This patient had progressive ulcerative blepharitis and associated ocular surface disease with no clinical response to anti-infective and anti-inflammatory treatment. By process of exclusion based on the differential diagnosis with supporting evidence from the eyelid biopsy, she was determined to have an allergic granulomatous reaction to blepharopigmentation (eyeliner tattoo).
She was started on eyelid intradermal Kenalog (Bristol-Myers Squibb) injections along indurated areas and showed great improvement with resolution of ulcers after two rounds of injections (Figure 3).
Blepharopigmentation, commercially known as eyeliner tattoo, involves the introduction of ferrous oxide or other metallic pigment into the eyelid margin with a needle of microblade. This procedure is marketed as “permanent,” although pigmentation typically fades over years. While it was originally performed by physicians, it is now mostly done by cosmetologists with freehand tattooing or blading the eyelid.
Only a few cases of allergic granulomatous reaction to blepharopigmentation have been reported in the literature.1–4 This reaction causes chronic inflammation that can lead to permanent scarring, lid deformity, eyelash loss and misdirection. Blepharopigmentation has been demonstrated to cause meibomian gland loss,5 tear film and ocular surface abnormalities,6 as well as trigger diffuse lamellar keratitis.7