Black Ink Tattoos, An Underestimated Differential for Uveitis

Uveitis has some 2 dozen known etiologies. Body art ink is a less commonly known causal factor, but can be involved in cases of granulomatous and nongranulomatous uveitis. A remarkable case report of black ink tattoo-associated posterior-intermediate uveitis was presented at the annual meeting of the American Society of Cataract and Refractive Surgery (ASCRS), held in Las Vegas, on July 23 to 27, 2021.

The patient, a 39-year-old woman, presented with pain, irritation, and light sensitivity, as well as inflammatory cells appearing bilaterally in the anterior chamber and vitreous — puff balls at the ora junction were also visible.¹ Laboratory and imaging evaluations came back negative for a specific disease origin, although medical history revealed that the patient’s chronic, intermittent ocular inflammation typically occurred at the same time as induration and swelling in regions of skin with black ink tattoos. Colored tattoos without black were not affected, the report shows. There was no hardening or inflammation in the tattoos after they were initially set.¹

Uveitis associated with black ink body art may be off the radar of researchers. However, “A straw poll suggests that this entity is possibly more common than once believed,” according to the investigators. Nevertheless, the American Academy of Ophthalmology published a study of seven such uveitis cases in 2014 treated at Wilmer Eye Institute during an 18-month time period.² The patients, from 20 to 42 years of age also experienced concurrent indurated and raised skin at sites of black-ink-only tattoos. Systemic high-dose corticosteroid therapy reduced inflammation in all seven, and three also needed immunomodulatory therapy.²

To date, a number of affected tattoos have revealed on biopsy a sarcoid-like effect, including granulomatous lesions consisting of not only inflammatory cells, but also bits of black pigment.¹ 

“Pathophysiology is believed to involve molecular mimicry, and a CD4+, TH1 immune response is observed,” according to the study.¹ This condition can occur more often in those with a large number of black ink body art, according to research. Tattoo-associated uveitis has been treated with immunosuppressive medication and biologics, or with tattoo excision.

The patient highlighted in the current study displayed resolution of symptoms with oral prednisone, but her acute uveitis recurred when the steroid was gradually reduced.¹ Clinicians were able to effectively treat the patient’s ocular inflammation with a biologic, adalimumab.¹

References

1. Shader JD, Khademi ZN, Boniske C. Art & Science, a Fascinating Case of Black Ink Tattoo Associated Uveitis. Presented at the American Society of Cataract and Refractive Surgery (ASCRS) annual meeting; July 23–27, 2021; Las Vegas, Nevada. Poster 72497.

2. Moorthy, Ramana S., MD; American Academy of Ophthalmology. Seven cases of tattoo-associated uveitis. https://www.aao.org/editors-choice/seven-cases-of-tattooassociated-uveitis. Published July 24, 2014. Accessed July 21, 2021.