Wall of Fame

Tattoo-induced uveitis

Congratulations to Natasa Draca and Ratko Lazic for submitting the Retina Rocks Case of the Month. Vision was 20/25 OD and 20/20 OS. Anterior segments were normal. There was mild bilateral vitritis and scattered amelanotic subretinal lesions in each posterior pole (image 2 and 3, top). Fluorescein angiography showed staining of these lesions (images 2 and 3, middle) with cystoid leakage in his right macula (image 2, middle). OCT scanning showed a mild epiretinal membrane with cystoid edema OD (image 2, bottom). The initial differential diagnosis included birdshot chorioretinopathy and sarcoidosis. The initial differential diagnosis included birdshot chorioretinopathy and sarcoidosis. HLA-A29 was negative, but on further questioning he told us that the tattoos on his arms always became swollen and painful prior to the recurrent uveitis (image 1, right upper arm). A biopsy of one of the inflamed tattoos revealed inflammation granulomatosa, classified as a foreign body or sarcoid type reaction. However, sarcoidosis workup, including angiotensin converting enzyme, chest X-ray and chest computed tomography, were all normal. The uveitis continues to be treated as needed with oral and topical steroids. Tattoo-associated uveitis presents as a bilateral granulomatous anterior or panuveitis (see Ostheimer et al, AJO 2014;158;637-643). Although the uveitis can often develop years following the tattoo placement, ocular inflammation usually occurs concurrent with raised and indurated tattoos. Skin biopsy of these inflamed lesions shows noncaseating granulomatous inflammation surrounding the tattoo pigment. This inflammation is felt to represent an immune response against the dermal pigment, and sarcoidosis is a known risk factor. The uveitis can be controlled with systemic steroids and/or immunosuppressants.