Tattoo-associated uveitis following intravitreal aflibercept injection in a patient with diabetic macular edema: A case report

Tattoo-associated uveitis is a condition thought to result from an immune response to tattoo pigments. Periocular tattoos pose a specific risk due to their proximity to ocular tissues. Intravitreal anti-vascular endothelial growth factor (anti-VEGF) agents such as aflibercept are also known to rarely cause intraocular inflammation (IOI), particularly posterior uveitis. This report describes a unique case of vitritis developing in a patient with diabetic macular edema (DME) following an aflibercept injection in temporal association with a recent periocular tattoo. A 59-year-old male with a history of DME presented with complaints of floaters, moving cobwebs, and progressively blurred vision in the right eye, starting two days after 6th intravitreal injection of 2 mg aflibercept. Anterior segment findings were unremarkable. Dilated fundus examination revealed significant vitritis in the right eye, with dense vitreous cells and opacities obstructing fundus view. Extensive systemic and infectious workup was negative. Three weeks prior to symptom onset, the patient had undergone a new periocular tattoo on the right facial side. The patient opted for outpatient management, including intensive topical steroids, sub-tenon’s betamethasone, intravenous dexamethasone, and an oral prednisone taper. The vitritis resolved in 3 weeks with improvement in visual acuity. In this patient, the close temporal relationship between aflibercept administration and recent periocular tattoo placement suggests a synergistic immunologic response. Detailed history, including recent tattoos and cosmetic procedures, should be routinely obtained in patients with new-onset intraocular inflammation.