We sincerely appreciate the interest and feedback provided by Drs Mansour and Chan, who astutely noted that there are additional case reports of tattoo-associated uveitis in the literature not referenced in our case series. We originally performed our PubMed literature search in 2013 using the terms “tattoo” and “uveitis.” One such report did not describe associated tattoo inflammation and was therefore excluded, whereas all other articles identified by this search method were mentioned in our report. Drs Mansour and Chan have highlighted additional case reports that complement and enhance our original case series report.
We further commend Drs Mansour and Chan for the information provided by their prior case report, which described tattooed skin exhibiting granuloma formation with a predominance of mononuclear cells. This tissue displayed a high ratio of B lymphocytes and macrophages and an equal number of T-helper and T-suppressor cells, which they reported was indicative of a delayed hypersensitivity response. Drs Mansour and Chan also reported the presence of tattoo swelling 1 week prior to eye involvement in their case report, providing further evidence for the theory of sensitization of dye in the tattoo leading to subsequent recurrences of uveitis.
In our case series, all patients relayed that the onset of their cutaneous and ocular symptoms were simultaneous. The onset of tattoo inflammation and bilateral uveitis can occur with or without additional features consistent with systemic sarcoidosis. Although we feel that the clinical findings of patients in our case series are not inconsistent with the clinical spectrum of sarcoidosis, the lack of additional systemic findings in most patients at the time of our report was discussed, which prompted us to mention the possibility of a hypersensitivity response as the underlying mechanism for this process. We agree that the clinical entity of chronic recurrent anterior uveitis preceded by swelling of skin tattoos as described by Drs Mansour and Chan should be differentiated from similar presentations occurring in the context of systemic sarcoidosis. Hopefully, long-term follow-up of the patients like those described in our series, and further detailed pathologic examination of biopsy specimens from such patients, will help to elucidate this matter further.