courtesy of Jorge L. Alió, MD, PhD, FEBOphth)

Purposeful disabilities are attributable to iris issues resembling aniridia, iris atrophy and iris colobomas.3-5 A few of these instances, whichither don’t have any answer or require in depth and invasive surgical procedures, could also be approached as we speak with intrastromal keratopigmentation. Even intractable diplopias could be solved with keratopigmentation making a central scotoma by the creation of a simulated pupil of satisfactory diameter.15,16

Controversial subject

The purely beauty use of keratopigmentation is disruptive and controversial due to the voluntary change of shade of the attention that intrinsically has this drawback. The process is elective, could be carried out inadequately, and may result in issues in regular eyes. With respect to this reality, findings from a latest research13 demonstrated that keratopigmentation is, undoubtedly, the best choice out there for these people who want to change the obvious shade of the attention on a voluntary foundation. It demonstrates superior security to and higher outcomes than the choice approaches utilizing iris shade prosthesis or laser iris depigmentation procedures, that are affected by myriad extreme issues that may result in extreme visible loss and even blindness.14 Specifically, the usage of prosthetic coloured irises must be thought-about as we speak as a medical malpractice process due to the confirmed extreme comorbidities which were demonstrated to be induced by their implantation within the medium and lengthy phrases.

Rising surgical approach

With this in thoughts, it must be thought-about that this rising surgical strategy of keratopigmentation has been refined with the fashionable improvement of particular surgical devices. These embody femtosecond lasers and the fashionable improvement of pigments. Nonetheless, the corneal pigments used are thought-about underdeveloped owing to the primary limitation of this method for use on the whole.

Thus, this method is open to future developments that might be extraordinarily enticing for ophthalmologists, corneal specialists, and beauty surgeons. It would even be enticing for sufferers affected by morbidities that have an effect on the cosmetics of their eyes resulting from disfiguring corneal leukomas. The process may also enchantment to sufferers who need to vary their look by the colour of their eyes, which must be completed for good cause and with applicable choice by their surgeons.

A brand new corneal surgical perspective is now out there with a very good stage of revealed proof in assist. I envision a promising future that can observe this group of latest surgical methods. This subject will most likely progress immensely within the coming years together with the rise in clinician expertise and the event of extra applicable, particular, and numerous corneal pigments.

Jorge L. Alió, MD, PhD, FEBOphth
E: [email protected]
Alió is professor and chairman of ophthalmology at Miguel Hernández College, and founding father of Vissum Miranza in Alicante, Spain.
1. Alio JL, Sirerol B, Walewska-Szafran A, Miranda M. Corneal tattooing (keratopigmentation) with new mineral micronised pigments to revive beauty look in severely impaired eyes. Br J Ophthalmol. 2010;94(2):245-249. doi:10.1136/bjo.2008.149435
2. Sirerol B, Walewska-Szafran A, Alio JL, Klonowski P, Rodriguez AE. Tolerance and biocompatibility of micronized black pigment for keratopigmentation simulated pupil reconstruction. Cornea. 2011;30(3):344-350. doi:10.1097/ICO.0b013e3181eae251
3. Alio JL, Rodriguez AE, Toffaha BT. Keratopigmentation (corneal tattooing) for the administration of visible disabilities of the attention associated to iris defects. Br J Ophthalmol. 2011;95(10):1397-1401. doi:10.1136/bjophthalmol-2011-300170
4. Alió JL, Rodriguez AE, Toffaha BT, Piñero DP, Moreno LJ. Femtosecond-assisted keratopigmentation for practical and beauty restoration in important iris atrophy. J Cataract Refract Surg. 2011;37(10):1744-1747. doi:10.1016/j.jcrs.2011.08.003
5. Alio JL, Rodriguez AE, Toffaha BT, El Aswad A. Femtosecond-assisted keratopigmentation double tunnel approach within the administration of a case of Urrets-Zavalia syndrome. Cornea. 2012;31(9):1071-1074. doi:10.1097/ICO.0b013e318243f6b1
6. Amesty MA, Alio JL, Rodriguez AE. Corneal tolerance to micronised mineral pigments for keratopigmentation. Br J Ophthalmol. 2014;98(12):1756-1760. doi:10.1136/bjophthalmol-2014-305611
7. Alió JL, Rodriguez AE, El Bahrawy M, Angelov A, Zein G. Keratopigmentation to vary the obvious shade of the human eye: a novel indication for corneal tattooing. Cornea. 2016;35(4):431-437. doi:10.1097/ICO.0000000000000745
8. Amesty MA, Rodriguez AE, Hernández E, De Miguel MP, Alio JL. Tolerance of micronized mineral pigments for intrastromal keratopigmentation: a histopathology and immunopathology experimental research. Cornea. 2016;35(9):1199-1205. doi:10.1097/ICO.0000000000000900
9. Rodriguez AE, Amesty MA, El Bahrawy M, Rey S, Alio Del Barrio J, Alio JL. Superficial automated keratopigmentation for iris and pupil simulation utilizing micronized mineral pigments and a brand new puncturing gadget: experimental research. Cornea. 2017;36(9):1069-1075. doi:10.1097/ICO.0000000000001249
10. Alio JL, Al-Shymali O, Amesty MA, Rodriguez AE. Keratopigmentation with micronised mineral pigments: issues and outcomes in a sequence of 234 eyes. Br J Ophthalmol. 2018;102(6):742-747. doi:10.1136/bjophthalmol-2017-310591
11. Al-Shymali O, Rodriguez AE, Amesty MA, Alio JL. Superficial keratopigmentation: an alternate answer for sufferers with cosmetically or functionally impaired eyes. Cornea. 2019;38(1):54-61. doi:10.1097/ICO.0000000000001753
12. Balgos JD, Amesty MA, Rodriguez AE, Al-Shymali O, Abumustafa S, Alio JL. Keratopigmentation mixed with strabismus surgical procedure to revive cosmesis in eyes with disabling corneal scarring and squint. Br J Ophthalmol. 2020;104(6):785-789. doi:10.1136/bjophthalmol-2019-314539
13. D’Oria F, Alio JL, Rodriguez AE, Amesty MA, Abu-Mustafa SK. Beauty keratopigmentation in sighted eyes: medium- and long-term scientific analysis. Cornea. 2021;40(3):327-333. doi:10.1097/ICO.0000000000002417
14. D’Oria F, Abu-Mustafa SK, Alio JL. Beauty change of the obvious shade of the attention: a overview on surgical alternate options, outcomes and issues. Ophthalmol Ther. 2022;11(2):465-477. doi:10.1007/s40123-022-00458-2
15. Alio JL, Amesty MA, Rodriguez A, El Bahrawy M, eds. Textual content and Atlas on Corneal Pigmentation. 1st ed. Jaypee Brothers Medical Publishers (P) Ltd; 2015.
16. Laria C, Alió JL, Piñero DN. Intrastromal corneal tattooing as therapy in a case of intractable strabismic diplopia (double binocular imaginative and prescient). Binocul Vis Strabismus Q. 2010;25(4):238-242.