We read with great interest the article by Ostheimer and associates. This is the largest series reporting 7 cases gathered over 18 months at the Ocular Immunology Service at the Wilmer Eye Institute, denoting that the discussed entity is not rare. We attribute this large number to both an increased awareness of the medical community to health hazards of tattooing and increasing numbers of subjects undergoing artistic tattooing.
The authors mentioned in their report that “Altogether, the clinical presentation of the patients collected for this series nearly equals the cumulative number of previously reported cases.” The authors mentioned 7 references, while we could gather 20 additional cases using Google Scholar or Scopus search engines, with 14 cases mentioned by references 2–6 (owing to space limitations).
The paper lacks mention of pivotal immunopathologic findings that help in clarifying further the relationship between sarcoidosis and tattoo granulomas. Mansour and Chan reported a case of recurrent bilateral uveitis in a 35-year-old Hispanic man with extensive skin tattoos. Biopsy of the tattoos revealed non-necrotizing granulomas surrounding pigment granules. Immunopathology of the lesions during the phase of acute swelling showed nests of infiltrating cells in the dermis, consisting mainly of T and B lymphocytes as well as macrophages. Ninety percent of the infiltrating cells stained positive for major histocompatibility complex class 2 antigens. In this case there was a high ratio of B lymphocytes and macrophages with equal numbers of CD4+ and CD8+ T cells, characteristic of delayed-type hypersensitivity, in contrast to sarcoidosis.
The temporal relationship between uveitis and swelling of skin tattoos is important in differentiating sarcoidosis from tattoo inflammation–related uveitis. Mansour and Chan described the tattoo swelling to precede uveitis by 1 week on repeated episodes (also reported by others ). This repeated temporal sequence is additional evidence for the theory of sensitization to the dye in the tattoo with subsequent flare of the ocular inflammation. In addition, resolution of uveitis following excision of inflamed tattoos does favor the tattoo-induced granuloma and not sarcoidosis. Last, absence of signs and symptoms of systemic sarcoidosis also supports a tattoo granuloma with uveal inflammatory response to the circulating dye.
Many questions remain unanswered, such as why the vast majority of cases involved men (could it be related to extensive tattooing in men while tattooing is more site-specific in women?).
We commend the authors for reminding ophthalmologists to look for this unique cause of uveitis, and for emphasizing the existing risk of blindness from artistic tattoos and the need for better control of human use of dye materials. The clinical entity of chronic recurrent anterior uveitis preceded by swelling of skin tattoos needs to be differentiated from the same manifestations occurring in the context of systemic sarcoidosis.