More people are permanently changing their eye color. How risky is it?

When CassieAnn learned there was a procedure that could permanently change the color of her eyes, she decided to fly to New York City to get it done. She had always wanted blue eyes and had been wearing colored contact lenses to change her appearance for years.

"I always wanted to have a little bit of change when it comes to the eyes," CassieAnn, who is using her first name only for privacy reasons, told Salon in a phone interview. "For people that are family, or a significant other, I didn't want to have to take my contacts out and then look different."

CassieAnn got her operation done at Manhattan Lasik Center by Dr. Kevin Niksarli, who has been performing keratopigmentation surgeries since 2022. Originally introduced in Europe, this 20-minute cosmetic procedure involves using a laser to create a channel in the cornea, where colored pigment is deposited to change the color of the eye. Slight changes in color can occur within the first six months after surgery, but the surgery is permanent.

Although it has been referred to as "eye tattooing," doctors performing it said that the procedure is more like popular corrective surgeries like laser-assisted in situ keratomileusis (LASIK) or small incision lenticule extraction (SMILE). These surgeries improve vision, however — they aren't cosmetic.

Keratopigmentation is not to be confused with scleral tattooing, which involves tattooing the white part of the eye and carries a risk for infection and vision loss. Other procedures like laser depigmentation and iris implants have also been used to change the eye color, but may result in corneal damage or vision loss as well. These procedures also carry a risk of glaucoma and cataracts.

“If you put an implant, or if you remove the pigment of the iris, you have to go into the eye,” said Dr. Francis Ferrari, an ophthalmologist in France credited as being the first to start doing these procedures cosmetically in 2013. “We just remain on the eye’s surface, so it is less invasive.”

As it stands, research following patients who underwent keratopigmentation shows the procedure to be relatively safe. Since the 1990s, doctors have been performing medical keratopigmentation for people born without irises and certain other eye conditions.

However, in one 2020 study of 40 patients who underwent the procedure, one patient who had undergone LASIK developed corneal ectasia, an elongation of the cornea. As a result, a 2022 review on various eye color-changing procedures concluded that “LASIK might represent a contraindication” to keratopigmentation given the available evidence.

In another study of 204 patients who underwent keratopigmentation, a small portion of patients experienced complications when they went into an MRI machine, and one patient also experienced corneal ectasia after going into an MRI machine in another case report.

Ferrari said this was because some older versions of the pigments used in this procedure contained iron, but those are no longer used. The Conformite Europeenne in Europe regulates these micronized mineral pigments to make sure they meet certain standards, but the U.S. Food and Drug Administration does not.

Want more health and science stories in your inbox? Subscribe to Salon's weekly newsletter Lab Notes.

As keratopigmentation is getting more popular, Dr. Alexander Movshovich, an ophthalmologist performing it at KERATO clinic in New York, said he is planning a talk for an upcoming scientific meeting about keratopigmentation to share some of the challenges of performing the procedure with his peers in order to reduce the risks of them happening.

"Usually people ... see that something is interesting, they start to jump on it, and it's everywhere," Movshovich told Salon in an interview. If safety measures are not put in place, this could lead to mistakes in the procedures that impact patients, he added.

Ferrari estimates that about 30 doctors are performing this procedure worldwide, and just a handful offer this cosmetic procedure in the U.S. “off-label,” meaning it is not approved by the FDA as a medical treatment. Some have expressed concern that the procedure could have unknown long-term risks that are not being detected, and in a statement issued last year, the American Academy of Ophthalmology warned that the procedure could “carry serious risks.”

“While every surgery has inherent risks, those that are not carefully studied, and regulated, in the U.S. may carry even greater risks, especially when performed purely for cosmetic reasons on otherwise healthy eyes,” said Dr. Christopher Starr, an ophthalmologist at Weill Cornell and AAO spokesperson.

Many procedures, and particularly cosmetic ones, are performed off-label. Even though it does not fall under the same regulations as something that is FDA-approved, the agency is still required to act when medical safety concerns arise.

Doctors performing the procedure said that side effects are minor and short-lasting after the surgery. Patients may experience light sensitivity, watery eyes, blurry vision or irritation in their eyes for a few days after the procedure, Niksarli said. CassieAnn said it felt like she had a "small eyelash" on her eye the next day after the procedure, but it disappeared within a day.

“Some people have no real side effects and others get all of these side effects, but they are transient in our experience,” Niksarli told Salon in a phone interview. “We have had no one with long, lasting visual or other kinds of side effects following the procedure.”

Because it is performed off-label, insurance doesn't cover the procedure and patients must pay out-of-pocket for keratopigmentation, with prices sometimes ranging upwards of $10,000 in the U.S. Dr. Cyril Maillon, an ophthalmologist who performs the surgery in France, said people opt for keratopigmentation for many of the same reasons people elect for other cosmetic procedures: to improve confidence or simply change their appearance.

Some get the surgery to have their eye color more closely resemble their families if they are the only one born with a different eye color, he added. But nearly all patients choose to go from dark eyes to light ones, he said.

“It's quite rare to have [a person with] bright eyes wanting to turn to brown or dark eyes,” Maillon told Salon in a phone interview.

Although it has not been studied, social media may be influencing the desire to change eye colors. Social media filters have made it easier than ever to envision oneself with different eyes, which could be contributing to the rise in procedures like this as well as the increased use of colored contacts and eye drops. Recently, people have even been using technology to select embryos and choose their unborn baby’s eye color, among other traits.

Yet, while people elect for keratopigmentation for many of the same reasons as other forms of cosmetic procedures, there is something unique about changing the eyes, Maillon said.

“With the eyes, it can be a little more significant, because when you change the eyes, you also change the appearance quite a lot,” Maillon said. “The eyes are the first thing you see when you [look] at someone.”