Scleral Tattooing: Rare, But Dangerous Form of Body Modification

Using the outcomes of 2 cases of scleral tattooing with insulin needles and pen ink, and a literature review of previously reported cases, investigators found that those who undergo these risky body modifications should receive a thorough evaluation with dilated fundus exam because of potential globe penetration, according to a study published in American Journal of Ophthalmology Case Reports.

“We caution patients against the practice of scleral tattooing due to the very real danger of permanent blindness or loss of eye and advise patients to seek medical attention immediately for any adverse events,” the report says.

The cases presented — both men who received improvised scleral tattoos with gel pen ink administered with insulin needles — had minimal complications and were managed with topical medications. They appeared to have no long-term effects from scleral tattoos (also called episcleral, subconjunctival, or eyeball tattooing). These cases are unique, novel, and the first report of pen ink scleral tattoos in the literature, according to the investigators. They show that ink scleral tattoos evolve quickly when compared with other tattoo methods “with the ability to clear the ink from the subconjunctival space.” 

Both men were living in incarceration at the time they received the tattoos. Investigators report that, though tattooing in prisons in the United States and other countries is prohibited, about 45% of inmates receive tattoos during incarceration (but that rate might be decreasing). These 2 cases also reflect a relatively new (first reported in 2007) form of extreme body modification. So investigators conducted a search of the literature to learn more about management and outcomes of such cases and found 14.

“From our literature review, 10 out of 14 (71%) cases previously reported were complicated by inadvertent globe puncture, and these cases had more serious visual consequences,” the study says. “Especially if ink was injected while inside the eye.”

In cases without globe puncture, the researchers noted less serious side effects that are likely related to hypersensitivity of the conjunctiva to the ink itself. These include irritation and conjunctival chemosis as in our cases and others, as well as episcleral nodules. They are likely secondary to “known iron, barium, copper, or titanium dioxide pigments in tattoo ink or other associated components of the ink formulation,” the study explains.

Other issues that could occur with traditional tattoo inks injected into the anterior chamber or vitreous include uveitis, corneal endothelial failure, secondary glaucoma, retinal detachments, infection, and loss of the eye.

“Evidenced by our cases and others, uncomplicated scleral tattooing can be treated conservatively with various topical medications, but every patient should be thoroughly evaluated with a dilated fundus exam due to risk of inadvertent globe penetration. Insight into the long-term complications of scleral tattooing remains to be seen, and even seemingly uncomplicated tattooing may have long-term consequences. One of the more concerning consequences of scleral tattooing could be the masking of underlying ocular surface malignancy, though this has not yet been reported,” the study says.

Reference

Rohl A, Christopher KL, Ifantides C. Two cases of pen ink scleral tattoos and a brief review of the literature. Am J Ophthalmol Case Rep. 2021;21(3);101015. doi:10.1016/j.ajoc.2021.101015.