Ophthalmologists should consider cosmetic permanent eyeliner tattoos (blepharopigmentation) as a risk-factor for ocular surface disease.
Allergic granulomatous reaction to blepharopigmentation should be on the differential diagnosis for patients presenting with ulcerative blepharitis and associated ocular surface disease resistant to medical therapy.
A careful history is critical because patients often can think of it as a cosmetic treatment and not attribute it to be an invasive medical procedure. The degree of pigmentation can fade in time but a delayed allergic reaction can still develop years later.
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