Physicians who treat uveitis should ask patients about any tattoo changes. Some component of black tattoo ink may act as an environmental trigger-leading to the development of simultaneous bilateral ocular inflammation and elevation of tattooed skin.

Listen to Trucian Ostheimer, MD, present cases of tattoo-associated uveitis and his findings during the annual Current Concepts in Ophthalmology meeting at the Wilmer Eye Institute/Johns Hopkins University.

Take-home

By Liz Meszaros; Reviewed by Trucian Ostheimer, MD

Baltimore-Though tattoo-associated uveitis is rarely reported, the likelihood of its presence is more common than the literature would suggest, according to Trucian Ostheimer, MD.

Only eight cases of patients with uveitis and associated changes in tattooed skin have been published in the English literature, noted Dr. Ostheimer, a second-year uveitis fellow, Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore.

Interestingly, he has seen seven such patients since beginning his fellowship with the Wilmer Ocular Immunology Service.

“All of these patients were young, aged 20 to 44 years, at the time of presentation,” Dr. Ostheimer said.

Five of seven patients had bilateral non-granulomatous anterior uveitis-four with chronic and one with recurrent disease. Two patients had bilateral chronic granulomatous panuveitis. Initial visual acuity varied widely.

Five of seven patients presented with potentially vision-threatening ocular complications, such as severe cystoid macular edema, neurosensory retinal detachment, and iris bombe.

What they had in common

Most of the patients had extensive tattoos, and many of these were multicolored. Interestingly, only portions of tattooed skin containing black pigment were affected and visibly raised.

No abnormalities were noted in the portions of tattoo containing other types of pigment, Dr. Ostheimer noted.

All seven patients underwent routine examination and received a focused uveitic workup to exclude syphilis, sarcoidosis, and other selected etiologies.

Ocular manifestations

The pathologic hallmark of sarcoidosis is the non-caseating granuloma, but it remains a diagnosis of exclusion because of its lack of pathognomonic histopathology, imaging, or serologic studies.

Anywhere from 25% to 80% of those with sarcoidosis develop ocular or adnexal involvement. Anterior uveitis is the most common ocular manifestation, accounting for 65% of patients with ocular involvement. About 25% to 35% of those with sarcoidosis develop skin findings, Dr. Ostheimer said.

Various patterns of reactions occur in tattooed skin, and one of the more common findings is granulomatous inflammation.

“Histologically, this can be classified as a foreign body or sarcoid-type reaction, and the differentiation of these two types of granulomas may be challenging and open to controversy,” Dr. Ostheimer said. “The skin biopsies performed in two of our patients and in some prior reports displayed non-caseating inflammation in association with dermal tattoo pigment that I believe is consistent with, but not specific for, sarcoidosis.

“Unfortunately, these biopsies, although interesting, do not seem to tell us what the actual cause is,” he said.

“It’s useful as part of your uveitic review of systems to ask patients who have uveitis about tattoo changes,” Dr. Ostheimer continued. “It is purely speculative, but I think it is reasonable to conclude that there may be some component of black tattoo ink that acts as an environmental trigger-leading to the development of simultaneous bilateral ocular inflammation and elevation of tattooed skin.”

Altogether, the physical findings in these patients may represent a forme fruste of sarcoidosis, Dr. Ostheimer concluded.

A manuscript detailing his findings in currently under review.

Trucian Ostheimer, MD

P: 410/955-2966

E: tosthei1@jhmi.edu

This article was based on Dr. Ostheimer's presentation at the annual Current Concepts in Ophthalmology meeting at Wilmer Eye Institute/Johns Hopkins University, Baltimore. He has no financial interest in the subject matter.

Suggested reading

Anolik R, Mandal R, Franks A. Sarcoidal tattoo granuloma. Dermatology Online Journal. 2010;16:19.

Barbarasi Z, Kiss E, Balaton G, Vajo Z. Cutaneous granuloma and uveitis caused by a tattoo [in German]. Wien Klin Wochenschr. 2008;120:18.

Bonfioli AA, Orefice F. Sarcoidosis. Semin Ophthalmol. 2005;20:177â182.

Iannuzzi MC, Rybicki BA, Teirstein AS. Sarcoidosis. N Engl J Med. 2007;357:2153â2165.

Lubeck G, Epstein E. Complications of tattooing. Calif Med. 1952;76:83â85.

MoralesâCallaghan AM, AquilarâBernier M, MartinezâGarcia G, MirandaâRomero A. Sarcoid granuloma on black tattoo. J Am Acad Dermatol. 2006;55(5 Suppl):S71â3. Epub 2006 Aug 28.

Marcoval J, Mana J, Moreno A, et al. Foreign bodies in granulomatous cutaneous lesions of patients with systemic sarcoidosis. Arch Dermatol. 2001;137:427â430.

Post J, Hull P. Tattoo reactions as a sign of sarcoidosis. CMAJ. 2012;184:432.

Rorsman H, BrehmerâAndersson E, Dahlquist I, et al. Tattoo granuloma and uveitis. Lancet. 1969;294:27â28.

Saliba N, Owen M E, Beare N. Tattooâassociated uveitis. Eye. 2010;24:1406.

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