Tattoo-Associated Uveitis

Jessica Mendall

North Middlesex University Hospital NHS Trust, London, UK

Introduction

Tattoo-associated uveitis is a rare condition that was first described in a case series by Lubeck and Epstein in 1952 (1). It is characterised by uveitis developing after obtaining a tattoo, with or without granulomatous inflammation of the tattoo.

Tattoo-associated uveitis can be broadly divided into three categories: cases occurring without systemic sarcoid involvement (10-20%); cases with a sarcoid-like reaction limited to the tattoo (20-30%); and cases concurrently diagnosed with distant cutaneous or systemic sarcoidosis, with or without tattoo involvement (50-60%) (2).

Risk factors

The recognised risk factors for tattoo-associated uveitis include the presence of tattoos, but particularly black tattoos as opposed to other colours of dye. Furthermore, patients presenting with this condition tend to be of younger age (3).

Prevalence

The prevalence of tattoo-associated uveitis is unknown, but it is known to be a rare condition. A review found only 39 reported cases between 1952-2018 of uveitis with an associated granulomatous tattoo reaction (3), however the condition is likely to be under-reported. Currently, 10-30% of the general population in Western countries are estimated to have tattoos, and the prevalence of tattoo-related uveitis is likely to rise as the prevalence of tattoos increases (4,5).

Aetiology

The pathophysiology of tattoo-associated uveitis is poorly understood. One theory proposes that a delayed hypersensitivity reaction to tattoo pigments, dye contaminants or heavy metals could mediate cases of tattoo granulomas with uveitis. Biopsies of inflamed tattoos have revealed non-caseating granulomas containing tattoo pigment, suggesting a relationship between the tattoo pigment and the inflammatory response (6). The precise cause is however difficult to investigate due to tattoo ink composition being mostly unregulated (7).

A second theory is that tattoo-associated uveitis represents a limited form of sarcoidosis (5). Rather than the tattoo itself triggering the inflammation, there could be an underlying inflammatory process affecting the tattoos. In support of this idea, Reinhard in 2017 describes a patient who developed tattoo granulomas and uveitis after starting immunotherapy (7).

Presentation

Tattoo-associated uveitis typically presents as bilateral uveitis (usually anterior uveitis or less commonly panuveitis), with non-granulomatous inflammation of the skin involved with the tattoo. There is a temporal association with the tattoo and development of uveitis. The uveitis usually develops around 6 months after acquiring the tattoo, and the majority of cases occur within the first year after tattooing (5).

Classic symptoms of a tattoo-related anterior uveitis include bilateral pain, photophobia, blurred vision, redness and floaters. Signs may include inflammatory cells in the anterior chamber, hypopyon, posterior synechiae, conjunctival chemosis and keratic precipitates. Involvement of the posterior uvea can present with retinal haemorrhage, macular oedema, optic disc oedema, retinal vasculitis, choroiditis and vitreous inflammation. Complications can be sight-threatening, and include serous retinal detachment, chorioretinal scarring and uveitic glaucoma (2,5,8–10). 

Investigation

Tattoo-associated uveitis is diagnosed clinically, based on the presence of uveitis and tattoos (particularly inflamed tattoos). It is however important to rule out other potential causes of uveitis and granulomatous disease, particularly sarcoidosis. Testing for sarcoidosis may include blood tests for angiotensin-converting enzyme and lysozyme levels, and chest imaging. Other useful blood tests include inflammatory markers (such as CRP and ESR), an autoimmune screen and syphilis testing. Testing for tuberculosis should also be considered. Histology of the involved skin may reveal non-caseating granulomas.

Management

The management usually involves short-term topical or systemic corticosteroids. Chronic or recurrent inflammation, or patients who respond poorly to corticosteroids, may require long-term or even lifelong use of other systemic immunosuppressants such as TNF-alpha inhibitors, methotrexate and mycophenolate mofetil (3,5,11).

Patients should also be advised to avoid having further tattoos, as further exposure to tattoo ink could exacerbate ocular inflammation. Some patients have experienced resolution of the uveitis after excision of the tattoo (where it is a small, isolated tattoo) (12,13). However, laser tattoo removal is not recommended, as it could worsen the uveitis by dispersing the tattoo ink throughout the body (14).

Conclusion

In summary, tattoo-associated uveitis is a rare but potentially serious cause of intraocular inflammation that may require long-term immunosuppression to prevent vision-threatening complications. Because it is so uncommon, it has been difficult to study and investigate the underlying pathophysiology of the condition. It is believed that tattoo-associated uveitis may be related to sarcoidosis or could represent a delayed hypersensitivity reaction.

It should be encouraged to explore a history of tattoo use in patients presenting with uveitis, and if present, whether the tattoo site became inflamed, swollen, itchy or painful prior to the onset of uveitis. It is also important to examine tattoo sites in these patients. Further research investigating the prevalence of tattoos amongst patients presenting with uveitis would also be useful to gain further understanding of this rare condition.

References

  1. Lubeck G, Epstein E. Complications of tattooing. Calif Med. 1952 Feb;76(2):83–5.
  2. Cunningham ET, Dunn JP, Smit DP, Zierhut M. Tattoo-Associated Uveitis. Ocul Immunol Inflamm. 2021 Jul 4;29(5):835–7.
  3. Carvajal Bedoya G, Caplan L, Christopher KL, Reddy AK, Ifantides C. Tattoo Granulomas With Uveitis. J Investig Med High Impact Case Rep. 2020 Jan-Dec;8:2324709620975968.
  4. Kluger N. Epidemiology of tattoos in industrialized countries. Curr Probl Dermatol. 2015 Mar 26;48:6–20.
  5. Kluger N. Tattoo-associated uveitis with or without systemic sarcoidosis: a comparative review of the literature. J Eur Acad Dermatol Venereol. 2018 Nov;32(11):1852–61.
  6. Saliba N, Owen ME, Beare N. Tattoo-associated uveitis. Eye . 2010 Aug;24(8):1406.
  7. Reinhard R, Gebhardt C, Schmieder A, Umansky V, Utikal J. Recurrent tattoo reactions in a patient treated with BRAF and MEK inhibitors. J Eur Acad Dermatol Venereol. 2017 Aug;31(8):e375–7.
  8. Kesav NP, Kaplan AJ, Hwang CK, Okeagu C, Sen HN. TATTOO-ASSOCIATED CASES OF POSTERIOR SEGMENT UVEITIS WITH VOGT–KOYANAGI–HARADA DISEASE-LIKE FEATURES. Retin Cases Brief Rep. 2022 Jul;16(4):457.
  9. Pandya VB, Hooper CY, Merani R, McCluskey P. TATTOO-ASSOCIATED UVEITIS WITH CHOROIDAL GRANULOMA: A RARE PRESENTATION OF SYSTEMIC SARCOIDOSIS. Retin Cases Brief Rep. 2017;11(3):272–6.
  10. Ostheimer TA, Burkholder BM, Leung TG, Butler NJ, Dunn JP, Thorne JE. Tattoo-associated uveitis. Am J Ophthalmol. 2014 Sep;158(3):637–43.e1.
  11. Nso N, Toz B, Ching TH, Kondaveeti R, Abrudescu A. Tattoo-Associated Sarcoidosis With Severe Uveitis Successfully Treated With Mycophenolate Mofetil: A Report of Two Cases. Cureus. 2021 Aug;13(8):e17197.
  12. Rorsman H, Brehmer-Andersson E, Dahlquist I, Ehinger B, Jacobsson S, Linell F, et al. Tattoo granuloma and uveitis. Lancet. 1969 Jul 5;2(7610):27–8.
  13. Barabasi Z, Kiss E, Balaton G, Vajo Z. Cutaneous granuloma and uveitis caused by a tattoo. Wien Klin Wochenschr. 2008;120(1-2):18.
  14. Piggott KD, Rao PK. Blurry Vision and a Black Ink Tattoo. JAMA. 2019 Feb 19;321(7):699–700.

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