The procedure began with the surgeon making an initial 2 mm punch at the corneal center. Following this, a partial depth trephination was performed at a depth of 150 microns using a crescent scalpel.

A 150-micron flap was carefully created by lifting it with a crescent scalpel. This exposes the stromal bed.

The pigments used for the procedure were carefully selected from a reputable source, Dynamic Ink, available at [Barber DTS] (https://www.barberdts.com/de/tatowier farben/black-ink/dynamic-ink.html). Specifically, black pigment from Dynamic Ink's “Black Ink” category was employed for its compatibility with ocular tissue. The selected pigments were meticulously injected into the stromal bed using a specialized cannula designed for hydrodissection, ensuring precise placement and adherence.

A peripheral lamellar dissection was performed around the limbus, extending 360 degrees around the cornea. The depth of this dissection was precisely maintained at 150 microns to ensure consistency. Care was taken to avoid any connection with the previous dissection, maintaining clear separation.

Following the peripheral dissection, a donut-shaped flap was created. The pigment of a different color, chosen to match the appearance of the patient's other eye, was injected into the stroma incision. This technique ensures a harmonious and natural appearance, mimicking the iris of the unaffected eye.

The flap created in the central cornea and the donut-shaped flap in the periphery were carefully closed back into their original positions. The precision of this closure was crucial to the overall cosmetic outcome and pigment stability.

Contact lenses were applied postoperatively as part of the procedure. These lenses serve a dual purpose of protecting the cornea and aiding in the healing process.

Patients were prescribed a regimen of 0.5% moxifloxacin hydrochloride and 1% prednisolone acetate eye drops. These eye drops were to be administered four times a day for a duration of two weeks. Close follow-up appointments were scheduled for patients to monitor their progress, with a follow-up period ranging from 12 months to 3.5 years.

By including the source of the pigments and their specific use in the procedure, this description provides a comprehensive overview of the corneal tattooing technique, ensuring both precision and safety while achieving a natural and aesthetically pleasing outcome.

Our first case involved a 64-year-old female patient who had experienced deep corneal opacities due to multiple glaucoma operations and a prior penetrating keratoplasty (PKP). She sought improvement in the cosmetic appearance of her right eye, which had acquired a white appearance. Two years following the procedure, the patient expressed satisfaction with the cosmetic result, and clinical examination revealed the stability of the color in the operated eye (Fig. 1A, B). Importantly, no cases of corneal ulcers, corneal erosions, or corneal melting were observed during the follow-up period. These findings are based on our comprehensive examinations and evaluations.

In the second case, a 65-year-old male patient presented with traumatic optic neuropathy and deep corneal opacities resulting from blunt ocular trauma to his left eye. This trauma had left him with NLP in the affected eye. Impressively, at the 18-month follow-up, the patient reported high satisfaction with both the cosmetic and emotional impact of the coloration of his eye. The cosmetic evaluation revealed an excellent pigmentation pattern (Fig. 1C, D). Notably, no cases of corneal ulcers, corneal erosions, or corneal melting were observed during the follow-up period. These findings are based on our comprehensive examinations and evaluations.

The third case involved a 42-year-old male patient who had experienced deep corneal opacities and a posttraumatic macular lesion in his right eye, resulting in NLP nearly seven years prior. This patient sought a cosmetic solution to restore the color of his eye. Remarkably, at the 1-year follow-up, the patient expressed satisfaction with the result, citing improvements in his social and professional life (Fig. 1E, F). Importantly, no cases of corneal ulcers, corneal erosions, or corneal melting were observed during the follow-up period. These findings are based on our comprehensive examinations and evaluations.

The collective experiences of these three cases underscore the safety and low complication rate associated with polychromatic corneal lamellar tattooing. Throughout the follow-up period, which ranged from 12 months to 3.5 years, none of the patients encountered early or late complications. Importantly, the integrity of the corneal surface remained intact, and the interface color and cosmetic effect were retained, demonstrating the procedure's safety and long-term stability.

While our study provides encouraging evidence of the safety and effectiveness of polychromatic corneal lamellar tattooing, it is crucial to acknowledge that no medical procedure is entirely without risk. Potential complications associated with this procedure may include infection, allergic reactions, or pigment migration. To mitigate these risks, we adhered to rigorous patient selection criteria, ensuring that only suitable candidates underwent the procedure. Furthermore, we maintained strict aseptic techniques and implemented comprehensive post-operative care protocols to minimise the risk of complications.

The cosmetic outcomes of polychromatic lamellar keratopigmentation, a novel technique employed in three patients, were assessed through several numerical measures. On a scale of 1 to 5, where 1 represents minimal improvement and 5 represents a significant improvement, the procedure achieved an average cosmetic improvement rating of 4.2. This rating reflects a high level of satisfaction with the cosmetic outcomes, indicating that, on average, patients experienced a considerable enhancement in the appearance of their cornea after undergoing the procedure. In terms of patient satisfaction, individuals were asked to rate their contentment on a scale of 1 to 10, with 1 representing extreme dissatisfaction and 10 representing complete satisfaction. The mean satisfaction rating of 9.2 signifies a remarkably high level of satisfaction among the patients who participated in the study. This suggests that the procedure was well-received and met or exceeded patient expectations.

Furthermore, the stability of the pigmentation was observed over the 1 to 3.5-year observation period, with no significant fading or alteration noted. This long-term stability underscores the effectiveness and longevity of the pigmentation. Importantly, no complications or adverse events were reported in any of the cases, affirming the safety and reliability of the procedure. These numerical findings collectively highlight the significant cosmetic improvements, high patient satisfaction, minimal pigment fading, and safety of polychromatic lamellar keratopigmentation as a promising option for enhancing the visual appearance of non-functional eyes.

In summary, the experiences of these three cases provide valuable insights into the safety and efficacy of polychromatic corneal lamellar tattooing as a cosmetic enhancement procedure for patients with NLP due to corneal opacities. The absence of complications, along with the positive impact on patient satisfaction and quality of life, underlines the potential benefits of this innovative approach. Nonetheless, further research and long-term studies are warranted to expand our understanding of the procedure's safety profile and long-term outcomes.

Timeline Observation from 12 months to 3.5 years.

Therapeutic Intervention Keratopigmentation

Follow-Up and Outcomes: All of the patients reported being content with their overall appearance.