Cataract Surgery Practice in the Republic of Korea: A Survey of the Korean Society of Cataract and Refractive Surgery 2020

Purpose@#To describe current cataract surgery practice patterns and trends among Korean ophthalmologists. @*Methods@#A survey was conducted among members of the Korean Society of Cataract and Refractive Surgery in October 2020. Of the 998 questionnaires, 262 (26.3%) were received for analysis. Data were analyzed using descriptive statistics and compared with those of previous surveys. @*Results@#The largest percentage of respondents (39%) had 11 years of practical experience. The average, median, and mode monthly volumes of cataract surgeries performed by the Korean Society of Cataract and Refractive Surgery members were 31, 20, and 10 cases, respectively. Topical anesthesia was administered by 85% of the respondents. For intraocular lens (IOL) calculations, 96% of the respondents used optical biometry. The proportion of surgeons providing femtosecond laser-assisted cataract surgery increased significantly from 5% in 2018 to 29% in 2020. This increase was accompanied by an increase in the multifocal IOLs. Those who implant multifocal IOL for >10% of their cases increased from 16% (2018) to 29% (2020). Topical nonsteroidal anti-inflammatory drugs were prescribed postoperatively by 76% of the respondents. Most respondents (70%) prescribed these anti-inflammatory drugs for 4 weeks. @*Conclusions@#This survey provided a comprehensive update on current cataract surgery practice in the Republic of Korea. The results highlighted the increasing use of premium IOLs, femtosecond laser-assisted cataract surgery, optical biometry, and topical anesthesia to better meet the patients’ needs.

Cataract Surgery Practice in the Republic of Korea: A Survey of the Korean Society of Cataract and Refractive Surgery 2020

Purpose@#To describe current cataract surgery practice patterns and trends among Korean ophthalmologists. @*Methods@#A survey was conducted among members of the Korean Society of Cataract and Refractive Surgery in October 2020. Of the 998 questionnaires, 262 (26.3%) were received for analysis. Data were analyzed using descriptive statistics and compared with those of previous surveys. @*Results@#The largest percentage of respondents (39%) had 11 years of practical experience. The average, median, and mode monthly volumes of cataract surgeries performed by the Korean Society of Cataract and Refractive Surgery members were 31, 20, and 10 cases, respectively. Topical anesthesia was administered by 85% of the respondents. For intraocular lens (IOL) calculations, 96% of the respondents used optical biometry. The proportion of surgeons providing femtosecond laser-assisted cataract surgery increased significantly from 5% in 2018 to 29% in 2020. This increase was accompanied by an increase in the multifocal IOLs. Those who implant multifocal IOL for >10% of their cases increased from 16% (2018) to 29% (2020). Topical nonsteroidal anti-inflammatory drugs were prescribed postoperatively by 76% of the respondents. Most respondents (70%) prescribed these anti-inflammatory drugs for 4 weeks. @*Conclusions@#This survey provided a comprehensive update on current cataract surgery practice in the Republic of Korea. The results highlighted the increasing use of premium IOLs, femtosecond laser-assisted cataract surgery, optical biometry, and topical anesthesia to better meet the patients’ needs.

Comparison of Long-Term Clinical Results after Implantation of Hydrophilic and Hydrophobic Acrylic Intraocular Lens

PURPOSE: To assess long-term clinical outcomes and factors influencing refractive change after implantation of hydrophilic (Akreos AO) and hydrophobic (Acrysof IQ) acrylic intraocular lens. METHODS: After phacoemulsification, intraocular lens was inserted in the bag (Akreos AO for 84 eyes and Acrysof IQ for 19 eyes). Uncorrected visual acuities (UCVA), refraction in both spherical equivalent (SE) and astigmatism were compared longitudinally in more than 2 years follow-up. Factors associated with SE change > or =0.5 diopter (D) after Akreos AO implantation were analyzed with logistic regression. RESULTS: Although Akreos AO showed hyperopic change mainly within 6 months, UCVA and astigmatism change were not statistically significant during follow up (+0.15 +/- 0.43 D, p = 0.027). UCVA, SE, astigmatism were not changed after Acrysof IQ implantation and not significantly different between two groups during follow up. Preoperative anterior chamber depth was a sole factor associated with SE change > or =0.5 D after Akreos AO implantation (p = 0.006). CONCLUSIONS: Possible hyperopic shift after Akreos AO implantation should be considered in setting target diopter, especially in eye with shallow anterior chamber.

Clinical Characteristics and Patient's Satisfaction in Pseudophakic Negative Dysphotopsia

PURPOSE: To investigate the clinical characteristics of patients with pseudophakic negative dysphotopsia after cataract surgery and to analyze the risk factors of pseudophakic negative dysphotopsia as well as the postoperative effects on patient's satisfaction. METHODS: This study included 1,020 eyes of 690 patients who underwent phacoemulsification and posterior chamber lens insertion between January 2010 and March 2012. Retrospective chart review was conducted to evaluate the prevalence of negative dysphotopsia according to the site of clear corneal incision during cataract surgery and the type of implanted intraocular lens (IOL). The clinical outcome of Neodymium:yttrium-aluminium-garnet (Nd:YAG) laser anterior capsulotomy in negative dysphotopsia patients was evaluated. Using a telephone survey, patients were asked to subjectively answer 18 questions regarding satisfaction after cataract surgery, the severity of visual symptoms and the effect of negative dysphotopsia in their daily life. RESULTS: Negative dysphotopsia developed in patients who underwent uneventful cataract surgery and successful implantation of IOL in the bag. The patients' vision was corrected up to 20/20 (0.00 log MAR) and HVF P60-4 showed no abnormality in their visual field. There were significantly more patients with the SN60WF IOL who reported negative dysphotopsia but no other factors associated with the prevalence of negative dysphotopsia. During the telephone survey, patients complained of difficulties in their daily life related to the negative dysphotopsia symptoms and reported decreased satisfaction after cataract surgery. CONCLUSIONS: Although negative dysphotopsia can decrease the patient's satisfaction after cataract surgery, the genesis of negative dysphotopsia and an objective method to test for negative dysphotopsia is necessary. Therefore, a prospective large study should be conducted to evaluate the cause and treatment of negative dysphotopsia.

Clinical Characteristics and Patient's Satisfaction in Pseudophakic Negative Dysphotopsia

PURPOSE: To investigate the clinical characteristics of patients with pseudophakic negative dysphotopsia after cataract surgery and to analyze the risk factors of pseudophakic negative dysphotopsia as well as the postoperative effects on patient's satisfaction. METHODS: This study included 1,020 eyes of 690 patients who underwent phacoemulsification and posterior chamber lens insertion between January 2010 and March 2012. Retrospective chart review was conducted to evaluate the prevalence of negative dysphotopsia according to the site of clear corneal incision during cataract surgery and the type of implanted intraocular lens (IOL). The clinical outcome of Neodymium:yttrium-aluminium-garnet (Nd:YAG) laser anterior capsulotomy in negative dysphotopsia patients was evaluated. Using a telephone survey, patients were asked to subjectively answer 18 questions regarding satisfaction after cataract surgery, the severity of visual symptoms and the effect of negative dysphotopsia in their daily life. RESULTS: Negative dysphotopsia developed in patients who underwent uneventful cataract surgery and successful implantation of IOL in the bag. The patients' vision was corrected up to 20/20 (0.00 log MAR) and HVF P60-4 showed no abnormality in their visual field. There were significantly more patients with the SN60WF IOL who reported negative dysphotopsia but no other factors associated with the prevalence of negative dysphotopsia. During the telephone survey, patients complained of difficulties in their daily life related to the negative dysphotopsia symptoms and reported decreased satisfaction after cataract surgery. CONCLUSIONS: Although negative dysphotopsia can decrease the patient's satisfaction after cataract surgery, the genesis of negative dysphotopsia and an objective method to test for negative dysphotopsia is necessary. Therefore, a prospective large study should be conducted to evaluate the cause and treatment of negative dysphotopsia.

Changes in Electroretinogram Parameters after Panretinal Photocoagulation in Diabetic Retinopathy

OBJECTIVE: This study was performed to evaluate the effect of panretinal photocoagulation (PRP) on parameters of electroretinograms (ERG). METHODS: Retrospective study was performed on 58 eyes of 29 patients with proliferative diabetic retinopathy (PDR) who underwent PRP. ERG was performed in each patient before and after PRP, and each ERG parameters were compared between the pre- and post-PRP state. Also, the results of ERG performed after PRP were compared between two groups: one group showing obvious new vessels regression and the other group showing poor regression after PRP. RESULTS: Marked reduction in amplitude and delay in implicit time were observed in all patients (P0.05). CONCLUSION: PRP in diabetic retinopathy patients may affect not only the outer retina but also the cells within the inner nuclear layer, causing changes in ERG parameters. However, ERG was not a good indicator for representing the amount of new vessel regression in PDR.

A Case of Meibomian Gland Dysfunction after Cosmetic Eyelid Tattooing Procedure

PURPOSE: To report a case of meibomian gland dysfunction as a chronic complication of eyelid tattooing and the corneal epithelial defect as an acute complication of eyelid tattooing well healed with proper treatment. CASE SUMMARY: A 31-year-old woman presented with severe eye pain, irritation and epiphora in both eyes. The patient underwent an eyelid tattooing procedure 2 hours before and dark pigments were placed on the inner eyelid margin. Slit lamp examination showed conjunctival injection and inferior corneal epithelial defect in both eyes. After 2 months, dry eye symptom still remained although the cornea was completely epithelialized. After 1 year, the patient improved completely, but still showed decreased tear film breakup time (TBUT). CONCLUSIONS: Due to the increased number of people who undergo cosmetic eyelid tattooing procedures, the number of reports associated with complications has increased and acute complications such as corneal epithelial defect can occur. Moreover, chronic discomfort associated with dry eye syndrome can occur when pigmentation is placed on the eyelid inner margin and lead to the destruction of meibomian glands. Thus, eyelid tattooing should be performed after careful consideration of possible complications.

Satisfaction Level of Physicians Who Have Undergone Corneal Refractive Surgery

PURPOSE: To evaluate the levels of satisfaction among physicians who have undergone corneal refractive surgery. METHODS: This study included 212 eyes of 107 consecutive patients who underwent laser in situ keratomileusis or laser sub-epithelial keratomileusis surgery. Patients were divided into two groups: one group of physicians and one group of other healthcare workers (HCWs). The physicians' group was also subdivided into two different groups: surgeons or doctors using microscopes and medical physicians. The main outcome measures were scale scores obtained by using the Visual Function Index-14 questionnaires; uncorrected distance visual acuity (UDVA), residual spherical equivalent (SE), optical zone diameter, and residual corneal thickness were also compared between the groups. RESULTS: No significant differences in preoperative parameters, with the exception of the ratio of types of refractive surgery, were noted between the physicians and the HCWs group. Additionally, no differences between the groups were noted in the postoperative UDVA, residual SE, optical zone diameter, residual corneal thickness, and level of satisfaction. When comparing the two subgroups of physicians, the differences in satisfaction rates were not statistically significant, even in terms of the performance of delicate manual work. CONCLUSIONS: No statistically significant differences in the clinical outcomes and satisfaction scores were detected after surgery between the physicians and HCWs groups, nor were any significant differences detected between the surgeons and medical physicians groups. Corneal refractive surgery can conceivably be recommended even for physicians who perform intensive near vision-dependent activities and delicate operations.

Neuroprotective Effect of Rapamycin in Optic Nerve Transection Model

PURPOSE: The present study investigated whether rapamycin activated autophagy in retinal ganglion cells (RGC) and evaluated its effect on RGC survival following optic nerve transection (ONT). METHODS: The activation of autophagy in RGCs after intravitreal injection of rapamycin was evaluated with the immunohistochemical staining of phospho-S6 ribosomal protein. Rapamycin or 0.1% DMSO was injected intravitreally immediately after ONT. At 1 and 2 weeks after ONT, the RGCs were counted. Rapamycin and autophagy inhibitors, 3-methyladenine or Wortmannin were co-injected intravitreally after ONT and the RGCs were counted 1 week later. RESULTS: Expression of phospho-S6 ribosomal protein was decreased in RGCs after intravitreal injection of rapamycin. The RGC number was significantly higher in the rapamycin group than in the control group 1 week after ONT. However, the RGC number was not different between the 2 groups 2 weeks after ONT. Repeated intravitreal injection of rapamycin at 1-week intervals showed neuroprotection 2 weeks after ONT. The RGC number was not different between the control group and the co-injection group of rapamycin-autophagy inhibitor. CONCLUSIONS: Activated autophagy by rapamycin was neuroprotective in RGC after ONT.

Comparison of the Detection Rate, Location and Amount of Retinal Nerve Fiber Layer Defect

PURPOSE: To compare the detection rate of the patients with retinal nerve fiber layer (RNFL) defect and the amount of RNFL defect according to the patients' age. METHODS: Retrospective chart reviews of 22,811 subjects, who visited the health care center from January 2009 to December 2009 were performed. The detection rate, location and average amount of RNFL defect and the proportions of the patients who were diagnosed with glaucoma through Humphrey visual field (HVF) test or determined as a glaucomatous optic disc were compared according to the patients' age. RESULTS: The proportions of the patients whose RNFL defect were detected was highest in the patients 60 years old or older (2.3%) and was statistically significant (p = 0.012). However, there was no significant difference among the other age groups (under 40 years: 1.7%, 40 thru 49 years: 1.5%, 50 thru 59 years: 2.0%). The proportions of the patients who were determined as glaucoma through the HVF test or glaucomatous optic disc were also highest in the patients 60 years old or older (1.4%), however, there was no statistically significant difference (p = 0.070) among the age groups (under 40 years: 1.1%, 40 thru 49 years: 0.9%, 50 thru 59 years: 1.2%). CONCLUSIONS: The RNFL defect is likely to be detected in subjects less than 40 years of age and the detection rate is similar to subjects in their 40's and 50's. The use of fundus photography to detect RNFL defect in a health care center is recommended in subjects under 40 years of age.

Intraocular Lens Power Calculation Using IOLMaster and Various Formulas in Short Eyes

PURPOSE: To evaluate the predictability of intraocular lens (IOL) power calculations using the IOLMaster and four different IOL power calculation formulas (Haigis, Hoffer Q, SRK II, and SRK/T) for cataract surgery in eyes with a short axial length (AL). METHODS: The present study was a retrospective comparative analysis which included 25 eyes with an AL shorter than 22.0 mm that underwent uneventful phacoemulsification with IOL implantation from July 2007 to December 2008 at Seoul National University Boramae Hospital. Preoperative AL and keratometric power were measured by the IOLMaster, and power of the implanted IOL was determined using Haigis, Hoffer Q, SRK II, and SRK/T formulas. Postoperative refractive errors two months after surgery were measured using automatic refracto-keratometry (Nidek) and were compared with the predicted postoperative power. The mean absolute error (MAE) was defined as the average of the absolute value of the difference between actual and predicted spherical equivalences of postoperative refractive error. RESULTS: The MAE was smallest with the Haigis formula (0.37 +/- 0.26 diopter [D]), followed by those of SRK/T (0.53 +/- 0.25 D), SRK II (0.56 +/- 0.20 D), and Hoffer Q (0.62 +/- 0.16 D) in 25 eyes with an AL shorter than 22.0 mm. The proportion with an absolute error (AE) of less than 1 D was greatest in the Haigis formula (96%), followed by those in the SRK II (88%), SRK-T (84%), and Hoffer Q (80%). CONCLUSIONS: The MAE was less than 0.7 D and the proportion of AE less than 1 D was more than 80% in all formulas. The IOL power calculation using the Haigis formula showed the best results for postoperative power prediction in short eyes.

Changes in Clinical Manifestations of Dry Eye Syndrome after Cataract Surgery and the Affecting Factors

PURPOSE: To evaluate the changes in the clinical signs and symptoms of dry eye syndrome before and after cataract surgery according to the main incision location and the type of artificial tears. METHODS: Twenty-four eyes of 17 patients who underwent phacoemulsification and posterior chamber lens insertion from May 2009 to July 2009 were enrolled in the present study prospectively. The main incision location (temporal or superior incision) was determined according to the axis of astigmatism and the postoperative artificial tears (sodium hyaluronate with or without preservatives) were determined randomly. The tear film break-up time (TF-BUT), Schirmer test, esthesiometer, corneal surface grading with Oxford system and ocular surface disease index (OSDI) questionnaire before and 1, 2 and 6 months after surgery were evaluated. The corneal nerve was also analyzed using corneal confocal microscopy (Confoscan 4, Nidek, Italy) before, and 1 and 6 months after surgery. RESULTS: The TF-BUT was significantly longer (p = 0.010) and the OSDI score was significantly lower (p = 0.007) in the patient group with preservative-free sodium hyaluronate than the group with sodium hyaluronate containing preservatives at 6 months after cataract surgery. There were no statistically significant differences according to the main incision location in the sodium hyaluronate without preservatives group. CONCLUSIONS: Symptoms and several signs of dry eye syndrome triggered by cataract surgery decreased with preservative- free artificial tears compared to tears with preservatives.

Surgical Treatment of Extensive Conjunctival Melanocytic Nevus Mimicking Conjunctival Melanoma

PURPOSE: To report a case of diffuse conjunctival melanocytic lesion mimicking conjunctival melanoma and treated by surgical excision and amniotic membrane transplantation. CASE SUMMARY: A 29-year-old man presented with diffuse pigmented lesion on the bulbar conjunctiva in the right eye, which had been present since birth. Circumferential pigmentation was observed in the perilimbal conjunctiva from 4 to 11 o'clock, and slightly elevated, dark brown-colored lesions with multiple small cysts were noted on the superior, inferior, and temporal bulbar conjunctiva. Incisional biopsy was performed from multiple sites to rule out conjunctival melanoma. Histopathologic examination showed small nevus cells and multiple cysts. Under local anesthesia, temporal conjunctival excision and amniotic membrane transplantation were performed. The surgical pathologist confirmed compound nevus. Four weeks after the surgery, full epithelialization was observed over the amniotic membrane. Several lesions were intentionally left during the surgery, and unnoticeable from the frontal view. The patient was satisfied with the surgical result. CONCLUSIONS: In extensive conjunctival pigmented lesion, biopsy should always be performed to rule out melanoma. Temporal conjunctival excision rather than whole lesion excision can be a cosmetically good surgical option for a diffuse conjuntival lesion proven as a benign conjunctival nevus.

Clinical Features of Nevus of Ota in Korean Population

PURPOSE: To investigate the clinical features of the nevus of Ota in the Korean population. METHODS: A retrospective chart review of the medical records from 94 patients (100 eyes), diagnosed to have a nevus of Ota from September 2005 to February 2010, was performed. RESULTS: The mean age of detection of a nevus of Ota was 8 months, and the mean extent of the nevus was 253 degrees, which covered more than 2 quadrants in most cases. The patients with a faint nevus tended to be younger. Pigmentation did not reach the fornix, but the limbus was mostly pigmented. Combined conjunctival pigmentation was observed in 61.7% of cases. The pigmentation was significantly associated with a greater extent of the nevus. Iris pigmentation was demonstrated in 98.7% of cases. CONCLUSIONS: The clinical features of nevi of Ota were diverse regarding the location, extent, and color of the lesion. Conjunctival pigmentation was associated with the extent of the nevus. Iris pigmentation was revealed in almost all cases; therefore, this feature had the diagnostic value for a nevus of Ota. Young patients with a nevus of Ota may mimic osteogenesis imperfecta, which necessitates careful consideration upon differential diagnosis.

The Epidemiology of Cosmetic Treatments for Corneal Opacities in a Korean Population

PURPOSE: To describe etiologies and clinical characteristics of corneal opacities leading patients to seek cosmetic treatments. METHODS: The medical records of 401 patients who presented for cosmetic improvement in corneal opacities between May 2004 and July 2007 were retrospectively reviewed. The following parameters were analyzed: age, gender, cause of corneal opacity, time course of the corneal disease, associated diseases, prior and current cosmetic treatments, visual acuity, location and depth of the corneal opacity, and the presence of either corneal neovascularization or band keratopathy. A single practitioner examined all patients. RESULTS: The most common causes of corneal opacity were ocular trauma (203 eyes, 50.6%), retinal disease (62 eyes, 15.5%), measles (38 eyes, 9.5%), and congenital etiologies (22 eyes, 5.5%). Prior treatments included iris colored contact lenses (125 eyes, 31.1%) and corneal tattooing (34 eyes, 8.46%). A total of 321 of 401 eyes underwent cosmetic treatment for corneal opacities. The most common treatment performed after the primary visit was corneal tattooing (261 eyes, 64.92%). CONCLUSIONS: This is the first study to investigate the causes and clinical characteristics of patients presenting for cosmetic treatment of corneal opacities rather than for functional improvement. Various cosmetic interventions are available for patients with corneal opacities, and these should be individualized for the needs of each patient.

Clinical Aspect of Low Vision Patients due to Macular Degeneration

PURPOSE: To investigate the clinical features of low vision patients due to macular degeneration and to evaluate the efficacy of low vision aids in patients with the disease. METHODS: Out of 283 patients who visited the vision clinic of Seoul National University Hospitalfrom March 2004 to January 2007, the number of patients with macular degeneration was 38. Their medical records were reviewed retrospectively. RESULTS: The study group consisted of 23 male and 15 female patients. The average age was 69.7+/-11.2 years and 34 patients (89.5%) were over 50 years of age. From the visits to the low vision clinic, results showed thenear vision improved in 63%, distant vision in 5.3%, and both in 7.9% of the patients. With the help of low vision aids, near visual acuity of 0.4 or better was achieved in 80% of the patients. Low vision aids were prescribed for near vision in 30 patients and for distant vision in 2 patients. CONCLUSIONS: Near vision can improve in most macular degeneration patients with the use of proper low vision aids. Consistent education and training could promote successful use of the devices.

Cosmetic Contact Lens-related Complications: 9 Cases

PURPOSE: To report the complications resulting from incorrect use of cosmetic contact lenses. CASE SUMMARY: The medical records of 9 patients with complications related to cosmetic contact lenses were retrospectively reviewed. All 9 patients had corneal erosion, and 2 patients had corneal epithelial defects. Corneal neovascularization more than 2 mm from the limbus was observed in 3 patients and one of the patients received a permanent impairment of visual acuity. Seven patients were not educated on the management of contact lenses and 2 patients had previous experience using contact lenses. None of the patients acquired any information or proper instructions regarding their cosmetic contact lenses. During the follow-up examination, 5 out of 6 patients had symptom relief after: 1) discontinuance of using the cosmetic contact lenses or 2) proper education of contact lens use with topical antibiotics and artificial tears. CONCLUSIONS: Many cosmetic contact lens users have insufficient information on usage of contact lenses. Providing proper education to cosmetic contact lens users is very important. Cosmetic contact lens users should have ophthalmic checkups on a regular basis. In addition, illegal production and sales of cosmetic contact lenses must be strictly regulated to prevent complications caused by inferior products.

A Case of Green Laser Pointer Injury to the Macula

PURPOSE: We report a case of macular injury by accidental exposure to a green laser pointer. CASE SUMMARY: A 25-year-old man had an acute reduction of visual acuity in his right eye two years ago after accidental exposure to a green laser pointer for a few seconds. The patient's best corrected visual acuity was counting fingers in his right eye. Fundus examination and optical coherence tomography showed a macular hole and a linear retinal scar in his right eye. CONCLUSIONS: Green laser pointers may cause macular damage after exposure of just a few seconds, which can lead to irreversible reduction of visual acuity.

Comparison of the Flap Complication Rate Between Microkeratomes for LASIK

PURPOSE: To compare intraoperative and postoperative flap complication rate between the Hansatome Excellus and Zyoptix XP microkeratomes for LASIK surgery. METHODS: The intra- and post-operative flap complication rate, in 323 eyes of 167 patients operated on using the Hansatome microkeratome were compared with 260 eyes of 132 patients that were operated on using the Zyoptix XP microkeratome. RESULTS: The Hansatome group showed an intraoperative complication incidence of 2.7% compared to 0.4% for the Zyoptix XP group (p0.05). There was no incidence of visually significant complications in either group. CONCLUSIONS: The Zyoptix XP showed a significantly decreased intraoperative flap complication rate compared to the Hansatome Excellus microkeratome. The preoperative K value is an important factor for safe LASIK.

7 Cases of Combined Corneal Tattooing and Amniotic Membrane Transplantation in Bullous Keratopathy

PURPOSE: We report on the clinical efficacy of the combined operation of corneal tattooing and amniotic membrane transplantation on the treatment of bullous keratopathy in patients with poor visual potentials. CASE SUMMARY: We performed corneal tattooing and amniotic membrane transplantation in 7 eyes with bullous keratopathy. Postoperatively, we assessed the status of corneal reepithelialization, postoperative pain, and cosmetic effects. In all cases but one, corneal reepithelialization was successful without pain, and the corneal tattooing persisted throughout the follow-up period. In one case, a corneal epithelial defect developed, so we performed an additional amniotic membrane transplantation. After 2 weeks, the corneal epithelial defect healed and caused no further pain. CONCLUSIONS: The combined operation of corneal tattooing and amniotic membrane transplantation is a good choice for the treatment of bullous keratopathy with regard to cosmetic problems, pain, and poor visual potential.