A seemingly harmless tattoo can, in rare cases, lead to significant vision loss. Australian eye doctors are reporting a growing number of cases of tattoo-associated uveitis, a rare inflammatory eye condition that can be difficult to treat and potentially cause lasting damage.
Nelize Pretorius, a chef from Australia, experienced this firsthand. After initially being diagnosed with conjunctivitis, her vision began to blur in both eyes. When standard treatments failed, doctors struggled to determine the cause. It wasn’t an issue with her eyes themselves, but a reaction linked to a tattoo she received years prior on her back. “I could hardly see,” Pretorius said. “I was losing my vision and nobody was able to tell me why.” The condition, tattoo-associated uveitis, carries the risk of permanent vision loss, glaucoma, and the need for lifelong immunosuppressant medication.
While previously considered extremely rare, recent research published in Clinical and Experimental Ophthalmology has documented 40 new cases of tattoo-associated uveitis in Australia. This doubles the number of published cases worldwide since 2010, suggesting the condition may be more common than previously thought. The research, conducted by an Australian team, indicates that while still uncommon given the prevalence of tattoos, the risk is not negligible.
Eyes in the Immune ‘Crossfire’
Ophthalmologist Josephine Richards, who treated Pretorius, explains that uveitis occurs when the body’s immune system mistakenly attacks the eye. This can be a complication of autoimmune diseases like arthritis. “We do not know why the eye gets caught in the crossfire,” Dr. Richards said. “There is something about the immune reaction that targets the eye.” Early symptoms include blurred vision, light sensitivity, and eye pain, potentially leading to glaucoma and permanent vision loss if left untreated.
Dr. Richards has observed a recent increase in uveitis cases linked to tattoo ink, sometimes appearing years after the tattoo was applied. The condition is often suspected when inflammation is observed within the tattoo itself, appearing slightly raised and inflamed. “I only became aware of it about four or five years ago, and then once I was aware of it, I had all these patients all of a sudden,” she said. A collaborative discussion with other ophthalmologists revealed a similar trend across multiple practices.
The recent research found that systemic treatment, often including immunosuppression, was needed in 67.5% of cases. Steroid-sparing immunosuppression was required in 62.5% of patients, with biological DMARDs (disease-modifying antirheumatic drugs) used in 42.5% of cases. Only 25% of patients responded adequately to topical treatments alone, and just 27.5% achieved lasting remission off treatment during the study period. Complications such as cataracts, cystoid macular edema, and glaucoma were also observed, with only three patients experiencing no visual loss throughout their care.
Pretorius continues to use steroid eye drops and has spent thousands of dollars on treatment, remaining in contact with Dr. Richards to manage regular flare-ups. “What really worries us is that we’re just not managing to get these people off the drugs,” Dr. Richards said. “Usually with an immune disease, we treat for two years and then slowly wind back treatment and hope that the person’s going to be OK off the treatment. But mostly we’re not managing to wind back the treatment.”
Why is this occurring?
The exact cause of tattoo-associated uveitis remains unclear, but the recent research offers some insights. Black ink tattoos appear to be more frequently associated with the condition, although cases involving pink and red ink have also been reported. The onset of symptoms typically occurs one to two years after receiving the tattoo, but can be delayed for up to 35 years.
Some cases involved tattoos received overseas, including in Bali, complicating efforts to identify the specific ink components responsible. Dr. Richards emphasizes the difficulty in determining the exact dyes used in these tattoos. “We see just so hard to find out what dye was used,” she said. Identifying the problematic dyes is crucial for developing preventative measures.
The condition shares similarities with sarcoidosis, an immune disease characterized by inflammatory cells clustering in various parts of the body. Dr. Richards suggests a possible genetic predisposition, combined with environmental factors, may play a role. “With all immune diseases, there is some genetic predisposition… and then you get exposed to something and that sets you off,” she added. Individuals with a family history of autoimmune diseases may be at increased risk.
How to make tattoos safer
Researchers acknowledge that discouraging people from getting tattoos is unrealistic. Instead, the focus is on understanding the problematic ink components and improving tattoo safety. “So many people get tattooed, and I feel like it would be very hard to stop people from doing it,” Dr. Richards said. “But I would like people to at least know.”
Dr. Richards hopes to raise awareness among both the public and healthcare professionals, enabling earlier diagnosis and treatment. While the risk remains low, recognizing the potential link between tattoos and vision loss is crucial. Pretorius emphasizes the importance of awareness, stating, “I think that my case in particular, was one of the first cases that Dr Richards had in Perth… It’s just lucky that she knew about it because if she wasn’t there on that day, I may still not know what the issue is.”
