Blurry vision, eye pain: An unexpected trigger

Published on 4 May 2026

While tattoos and eye conditions may seem unrelated, tattoo ink particles can trigger uveitis through a delayed immune reaction.

At a glance

• The Department of Ophthalmology at NUH sees an average of one to three cases of tattoo-associated uveitis (TAU) a year.
• In genetically predisposed patients, components of tattoo ink appear to act as persistent triggers of the immune system rather than inert pigments.
• Management of TAU entails a multidisciplinary approach, requiring collaboration with other specialties, including dermatology and rheumatology.

When Annie*, in her 30s, first developed redness, pain and blurry vision in her right eye in 2022, and subsequently in her left eye, she did not expect these symptoms to be related to her tattoos. “I got my first tattoo about seven years ago, and progressively got several more on my thighs and chest over the years since,” she shared.

Annie sought medical attention from a private practitioner for the troubling symptoms and was prescribed eyedrops. “I was on the eyedrops for a really long time before the symptoms went away, but the symptoms returned a year later,” she explained. “I went back for another consultation, but my eye didn’t get better.”

Annie was subsequently referred to the Department of Ophthalmology at the National University Hospital (NUH) and later on seen by Dr Dawn Lim, Senior Consultant, Head of Ocular Immunology, Department of Ophthalmology, NUH, who has dual sub-specialty practices in the fields of uveitis and glaucoma.

Piecing the puzzle

Dr Lim, who first attended to Annie about three years ago, performed a comprehensive series of eye checks and blood tests before diagnosing her with TAU.

There is no single definitive test to diagnose TAU, which is a potentially sight-threatening condition caused by a presumed immune reaction to tattoo pigments, particularly black ink. It may be diagnosed by recognising a characteristic pattern of eye inflammation, while excluding other causes of uveitis. The clinical diagnosis requires a high index of suspicion.

“For most people, tattoos remain immunologically silent after healing,” Dr Lim explained. “However, in a small, genetically predisposed group of individuals, whose immune systems respond abnormally to certain environmental triggers, it may cause tattoo-associated inflammation.”

“From an article published in the American Journal of Ophthalmology, the production of black tattoo ink is reportedly based on soot, which contains substances known to trigger inflammation.”

Research has shown that tiny particles in this type of ink, known as carbon black nanoparticles, can provoke immune reactions and cause cellular stress when the body is exposed to them over long periods. These particles are usually harmless for most people, but in susceptible individuals they may spark an abnormal immune response.

Once thought to be extremely rare due to an underappreciated link between tattoos and uveitis, TAU is now increasingly reported, reflecting the rising popularity of tattoos.

An army that never switches off

While the immune system plays a pivotal role in fending off harmful pathogens, a persistently triggered state can evoke an exaggerated response, creating inflammation in different parts of the body.

“The immune system is our ‘army’, designed to attack foreign invaders such as germs,” explained A/Prof Manjari Lahiri, Senior Consultant, Division of Rheumatology and Allergy, Department of Medicine, NUH. “When the threat is gone, the immune system automatically ‘switches off’.”

“However, in some genetically predisposed people, it can either be triggered abnormally from environmental or ‘self’ triggers, or remain persistently triggered without the ‘off switch’.”

Instead of being ignored by the immune system, the tattoo ink may provoke an exaggerated immune response characterised by activation of immune cells, leading to release of certain chemicals called cytokines and formation of granulomas, which are areas of chronic inflammation in the body.

Why the eyes?

While the mechanisms that lead to ocular inflammation are poorly understood, studies have revealed that once an immune response is systemically activated, inflammatory cells can localise to immune sensitive tissues in the eye. Tattoos may trigger the immune response where the eyes can potentially be involved.

“The eyes are a potential target of systemic granulomatous inflammation, and anterior uveitis is the most frequent ocular manifestation of sarcoidosis, an inflammatory disease characterised by the formation of granulomas,” explained Dr Lim.

This exaggerated immune response is not isolated to just the eyes. “The immune system may also start attacking other organs besides the eye – such as the lungs, heart, joints and skin in these patients,” added Dr Julian Lim, Associate Consultant, Division of Rheumatology and Allergy, Department of Medicine, NUH.

For Annie, who has large swathes of black and colourful tattoos, receiving the diagnosis and appropriate treatment brought much relief. “Dr Lim started me on a regime of high-dose oral steroids and eyedrops,” she explained. “My dosage was tapered down gradually and carefully with the introduction of a steroid sparing medication (subcutaneous adalimumab biosimilar injections).”

Today, Annie takes an extremely low dose of oral steroids twice a week and administers subcutaneous adalimumab biosimilar injections through her abdomen twice a month to keep her condition under control.

She has follow-up appointments once every three to six months, to monitor her condition, and is seen in the NUH Eye and Rheumatology in Adults (NUH ERA), a multidisciplinary collaborative clinic co-run by NUH Ophthalmology doctors and A/Prof Manjari Lahiri and Dr Julian Lim from the Division of Rheumatology and Allergy, Department of Medicine.

In consultation with Dr Dawn Lim, Senior Consultant, Head of Ocular Immunology Service, Department of Ophthalmology, NUH; A/Prof Manjari Lahiri, Senior Consultant, Division of Rheumatology and Allergy, Department of Medicine, NUH and Dr Julian Lim, Associate Consultant, Division of Rheumatology and Allergy, Department of Medicine, NUH.