EYE TATTOO AND ITS ADVERSE EVENTS

Abstract
Introduction:

Eye tattoos are permanent cosmetic tattoos that inject ink into various eye areas. The sclera, cornea,
eyelid, and eyebrow tattoos are becoming more popular for cosmetic and medical reasons. This
literature review aims to summarise existing case reports and case series reporting adverse reactions
to eye tattoos.

Method
We conducted a literature search by using the database Pubmed from 2001 and November 2022.
The Boolean operators used in the literature search were ‘OR’ & 'AND'. Only case reports
and case series studies reporting adverse events associated with eye tattoos, as well as
English-language articles with full-text availability, were included.
Result
The most common adverse reaction was granulomatous reaction and sarcoidosis. Other
reactions were vitiligo, Glaucoma, Secondary glaucoma Eye pain, Vision loss, Uveitis,
Conjunctival swelling, Perilimbus pigmentation, Basal cell carcinoma, Hypersensitivity
reaction, Melanopenic hypomelanosis, Verruca Vulgaris, Scleritis, Sub episcleral nodules,
Mycobacterium haemophilum infection, Retinal atrophy, Dermatitis, Conjunctival
pigmentation
Conclusion
Eye tattoos have been linked to a number of complications. Concerns about tattoo issues must
be raised among the general public, tattoo artists, and dermatologists. Its application must be
strictly regulated.
Keywords: Eye tattoo; Corneal tattoo; Scleral tattoo; Eyelid tattoo; Eyebrow tattoo; Adverse
effects; Side effects

1. Introduction
Since ancient times, people have used tattoos as a form of body art. It was occasionally used
as a form of punishment during that time period but mostly it was used to create identities for
various tribes and for beautification. Its function in the present age has a quite distinct
appearance. Tattoos are often used to convey a deep message or to give off threatening
seductive, or attractive looks. Particularly in Western nations, this has grown to be a very
popular trend [1]. In the past, permanent tattoos were made by rubbing soot into the skin and
puncturing it with a sharp tool. Pigmented solids are applied topically in the modern world
after being dispersed in a medium. Advanced tools that penetrate the skin are then used to
implant it into the skin layer. It is typical to see inflammatory reactions in response to tattoos.
This reaction is brought on by rubbing alcohol, needle penetration, and other factors in
addition to the ink pigment [2]. Because of technological advancements, more and more
people are opting for periocular cosmetic augmentation procedures. Micropigmentation,
which is used to apply cosmetics permanently, has reached the public's attention and offers
many benefits, especially for women in their old age. The benefits include time savings (no
daily application required), cost-effectiveness, and avoiding difficult-to-apply makeup due to
poor vision. The dermal surface of the eyelids, brows, cornea, and sclera are tattooed with ink
to create permanent and semi-permanent modifications. It has drastically reduced the daily
cosmetic routine and made it accessible to people with physical impairments. In addition to
aesthetics, it has been successful in treating diseases such as corneal opacities. Despite the
simplicity and aesthetic appeal of eye tattoos, the risks are greater. Eyelid and eyebrow tattoo
complications can be caused by a number of factors, including an allergy to the ink's
chemicals, improper injection technique, or damage to the ocular adnexal tissues or ocular
surface. The causes of these problems can vary. Ocular tattoos could potentially cause
permanent damage to the eyes. In extreme cases, irreversible vision loss may occur [3]. It is
believed that any adverse effects associated with eye tattoos are due to the variable chemical
composition of tattoo ink. Tattoo inks contain organic azo colorants and primary aromatic
amines (PAA), which are thought to have carcinogenic properties [4]. Metals, organic
colours, and solvents are possible components of ink. Despite being banned from
composition in the USA, cinnabar is still a component of red inks. Titanium dioxide is found
in blue ink [5]. Granulomatous response and sarcoidosis were reported to be the most
frequent adverse reactions related to eye cosmetics. Other side effects included vitiligo,
glaucoma, and secondary glaucoma, eye pain, vision impairment, uveitis, conjunctival
swelling, perilimbus pigmentation, basal cell cancer, hypersensitivity reaction, melanopenic
hypomelanosis, verruca vulgaris, scleritis, sub episcleral nodules, mycobacterium
haemophilum infection, retinal atrophy, dermatitis, and conjunctival pigmentation.
It has become vital to educate the public, tattoo artists, and dermatologists about the negative
effects of eye tattoos and the need for their application to be strictly regulated because of the
increase in demand for these cosmetic operations.

2. Categories of eye tattoo

2.1 Eyelid tattoo
The process of blepharopigmentation is also known as eyelid tattoo. It involves injecting
colour into the dermis layer along the lash line on either the upper or lower eyelid, or both,
most frequently to mimic the appearance of eyeliner. In order to make the eyes appear fuller,
this has been a common practice over time. This procedure has gained popularity as it
provides a convenient makeup look for working women, female athletes, and women with
physical disabilities [6]. Tattoo ink particles stay in the dermis of the eyelid for a while. Some
granules unavoidably migrate to the lymph nodes, where they will trigger an immediate
foreign body response. Blepharopigmentation has become more common, but it has also been
linked to an increase in reported cases of problems like infection, eyelash loss, and scarring
[7].
2.2 Eyebrow tattoo
Eyebrow tattooing is a form of augmentation that can be done for both cosmetic goals and to
correct hair development irregularities. Micro-pigmentation, micro-blading, ombre powder
fill, and micro-shading are a few techniques that are used for eyebrow tattoos.
Hypersensitivity reactions to ink components could cause inflammation and allergic
reactions, or an infection could occur, both of which are serious complications that could
arise from this technique [8].
2.3 Scleral tattoo
Depending on where it is located, a sclera tattoo may be referred to as an episcleral,
subconjunctival, or eyeball tattoo. Scleral tattooing is the practice of inserting a needle into
the episcleral layer of the eye, typically for aesthetic reasons. Aestheticians and doctors are
the ones that do this surgery. Extreme measures to improve the body's appearance are often
accompanied by equally extreme risks. Eye discomfort, uveitis, glaucoma, and conjunctivitis
are some of the more prevalent side effects [9].
2.4 Corneal tattoo
To perform a corneal tattoo, ink pigments are injected directly into the corneal stroma. It has
found use in both the medicinal and beauty industries. Corneal tattooing has lost some of its
relevance due to advancements in corneal transplantation techniques. This technique still has
utility in circumstances where the recipient's immune system rejects the corneal transplant.
Some cases of visual impairment, semi-translucent scars, and visual glare may also benefit
from its use [10].
3. Method
A literature search was conducted by using the reliable scientific database Pubmed. The
Boolean operators used in the literature search were ‘OR’ and 'AND'. The search was done
for literature published between the duration of 2001 and November 2022. The filters of case
reports and free text were applied. The keywords used were eye tattoo, corneal tattoo, scleral
tattoo, eyebrow tattoo, eyelid tattoo, adverse effects, and side effects. Inclusion criteria were
articles available in the English language, full text, case reports and case series showing
relevance to adverse events associated with eye tattoos were considered for the study.
 Identification

Additional records identified

Records identified
through other sources (n=0)
through database
searching (n= 511)

Records after duplicated removed (n= 373)

Screening

Records screened (n= 138) Records excluded by title and

abstract (n= 63)

Full text articles assessed for Full- text article excluded (n=36)
Not eye tattoo (8)
eligibility (n= 75)
Not adverse event (14)
Not case report or case series (3)
Not English (2)
Full text unavailable (9)

Included
Studies included in this
systemic review (n=39)
Table 1. Eye tattoo-related adverse events from various literature
Author (Year) Study Sample size Type of tattoo Suspected ingredient/ Adverse Events
Design cause
Country (Ref) Patient(s) Description

Paulo et al. (2018) CR 29-year old male Scleral tattoo Needle penetration Glaucoma
Colombia [11]
Chan et al. (2019) CS 39-year-old female Scleral tattoo NM Eye pain
[12]
41-year-old male Needle penetration Vision loss

24-year-old male Needle penetration Vision loss

Haq et al. (2019) CR 47-year-old male Scleral tattoo Needle penetration Uveitis
USA [13]
Brodie et al. (2015) CR 43-year-old male Scleral tattoo Needle penetration Conjunctival swelling
UK [14]
Kojima (2005) CR 45-year-old female Eyelid tattoo Needle penetration Meibomian Gland Disease
Japan [15]
Rohl et al. (2021) CR 20-year-old male Scleral tattoo Black ink Allergic contact conjunctivitis
USA [9]
20-year-old male Black ink Conjunctivochalasis
Cruz et al. (2017) CR 25-year old women Intraocular tattoo Black ink Secondary glaucoma
Brazil [16]
Tubek et al. (2019) CR 21-year-old female Eyeball tattoo Black ink Secondary glaucoma
Poland [17]
Moshirfar et al. (2009) CR 54-year-old woman Eyelid tattoo Black ink Perilimbus pigmentation
USA [18]
Valbuena et al. CS 55-year-old female Eyebrow tattoo Black ink Sarcoidosis
(2017)
Colombia [19]
20- year-old male Sarcoidosis
Sharma et al. CR 33-year-old male Corneal tattoo Black ink Granulomatous keratitis
India [20]
De et al. (2008) CR 46-year-old female Eyelid tattoo Black ink Conjunctival pigmentation
USA [21]
Bombonato et al. CR 38-year-old female Eyebrow tattoo Black ink Granulomatous reaction
(2015)
Italy [22]
Liao et al. (2013) CR 67-year-old female Eyelid tattoo Black ink Melanopenic hypomelanosis
[23]
Nemer et al. (2019) CR 66-year-old female Eyebrow tattoo Black ink Verruca Vulgaris
USA [24]
Vera et al. (2018) CR 50-year-old female Eyebrow tattoo Black ink Sarcoidosis
Venezuela [25]
Han et al. (2020) CR 48-year-old female Eyebrow tattoo Black ink Basal cell carcinoma
Korea [26]
Calzado et. al. (2008) CR 58-year-old female Eyelid tattoo Black ink Granulomatous dermatitis
Spain [27]
Cruz (2017) CR 28-year-old male Conjunctival tattoo Blue ink Ocular pain, conjunctival edema and
anterior uveitis
Brazil [28]
Jalil et al. (2015) CR 49-year-old male Eyeball tattoo Blue ink and Copper Hypersensitivity reaction
UK [29]
Rodríguez-Avila et. CR 32-year-old male Conjunctival tattoo Red ink Hypersensitivity reaction
al. (2019)
Mexico [30]
Duarte et al. (2017) CS 26-year-old male Case1: Eyeball NM Scleritis
tattoo
Mexico [31]
17-year-old male Orange ink Sub episcleral nodules
Case2: Eyeball
tattoo
Tukenmez et al. CR 34-year-old female Eyebrow tattoo Dark brown ink Granulomatous reaction
(2016)
Turkey [32]
Martín et al. (2007) CR 61-year-old female Eyebrow tattoo Brownish-black ink Granulomatous reaction
Spain [33]
Wollina et al. (2014) CS 84-year-old female Eyelid tattoo Tattoo ink Hyperpigmentation
Germany [34]
56-year-old female Eyebrow tattoo Hyperpigmentation
Morrison et al. (2016) CR 59-year-old female Eyelid tattoo Tattoo ink Meibomian gland disease
Canada [35]
Bee et al. (2014) CR 68-year-old female Eyelid tattoo Tattoo ink Granuloma
USA [36]
Hinojosa et al. (2017) CR 52-year-old female Eyebrow tattoo Tattoo ink Sarcoidosis
USA & Mexico [37]
Wollina et al.(2011) CS 26-year-old female Eyebrow tattoo Tattoo ink Granulomatous reaction
[38]

47-year-old female Eyebrow tattoo NM Mycobacterium haemophilum

infection

Pan et al.(2011) CR 29-year-old female Eyebrow tattoo Tattoo ink Vitiligo

China [39]
Cronin et al. (2012) CR 45-year-old female Corneal tattoo Tattoo ink Retinal atrophy
USA [40]
Quint et al. (2012) CR 28-year-old female Eyebrow tattoo Tattoo ink Granulomatous reaction
Netherlands [41]
Antonovich et al. CR 41-year-old female Eyebrow tattoo Tattoo ink Sarcoidosis
(2005)
USA [42]
Vagefi et al. (2006) CS 60-year-old female Eyelid tattoo Tattoo ink Granulomatous reaction
USA [43]
59-year-old female NM Granulomatous reaction

39-year-old female NM Granulomatous reaction

53-year-old man NM Granulomatous reaction

Korsaga et al. (2012) CR 16-year-old female Eyebrow tattoo PPD Vitiligo

Burkina Faso [44]
Miguel et al. (2014) CR 42-year-old female Eyebrow tattoo NM Granulomatous reaction
Spain [45]
Motoki et al. (2020) CR 50-year old Eyebrow tattoo NM Dermatitis
Brazil [46]
Ebrahimiadib et al. CR 46-year-old female Eyebrow tattoo NM Granulomatous reaction
(2021)
Iran [47]
49-year-old female NM Sarcoidosis
Wang et al. (2018) CR 62-year-old female Eyebrow tattoo NM Granulomatous reaction
China [48]

Ng et al. (2019) CR 34-year-old male Corneal tattoo NM Anterior uveitis

UK [49]
4. Complication of eye tattoo

Needle injury
In order to get a scleral tattoo, a needle is used to inject ink beneath the conjunctival bulbar.
These are carried out by inexperienced people who lack medical knowledge. Due to the
perforating tattoo needles, this may result in injury. It also causes eye infections, hypopyon,
glaucoma, and uveitis in addition to harming the ocular structure [13] [14]. It's been shown
that metal residues in tattoo ink make post-needle injury consequences worse. Tattoo
pigments frequently contain chromium, copper, and cobalt to create a variety of colour tones.
Hypopyon is caused by copper [11]. According to W. Chan et al., copper in scleral tattoos
can result in uveitis and the death of ganglion cells. Titanium dioxide nanoparticles induce
corneal endothelium to leak more and produce superoxide, which when combined with
copper results in severe inflammation and corneal oedema. Another instance involved ocular
irritation and blurred vision that was attributed to A. faecalis contamination of tattoo ink or
needles. A puncturing needle trauma also resulted in damage to the eye lens [12]. The inferior
temporal cortex of the eye may have been punctured, according to a case study by Z. Haq et
al. In addition to endophthalmitis and retinal detachment, this resulted in vision impairment.
A delayed granulomatous uveitis condition also affected the patient [13]. The injection sites
may cause lumps to develop and the conjunctiva to enlarge [14]. Dry eye syndrome linked to
eyelid tattoos may eventually result in meibomian gland dropout and unstable tear films. This
occurs as a result of the meibomian glands' high sensitivity to inflammation, which is a
frequent side effect of the incorrect blepharopigmentation method [15] [35].
Black ink
Micropigmentation technique is involved in permanent makeup using ink, commonly black
ink [34]. The majority of adverse effects are observed in the case of red and black inks
containing poly and azo dyes [34] [11] [30]. The nanoparticles found in black ink react with
water and produce reactive oxygen moieties which lead to inflammatory reactions. Age is not
a contributing factor but in certain cases, adverse effects can be aggravated due to facial
aging [34]. The subconjunctival injecting of black ink might lead to swelling and
discoloration of the eyelid as well as eye drainage. Allergic contact with black ink is found to
cause subconjunctival haemorrhage, hyperpigmentation, and inflammatory reactions. A
serious consequence associated with conjunctival pigmentation is the inability to detect any
underlying symptom such as corneal malignancy. Even vision loss may result from a globe
penetration infection [9]. N. F. Cruz et al. presented a case of vision loss following
conjunctival tattooing. The black deposits lead to hypopyon, anterior uveitis, and conjunctival
oedema. The cause of these manifestations is the infiltration of black ink in conjunctival
tissues leading to its collagenisation. This might turn into severe complications such as
capsular opacification and secondary glaucoma [16]. There have been other incidences of
secondary glaucoma and severe eye discomfort where the patient lost their vision while
having their eyeball tattooed. This occurred as a result of decreased intraocular pressure and
visual acuity caused by black ink depositions on the trabecular meshwork [17]. After corneal
tattooing, ink infiltration can induce granulomatous keratitis. Keratin depositions and ocular
edema were seen in the cornea. The condition was caused by a granulomatous reaction to
black ink deposition [20]. Adverse effects associated with eyelid tattoos by black ink include
misplacement of ink, hypersensitivity reactions, hyperpigmentation, eyelash loss, and ocular
injury [48] [21] [23]. An author reported a case of unintended pigmentation of limbus as a
complication of blepharopigmentation. The black ink had migrated to the limbus and
superficial cornea leading to their unwanted pigmentation but no inflammatory reaction was
accompanied [18]. Another incident of unintentional conjunctival staining during
blepharopigmentation has been documented, in which the needle completely pierced the
eyelid. There was erythema and swelling of both eyelids [21]. Eyelid tattoos have been linked
to complications such as skin-coloured bumps and vitiligo-like hypopigmentation. This might
be due to black ink debris surrounded by immune cells causing severe inflammatory reactions
and a decrease in melanocyte count. It is suspected that certain components of black ink
inhibited melanin synthesis [23]. Another complication associated with the use of black ink
for blepharopigmentation is granulomatous dermatitis with swelling along the eyelid. The
suspected cause of this condition is a delayed hypersensitivity reaction to the black pigment
[27]. Clinical studies revealed that common side effects of using black ink in the case of
eyebrow tattoos include sarcoidosis, granulomatous responses, and eyebrow loss [19] [22]
[25]. Eyebrow tattoo-associated sarcoidosis may involve the progressive growth of pruritic
lesions. The mechanism of the sarcoidal granulomatous reactions is still unknown [19] [25].
Other than the sarcoidal granulomatous reactions, foreign-body granulomatous reactions have
also been found as a reaction towards black ink components. Eyebrow tattoos have been
linked to the development of orange, crystal-like papules along the ink's pigmentation line, as
described by C. Bombonato et al. The person also lost an eyebrow. It was determined that
this was a granulomatous reaction to the ink [22]. Development of Verruca Vulgaris has been
reported by K. M. Nemer et al. where papillomatosis of the epidermis and dermal keratin
depositions were found following eyebrow tattoo. They appeared as thick plaques along the
eyebrow. It is believed that Verruca Vulgaris is more common for dark-coloured inks such as
black because of their effective ability in modulating the cell-mediated immune response
[24]. Basal cell carcinoma is also among the reported unexpected response after eyebrow
tattoos. The process of carcinoma post eyebrow tattoo has not been completely established
but it is suspected to be caused by traumatic invasion of the skin accompanied by
granulomatous reaction to ink particles. [26]. It can be speculated that carcinoma
development might be due to continuous immune response to ink which causes a delayed
type of complication.
Blue ink
Blue ink is found to cause more adverse effects than other inks because of the presence of
metal phthalocyanines. This is far more stable than inks containing cobalt and chromium.
Although traces of copper are also present in blue ink. Complications linked to eyeball tattoos
commonly occur due to piercing needles and injury to ocular structures but ink deposition is
also a contributing factor. Foreign-body reactions, inflammatory reactions, retinal toxicity,
and eye infections are some of the manifestations of intraocular tattoos with the use of blue
ink [28] [29]. In the case presented by A. Jalil et al. misplacement of blue ink granules in the
vitreous humour and subretinal space lead to inflammation of the uvea, retinal detachment,
and visual impairment [29]. Injecting blue ink in conjunctiva for subconjunctival tattoos may
lead to conjunctival swelling as a response to an allergic reaction to ink components.
Photophobia, uveitis, and eye pain are faced as a result [28].
Red ink
The majority of adverse effects are observed in the case of red and black inks containing poly
and azo dyes [34] [11] [30]. Primary components of red ink are mercuric sulphide which has
been substituted with organic dyes, ferric hydrate, sienna, and cadmium selenide. JO
Rodríguez-Avila et. al. presented a case of a severe hypersensitivity reaction following an
intraocular tattooing procedure where globules of red ink were found suspended in an
aqueous chamber. The patient suffered vision impairment due to staining of the anterior
capsule. The inflammation from the reaction to red ink also caused eye pain and difficulty in
eye movement [30].
Orange ink
Orange lesions may form on the sclera due to depositions of injected pigment. The lesions are
believed to form in response to granulomatous formation. A close lookout must be taken for
the delayed type of hypersensitivity reaction toward the ink chemicals [31].
Brown ink
Brown or brownish-black inks are utilised in eyebrow tattoos. There are adverse reactions to
this such as lesions formation, allergic reactions, and sarcoidosis. There is a formation of
erythemic lesions following inflammatory response in the presence of foreign bodies. This
foreign-body granuloma causes sarcoidal reactions. In certain cases, these conditions might
progressively turn into sarcoidosis if severe ocular manifestations occur [32] [33].
Others
A large number of cases of granulomatous reactions have been reported following eye tattoos
[41] [43] [45] [46] [47] [48]. Granuloma in response to foreign- body is a delayed type of
reaction to intradermal foreign bodies such as filler injections or tattoo-ink injections. It is
generally accompanied by ocular inflammation in case of eye tattoo-associated adverse
events. Superficially local nodules or scaly lesions appear at the site of the tattoo. This is
generally due to the accumulation of ink deposits along with immune- cells. Literature search
revealed that erythema, pruritus, and oedema of the site is possible [36] [38] [41] [43]. The
granulomatous reaction can occur either immediately after the eye tattoo or be delayed type.
The bigger the time gap between the ocular tattoo procedure and granulomatous reaction, the
greater the chances of the development of manifestations such as sarcoidosis [41]. There have
been reports of cases where granulomatous reaction lead to sarcoidosis. The initial
manifestations of systemic sarcoidosis such as opaque findings on the lungs, the appearance
of nodules in chest viscera, uveitis, and dermatitis appeared [46] [47] [48] [37] [42].
Transmission of infectious micro bacterium can also be caused by tattoos [38]. The
displacement of ink post-eye tattoo procedure can lead to hyperpigmentation which appears
as dark-coloured patches on the skin [34]. Vitiligo is also a complication that arises in
response to tattoo ink. Hypopigmentation is caused because of melanocyte destruction in
response to ink components such as PPD [39] [44]. Retinal atrophy can also be caused due to
displacement of pigment of eye tattoo [40]. Anterior uveitis is also an implication of ocular
tattoo as a response to calcified plaque formation [49].
5. Conclusion
It is evident that severe complications are associated with the ocular tattooing procedure and
the tattoo ink utilised for it such as hypersensitivity reactions, vitiligo, ocular pain, uveitis,
vision impairment, glaucoma, ocular infections, conjunctival pigmentation, retinal atrophy
and dermatitis. Black ink associated complications appear to be most common and drastic in
certain cases. The lack of standardization of tattoo ink components can be concluded as major
reason for the rise in number of cases. There is need to encourage reporting of adverse events
arising as a result of eye tattoos to facilitate further study. With the increasing popularity of
permanent make-up, it has become a necessity for the circulation of information regarding
adverse effects caused by it. Medical help should be sought if manifestations arise following
eye tattooing to minimise the potential risks.