We were very interested to read the recent article by Ostheimer and associates, describing a series of 7 patients with tattoo-associated uveitis. The authors imply that this represents a distinct clinical entity with temporally associated skin inflammation and uveitis, triggered by recent tattooing. Notably, the patients in this series had no evidence of systemic sarcoidosis or infective causes of uveitis. As originally detailed by Rorsman and associates, the proposed underlying pathophysiology of this condition is a specific delayed type of hypersensitivity reaction to particular tattoo pigments, which contain metallic compounds such as cobalt, nickel, and iron. Identification of the specific tattoo pigments that trigger this condition in susceptible individuals would therefore be useful and could lead to elucidation of therapeutic targets.

In our practice, we have managed 3 patients with tattoo-associated uveitis in the last year. One of these patients is a 21-year-old tattoo artist, who presented with bilateral anterior uveitis and skin inflammation, centered on black pigment in extensive whole body tattoos. He was otherwise in good health and did not have any features of systemic inflammation. He responded well initially to oral prednisolone treatment and subsequently commenced methotrexate immune suppression for maintenance therapy. Given the extent of the tattoos, removal was not considered; but despite this, the inflammation has remained under control on follow-up. Further questioning of our patient revealed that the black parts of his tattoos that became inflamed were done with a specific calligraphy ink (Royal Talens, The Netherlands), not recommended for use on human skin for tattooing. In contrast, a different black ink (Kuro Sumi, Islandia, NY, USA) used in other parts of his tattooed skin was not involved in the inflammation.

It is clear that greater awareness among tattoo artists and their clients of the potential problems of certain inks may reduce the frequency of tattoo-associated uveitis. For the ophthalmologist treating uveitis, we would emphasize the importance of thorough systemic evaluation in all cases, including specific examination of the skin, to identify this rare but increasingly recognized condition.