Over the past 10 years, an increasing number of studies have been conducted on the topic of keratopigmentation, that is, the induced cosmetic pigmentation change in the cornea.
This cosmetic change can be done for therapeutic purposes (eg, for corneal leukomas and blind and disfigured eyes, as well as cases with traumatic aniridia or other problems that affect the eye’s quality of vision).
The topic has been extensively studied and covered in a series of papers that have demonstrated that such techniques are effective, feasible, and very useful for patients.1-16
Following this, the purely cosmetic application of this technique has offered the possibility to change the apparent color of the eye on a voluntary basis. This is purely an aesthetic application that has been obviously disruptive and controversial. My colleagues and I first described this technique,7 and it has been practiced in Europe by a few surgeons on a continual but selective basis. The biotolerance and local toxicity of the pigments used in keratopigmentation have been the subject of extensive experimental studies.2,6,8 In Figure 1, we display the instruments used in the modern keratopigmentation surgical technique.
FIGURE 3. Superficial Keratopigmentation (Images courtesy of Jorge L. Alió, MD, PhD, FEBOphth)
Therapeutic keratopigmentation is indeed a new and relevant type of corneal surgery; however, it is still not in general use, essentially because of the insufficient development of pigments specifically for corneal use. Patients with disfigured corneas and blind eyes, and patients who prefer not to go through the trauma associated with evisceration and enucleation and their potential complications, find this new type of surgery can prove to be a very valuable alternative that can successfully restore their appearance in a less invasive manner.1,10
The pigment may be placed inside the corneal stroma when the superficial cornea is transparent (intrastromal keratopigmentation); (Figure 2). With totally opaque corneas, the technique should be performed by applying the pigment on the corneal surface (superficialkeratopigmentation)9,11; (Figure 3), either manually or using an automatic device (Figure 4). In superficial keratopigmentation, the pigment is injected into the superficial corneal stroma up to the level of 140 mm, after denuding the corneal epithelium (Figure 3).
Superficial leucomas are treated with superficial techniques, whereas deep opacities, aniridias, and other problems that happen in a patient’s eye are better treated by intralamellar techniques.4,5 Surgical instruments and techniques have also been described in detail in other publications.15 (Figures 1 and 4).
When the superficial corneal stroma is transparent, the intrastromal pigmentation technique can be better used. For this purpose, corneal stromal tunnels are created, assisted by femtosecond laser at the adequate corneal depth,4,5 which also creates a dissection to simulate the pupil at an adequate diameter (Figure 2).
Such corneal tunnels may also be created manually using adequately designed instruments (Figures 1 and 2).
The pigment is matched to the color of the contralateral normal eye, whereas the pupil is simulated with black pigment (Figure 5).
The main limitation of this technique is the availability of pigments, which are, as of the writing of this article, limited to a few colors and labeled for corneal use with the CE mark. The use of dermatological pigments probably could be acceptable, but the lack of negative effects has not yet been demonstrated on the normal or diseased cornea, as the pigments are made of compounds that are often reactive when in contact with light; thus, oxidation may occur. This can lead to a change in the color over time and might make outcomes of this surgery unpredictable.
Frequently, severely compromised and blind eyes are associated with other disfiguring features such as squint and ptosis, which can also be successfully corrected at the same time as the keratopigmentation procedure is performed. A high level of patient satisfaction has been reported with the use of such combined surgical techniques12 (Figure 6).
FIGURE 5. Manual Intrastromal Keratopigmentation and Pupil Simulation With Superficial Automated Keratopigmentation. Total corneal leucoma (left) and result after treatment with femtosecond- assisted intrastromal keratopigmentation and superficial automated keratopigmentation for the pupil (right).
FIGURE 6. Keratopigmentation With Strabismus Surgery. Preoperative appearance before keratopigmentation and squint surgery (top) and postoperative result (right). (Images courtesy of Jorge L. Alió, MD, PhD, FEBOphth)
Functional disabilities are caused by iris problems such as aniridia, iris atrophy and iris colobomas.3-5 Some of these cases, whichither have no solution or require extensive and invasive surgeries, may be approached today with intrastromal keratopigmentation. Even intractable diplopias can be solved with keratopigmentation creating a central scotoma through the creation of a simulated pupil of adequate diameter.15,16
Controversial topic
The purely cosmetic use of keratopigmentation is disruptive and controversial because of the voluntary change of color of the eye that intrinsically has this problem. The procedure is elective, can be performed inadequately, and can lead to complications in normal eyes. With respect to this fact, findings from a recent study13 demonstrated that keratopigmentation is, undoubtedly, the best option available for those individuals who wish to change the apparent color of the eye on a voluntary basis. It demonstrates superior safety to and better outcomes than the alternative approaches using iris color prosthesis or laser iris depigmentation procedures, which are affected by myriad severe complications that can lead to severe visual loss and even blindness.14 In particular, the use of prosthetic colored irises should be considered today as a medical malpractice procedure because of the proven severe comorbidities that have been demonstrated to be induced by their implantation in the medium and long terms.
Emerging surgical technique
With this in mind, it should be considered that this emerging surgical technique of keratopigmentation has been refined with the modern development of specific surgical instruments. These include femtosecond lasers and the modern development of pigments. However, the corneal pigments used are considered underdeveloped owing to the main limitation of this technique to be used in general.
Thus, this technique is open to future developments that will be extremely attractive for ophthalmologists, corneal specialists, and cosmetic surgeons. It will also be attractive for patients affected by morbidities that affect the cosmetics of their eyes due to disfiguring corneal leukomas. The procedure will also appeal to patients who desire to change their appearance through the color of their eyes, which should be done for good reason and with appropriate selection by their surgeons.
A new corneal surgical perspective is now available with a good level of published evidence in support. I envision a promising future that will follow this group of new surgical techniques. This topic will probably progress immensely in the coming years along with the increase in clinician experience and the development of more appropriate, specific, and diverse corneal pigments.
Alió is professor and chairman of ophthalmology at Miguel Hernández University, and founder of Vissum Miranza in Alicante, Spain.
References:
1. Alio JL, Sirerol B, Walewska-Szafran A, Miranda M. Corneal tattooing (keratopigmentation) with new mineral micronised pigments to restore cosmetic appearance 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 management of visual disabilities of the eye related 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 functional and cosmetic restoration in essential 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 technique in the management 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 change the apparent color 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 study. 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 using micronized mineral pigments and a new puncturing device: experimental study. 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: complications and outcomes in a series 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 alternative solution for patients 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 combined with strabismus surgery to restore 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. Cosmetic keratopigmentation in sighted eyes: medium- and long-term clinical evaluation. Cornea. 2021;40(3):327-333. doi:10.1097/ICO.0000000000002417
14. D’Oria F, Abu-Mustafa SK, Alio JL. Cosmetic change of the apparent color of the eye: a review on surgical alternatives, outcomes and complications. 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. Text 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 treatment in a case of intractable strabismic diplopia (double binocular vision). Binocul Vis Strabismus Q. 2010;25(4):238-242.
The Canadian government says it will donate up to 200,000 vaccine doses to fight the mpox outbreak in Congo and other African countries.
It says the donated doses of Imvamune will come from Canada’s existing supply and will not affect the country’s preparedness for mpox cases in this country.
Minister of Health Mark Holland says the donation “will help to protect those in the most affected regions of Africa and will help prevent further spread of the virus.”
Dr. Madhukar Pai, Canada research chair in epidemiology and global health, says although the donation is welcome, it is a very small portion of the estimated 10 million vaccine doses needed to control the outbreak.
Vaccine donations from wealthier countries have only recently started arriving in Africa, almost a month after the World Health Organization declared the mpox outbreak a public health emergency of international concern.
A few days after the declaration in August, Global Affairs Canada announced a contribution of $1 million for mpox surveillance, diagnostic tools, research and community awareness in Africa.
On Thursday, the Africa Centres for Disease Control and Prevention said mpox is still on the rise and that testing rates are “insufficient” across the continent.
Jason Kindrachuk, Canada research chair in emerging viruses at the University of Manitoba, said donating vaccines, in addition to supporting surveillance and diagnostic tests, is “massively important.”
But Kindrachuk, who has worked on the ground in Congo during the epidemic, also said that the international response to the mpox outbreak is “better late than never (but) better never late.”
“It would have been fantastic for us globally to not be in this position by having provided doses a much, much longer time prior than when we are,” he said, noting that the outbreak of clade I mpox in Congo started in early 2023.
Clade II mpox, endemic in regions of West Africa, came to the world’s attention even earlier — in 2022 — as that strain of virus spread to other countries, including Canada.
Two doses are recommended for mpox vaccination, so the donation may only benefit 100,000 people, Pai said.
Pai questioned whether Canada is contributing enough, as the federal government hasn’t said what percentage of its mpox vaccine stockpile it is donating.
“Small donations are simply not going to help end this crisis. We need to show greater solidarity and support,” he said in an email.
“That is the biggest lesson from the COVID-19 pandemic — our collective safety is tied with that of other nations.”
This report by The Canadian Press was first published Sept. 13, 2024.
Canadian Press health coverage receives support through a partnership with the Canadian Medical Association. CP is solely responsible for this content.
HALIFAX – The Nova Scotia government says it could be months before it reveals how many people are on the wait-list for a family doctor.
The head of the province’s health authority told reporters Wednesday that the government won’t release updated data until the 160,000 people who were on the wait-list in June are contacted to verify whether they still need primary care.
Karen Oldfield said Nova Scotia Health is working on validating the primary care wait-list data before posting new numbers, and that work may take a matter of months. The most recent public wait-list figures are from June 1, when 160,234 people, or about 16 per cent of the population, were on it.
“It’s going to take time to make 160,000 calls,” Oldfield said. “We are not talking weeks, we are talking months.”
The interim CEO and president of Nova Scotia Health said people on the list are being asked where they live, whether they still need a family doctor, and to give an update on their health.
A spokesperson with the province’s Health Department says the government and its health authority are “working hard” to turn the wait-list registry into a useful tool, adding that the data will be shared once it is validated.
Nova Scotia’s NDP are calling on Premier Tim Houston to immediately release statistics on how many people are looking for a family doctor. On Tuesday, the NDP introduced a bill that would require the health minister to make the number public every month.
“It is unacceptable for the list to be more than three months out of date,” NDP Leader Claudia Chender said Tuesday.
Chender said releasing this data regularly is vital so Nova Scotians can track the government’s progress on its main 2021 campaign promise: fixing health care.
The number of people in need of a family doctor has more than doubled between the 2021 summer election campaign and June 2024. Since September 2021 about 300 doctors have been added to the provincial health system, the Health Department said.
“We’ll know if Tim Houston is keeping his 2021 election promise to fix health care when Nova Scotians are attached to primary care,” Chender said.
This report by The Canadian Press was first published Sept. 11, 2024.
ST. JOHN’S, N.L. – Newfoundland and Labrador‘s chief medical officer is monitoring the rise of whooping cough infections across the province as cases of the highly contagious disease continue to grow across Canada.
Dr. Janice Fitzgerald says that so far this year, the province has recorded 230 confirmed cases of the vaccine-preventable respiratory tract infection, also known as pertussis.
Late last month, Quebec reported more than 11,000 cases during the same time period, while Ontario counted 470 cases, well above the five-year average of 98. In Quebec, the majority of patients are between the ages of 10 and 14.
Meanwhile, New Brunswick has declared a whooping cough outbreak across the province. A total of 141 cases were reported by last month, exceeding the five-year average of 34.
The disease can lead to severe complications among vulnerable populations including infants, who are at the highest risk of suffering from complications like pneumonia and seizures. Symptoms may start with a runny nose, mild fever and cough, then progress to severe coughing accompanied by a distinctive “whooping” sound during inhalation.
“The public, especially pregnant people and those in close contact with infants, are encouraged to be aware of symptoms related to pertussis and to ensure vaccinations are up to date,” Newfoundland and Labrador’s Health Department said in a statement.
Whooping cough can be treated with antibiotics, but vaccination is the most effective way to control the spread of the disease. As a result, the province has expanded immunization efforts this school year. While booster doses are already offered in Grade 9, the vaccine is now being offered to Grade 8 students as well.
Public health officials say whooping cough is a cyclical disease that increases every two to five or six years.
Meanwhile, New Brunswick’s acting chief medical officer of health expects the current case count to get worse before tapering off.
A rise in whooping cough cases has also been reported in the United States and elsewhere. The Pan American Health Organization issued an alert in July encouraging countries to ramp up their surveillance and vaccination coverage.
This report by The Canadian Press was first published Sept. 10, 2024.
