Femtosecond Laser Assisted Corneal Tattoo

Keith A. Walter, MD Associate Professor of Ophthalmology

Disclosures

Royalty: Ocular Systems, Inc. Consultant: Abbott Medical Optics; Bausch + Lomb Fees for Non-CME Services: Abbott Medical Optics;

Bausch + Lomb

Intro

Corneal tattoo described first in 1950 Manual with small gauge

needle Similar to stromal puncture but

with titanium dioxide pigment Takes 20-30 minutes or longer Can be painful post-op Pigment tends to fade over

time 80% need to be retreated

Corneal Tattoo Palette

Image shown for educational purposes only

Imagination

Traditional Tattoo

Tamsulosin patient with temporal iris trauma after cataract surgery. Suffered from polyopia

and glare

Traditional Tattoo

Traditional Corneal Tattoo Drawbacks

Although effective it can be painstaking Prolonged effort Painful and inflammatory Pigment fades over time and not solid in blocking

light Difficult to do large areas

Femtoassisted Corneal Tattoo

First reported in blind eye with leukocoria Kymoinis, et al. Cornea 2009 Feb;28(2):211-3

Femtosecond laser allows you to make a custom pocket at any location Ring segment software Partial LASIK flap

Reporting my first four cases.

Case 1

Traumatic cataract Post op sector iridectomy Repaired but still had large “keyhole” Intolerable glare and “ghost images”

Case 1 Pre-op

Procedure Planning

Used Ring segment software Large ring to limbus with 3 mm width and 150

microns deep. Channel in same area Originally thought I could just inject ink into area Worked ok Had to supplement with needle punctures

Post op Case 1

Case 2 – Total Iris

62 y.o. man with history of traumatic aniridia S/P traumatic cataract extraction with pcIOL Complains of intolerable glare and difficulty seeing. Closes eye to drive at night or in bright sun Cosmetic contact lens intolerant

Case 2 Femto Planning

Case 2 post op

Case 3 Sector Iris Loss

39 yo with old paintball injury Traumatic cataract with iris tear at 7 o’clock Complains of edge glare and light sensitivity Closes eye to cope Contact lens intolerant for the last few years

Case 3 pre-op photos

Case 3 Femto preview

Case 3 Post op Day 1

Case 3 Post op Day 1

Case 3 Post op Day 1

Case 3 Slit beam view of pigment layer

Case 4

30 year old high myope Pre-op for ICL at outside location Had two laser iridotomies in each eye Right eye did fine Left eye ended up with horrible glare and polyopia Lid anatomy was atypical

Difficult to see the problem, right?

Case 4 preop

Surgical plan for Case 4

Remarkable improvement with holding finger over that temporal area Prismatic effect of tears? Plan was for partial LASIK flap Abort after cleared area 200 microns deep Wide channel

This time used iris sweep to dissect pocket

Post op Case 4

Hard to see area with lid in normal position

Summary

Excited about promising technique Much easier than with needle/manual Custom design for each patient Possibly improved cosmetic appearance with both

femto and puncture No pain Easy recover Less likely for redo

Surgical Alternatives

Iris Suture (when feasible) Level of difficulty = high Complicated by hemorrhage, iris tears, etc Post-operative risks of infection, glaucoma, etc

Iris prosthesis Level of difficulty = high Difficult to get – FDA restrictions Complicated by hemorrhage, iris tears, etc Post operative risks Expensive Incomplete coverage