We appreciate the letter from Pandya and associates describing 1 of 3 patients with tattoo induration and uveitis that are under their care. We have had several colleagues approach us with similar descriptions and have discovered another 3 cases in our practice, indicating that perhaps this is an underreported clinical entity. We were not able to investigate the source of the tattoo ink in our patients, so we are particularly grateful for this added information. It is not surprising that the calligraphy ink, which is not recommended for tattooing, would be more likely to cause skin inflammation than an ink specifically designed for tattooing (Kuro Sumi, Islandia, NY, USA). The authors raise an important issue in that it is possible that those patients with skin inflammation associated with tattooing may have received tattoos with ink that was not specifically designed for tattooing. Confusing the picture further, many if not most of the tattoo ink brands, such as Kuro Sumi, do not share the ingredients of their inks, and those tattoo inks considered to be of high quality may be subject to counterfeiting.
Further investigation as to the type of ink used in patients with inflamed tattoos and uveitis may help better define whether this reaction is limited to certain types of inks. We thank the authors and reiterate their suggestion that ophthalmologists treating uveitis should question patients regarding tattoos and tattoo inflammation in order to better define the prevalence of this clinical entity.