1. Permanent Tattoo of a Descemet–Stripping Endothelial Keratoplasty Button
Anil Vedula MD
Financial Disclosures: None
Richard M. Awdeh MD
Financial Disclosures: Alcon (G), Allergan (S), Inspire (S), ISTA (C,S)
David A. Goldman MD
Financial Disclosures: Alcon (C), Allergan (C), ASCRS Foundation (G), Sirion (C), Inspire (C), ISTA (C)
BASCOM PALMER EYE INSTITUTE

2. Purpose
To describe a case of permanent tattooing of the corneal button after DSEK surgery.

3. Methods
A 71-year-old male patient who presented with pseudophakic bullous keratopathy secondary to cataract surgery and intraocular lens exchange, subsequently underwent DSEK surgery. During the surgery, an "S" was marked on the donor stromal side to assist with orientation during the procedure.

4. Results
After 6 months, the donor graft was well attached, the cornea was clear, and the patient had a visual acuity of 20/50 (limited by epiretinal membrane). The ink marking, however, persisted as a permanent tattoo of the donor button.

5. The ‘S’ remains in the interface

6. Effect of Nontoxic Gentian Violet Marking Pen on DSAEK Donor Tissue Viability by Using Vital Dye Assay. Cornea Jun;27(5):562-4.
Qualitatively assessed the endothelial damage on DSAEK donor tissue resulting from a gentian violet marking pen.
Demonstrated that marking the DSAEK donor stromal surface with a gentian violet marker damages the endothelium.
Suggested that surgeons should limit the size of the mark or use a an insertion technique that avoids confusion about orientation of the donor cornea.

7. Conclusion
Use of ink to assist with orientation of the donor button in DSEK surgery should be kept to a minimum and to the peripheral cornea only to minimize any negative visual consequences.
Furthermore, while our graft remained clear 6 months postoperatively, the literature demonstrates endothelial toxicity from gentian violet, another reason to minimize use of ink during DSAEK surgery.