Tattoo-associated Uveitis Presenting to the Emergency Department

Abstract

Eye complaints are common presentations to the emergency department that require prompt diagnosis and appropriate care to prevent visual impairment. Uveitis is a serious cause of visual problems needing urgent treatment. An uncommon etiology of uveitis is secondary to a systemic autoimmune reaction to dermal tattoos, whereby tattoo ink serves as an antigenic trigger that targets the eye. In this case, we describe a 22-year-old male who presented with 2 weeks of eye pain and blurred vision. Physical examination revealed conjunctival injection with decreased visual acuity bilaterally and skin peeling with elevation exactly along the lines of his tattoos. Based on these unusual but concomitant findings, a diagnosis of tattoo-associated uveitis was made. The patient received an emergency ophthalmology consultation and was treated with topical steroids. When presented with clinical findings of uveitis, physicians should ask about and inspect tattoos as a possible etiology of systemic inflammation, which may be overlooked.

INTRODUCTION

Eye complaints are a common presentation to the emergency department (ED), and serious causes must be considered. One such etiology, although rare, is tattoo-associated uveitis. Over the last 10 years, the prevalence of body tattoos has increased, with recent polls showing 30% of Americans have at least one.[1] With a rising number of tattoos, we can expect a corresponding increase in the number of tattoo-related complications. While the most common complication is acute local inflammation, infections, allergic contact dermatitis, and other inflammatory immune responses can also occur.[2] Although long-term sequelae of tattooing are less well-documented, an increasing number of case reports have identified an association between tattoo inflammation and uveitis.[3,4,5,6,7] In this case report, we review a patient who presented with visual changes and concurrent tattoo inflammation.

CASE REPORT

A 22-year-old male with no significant past medical history presented to the ED complaining of bilateral ocular pain, photophobia, and blurred vision for 2 weeks. The patient had been seen at an outside facility a few days earlier and was noted to have normal Wood’s lamp and slit-lamp examinations. He was prescribed ophthalmic ketorolac and oral prednisone, which initially provided mild relief. The patient then experienced worsening conjunctival injection and photophobia, resulting in his presentation to our ED. Upon further investigation, the patient revealed that tattoo lines on his chest and arms had become elevated with peeling starting 1 month prior. He had acquired these tattoos at different times over the prior two to 3 years.

Ophthalmologic examination revealed conjunctival injection, pain with ocular movement, and decreased visual acuity of 20/200 in each eye. Pupils were equally round and reactive to light. Dermatologic examination revealed black ink tattoos located across the chest and upper extremities with raised edges and peeling of the skin. No skin changes were noted outside of the tattoos.

With concomitant uveitis and tattoo inflammation, a diagnosis of tattoo-associated uveitis was made. Given the severity of this disorder with the potential for visual loss, specialists at a local eye institute were emergently consulted by telephone. They recommended topical prednisolone administration in each eye and transfer to their ophthalmology ED facility. The patient was discharged from our ED and instructed to have his partner drive him directly to the specialty facility for further evaluation and management.

Follow-up with the patient at 4 months post-ED visit revealed he was improving but was still experiencing some redness and swelling of the eyes and persistently raised edges of the tattoos. After being treated at the ophthalmology ED, the patient reported not having been prescribed any further medication, and he continued to follow-up with his ophthalmologist as an outpatient.

DISCUSSION

Emergency physicians commonly encounter eye pain as a chief complaint. Appropriate diagnosis and treatment are imperative, as some ocular pathologies may lead to serious complications, such as glaucoma, macular edema, retinal detachment, and vision loss. Uveitis is one consequential cause of eye pain and accounts for roughly 30,000 new cases of legal blindness in the United States every year.[8] This pathology is defined as inflammation of the uveal tract, which includes the iris, ciliary body, or choroid. Uveitis can be caused by multiple etiologies, such as autoimmune, inflammatory, and immunosuppressive disorders, although most cases are idiopathic.[8] Underlying systemic causes of uveitis should especially be suspected if uveitis is bilateral, granulomatous, or recurrent.[8]

A more unusual cause of uveitis is associated with an autoimmune reaction to tattoos, which then targets the eye. Uveitis as a late sequela of tattooing may be associated with systemic sarcoidosis or a delayed hypersensitivity reaction, where the ink serves as an antigenic trigger.[6] Recent studies have further explored this rare correlation, and a literature review from 2018 found only 39 reported patients diagnosed with tattoo-associated uveitis over the course of 66 years.[9] Cases associated with sarcoidosis, characterized by noncaseating epithelioid cell granulomas on tattoos, have been reported for over 80 years and are more likely to occur in male patients with black ink tattoos.[9] While eye manifestations are a very common symptom of sarcoidosis, uveitis and tattoo granulomas have also been reported in the absence of systemic sarcoidosis.[10] For this reason, Kluger coined the term “tattoo granulomas with uveitis” to describe isolated uveitis with granulomatous cutaneous reaction restricted to tattoos in the absence of systemic sarcoidosis.[9]

The physiopathology of tattoo-associated uveitis is not well understood, but multiple hypotheses have been suggested. Some view this phenomenon as a delayed hypersensitivity reaction, where aging tattoo pigment migrates into the deeper dermis and eventually into the lymphatic system, which then manifests systemically.[2] It has been speculated that as this allergen is absorbed, it may eventually accumulate in the uvea and induce ocular inflammation,[4] although the potential for tattoo particles to migrate beyond lymph nodes has not yet been proven. It has also been proposed that tattoo-associated uveitis is the initial presentation of sarcoidosis, and the antigenic components of certain tattoo inks serve as a trigger for genetically susceptible individuals.[9] In patients with tattoos, the sudden eruption of a papulonodular skin rash within a particular pigment in a tattoo can be the initial manifestation of undiagnosed sarcoidosis.[9]

In our case, a thorough history and physical exam of the patient revealed the finding of tattoo inflammation, as without this additional information, the diagnosis would not have been made. Patients diagnosed with tattoo-associated uveitis would benefit from further evaluation for new-onset sarcoidosis to limit potential complications of this disease. Treatment options may include topical or systemic corticosteroids as well as immunosuppressive treatments. Excision of the inflamed tattoo has also reportedly improved the uveitis in some patients.[5] Treatment should be administered urgently to avoid vision-threatening complications of intraocular inflammation such as posterior synechiae, pupillary membrane, cystoid macular edema, iris bombe, and uveitic glaucoma.[3]

Patients presenting with uveitis should be asked about tattoos, and these tattoos should be evaluated for signs of inflammation. Treatment options may include topical or systemic corticosteroids or immunosuppressive treatments. The ophthalmologic examination should be rapid to avoid vision-threatening complications, and tattoo excision may even be recommended in very severe cases.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

Research quality and ethics statement

The authors followed applicable EQUATOR Network (https://www.equator-network.org/) guidelines, notably the CARE guideline, during the conduct of this report.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.