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Emergency and Acute Medicine – Iritis (Anterior Uveitis)
Basics and description
Iritis is an inflammatory condition of the anterior uveal tract and is synonymous with anterior uveitis. When the inflammation occurs after blunt or penetrating eye injury, it is referred to as traumatic iritis. The condition may present acutely or follow a chronic, relapsing course and can threaten vision if not recognized and treated appropriately.
Etiology
Most cases of iritis are idiopathic, but many are associated with trauma, systemic inflammatory diseases, infections, malignancies, or drug reactions. Noninfectious systemic associations include ankylosing spondylitis, reactive arthritis (Reiter syndrome), sarcoidosis, Behçet disease, inflammatory bowel disease, juvenile rheumatoid arthritis, Kawasaki syndrome, interstitial nephritis, IgA nephropathy, Sjögren syndrome, and psoriatic arthritis. Infectious causes include viral pathogens such as herpes simplex virus, herpes zoster virus, cytomegalovirus, HIV, rubella, measles, mumps, varicella, adenovirus, and West Nile virus; bacterial causes such as tuberculosis, syphilis, Lyme disease, chlamydia, gonorrhea, brucellosis, pertussis, rickettsial infections, and leprosy; and less commonly fungal infections. Other associations include leukemia, lymphoma, multiple sclerosis, malignant melanoma, cocaine use, pesticide exposure, corneal foreign bodies, and blunt ocular trauma.
Diagnosis and clinical presentation
Acute iritis typically presents with ocular pain, a red eye, photophobia (often consensual), tearing, and mildly decreased visual acuity. On examination, characteristic findings include ciliary flush (perilimbal injection), miosis, inflammatory cells and protein “flare” in the anterior chamber, and sometimes hypopyon. Posterior synechiae, which are adhesions between the iris and the lens, may develop. Intraocular pressure is often low but can occasionally be elevated. Chronic iritis may present with recurrent episodes and few acute symptoms, making diagnosis more challenging.
Essential workup and evaluation
A thorough history and review of systems are critical, as up to half of patients have an associated systemic disease. Slit-lamp examination is diagnostic and reveals leukocytes (“cells”) and protein leakage (“flare”) in the anterior chamber; these findings are best appreciated with a short, wide beam of light. Intraocular pressure should be measured. Relief of pain with topical anesthetic suggests a superficial process and makes iritis less likely.
Diagnostic tests and interpretation
Routine laboratory testing is usually not required in the emergency setting. Further outpatient evaluation should be guided by clinical suspicion and coordinated with ophthalmology and other specialists. Targeted testing may include inflammatory markers, HLA-B27 typing, autoimmune serologies, tuberculosis screening, syphilis testing, Lyme serologies, ACE levels, or imaging such as chest radiography or sacroiliac joint films, depending on suspected systemic disease. Ultrasound biomicroscopy may assist in selected cases.
Differential diagnosis
Conditions that can mimic iritis include acute angle-closure glaucoma, conjunctivitis, corneal abrasion or foreign body, episcleritis, keratitis, intraocular foreign body, posterior segment tumors, and traumatic globe rupture. These must be carefully excluded because management differs significantly.
Treatment and emergency management
The primary goals of treatment are to reduce inflammation, relieve pain, prevent posterior synechiae, and preserve vision. Cycloplegic agents are the cornerstone of initial therapy, as they decrease ciliary muscle spasm, relieve pain and photophobia, and prevent synechiae formation. Topical corticosteroids may be indicated but should only be started in consultation with an ophthalmologist because of the risk of worsening infectious keratitis, particularly herpes simplex virus infection. Secondary glaucoma should be treated if present. Supportive care includes warm compresses, dark glasses, and appropriate analgesia. Identification and treatment of any underlying systemic or infectious cause are essential.
Medications
Cyclopentolate 1–2% is commonly used for mild to moderate inflammation, typically one drop three times daily. Homatropine 2–5% may be used for moderate inflammation. Atropine 1% is reserved for moderate to severe cases and should only be used with ophthalmology guidance. Prednisolone acetate 1% topical drops may be used for inflammation under ophthalmologic supervision. Analgesics such as acetaminophen or acetaminophen with codeine may be given for pain control.
Pediatric considerations
Cycloplegic agents are generally not recommended in children under 6 years of age because of the risk of systemic anticholinergic toxicity, which may cause flushing, tachycardia, hypotension, blurred vision, and hallucinations.
Disposition and follow-up
Hospital admission is rarely required unless there is a significant associated systemic illness. All patients with suspected iritis should be referred to an ophthalmologist within 24 hours for confirmation of diagnosis, monitoring, and adjustment of therapy. Referral to rheumatology, gastroenterology, or other specialists may be necessary when a systemic disease is identified.
Pearls and pitfalls
If topical anesthetic relieves eye pain, iritis is unlikely. Iritis must be distinguished from other causes of painful red eye that can rapidly threaten vision, including keratitis, herpes simplex conjunctivitis, bacterial conjunctivitis, acute angle-closure glaucoma, and globe rupture. Early recognition and appropriate referral are critical to preventing complications and vision loss.
Basics and description
Iritis is an inflammatory condition of the anterior uveal tract and is synonymous with anterior uveitis. When the inflammation occurs after blunt or penetrating eye injury, it is referred to as traumatic iritis. The condition may present acutely or follow a chronic, relapsing course and can threaten vision if not recognized and treated appropriately.
Etiology
Most cases of iritis are idiopathic, but many are associated with trauma, systemic inflammatory diseases, infections, malignancies, or drug reactions. Noninfectious systemic associations include ankylosing spondylitis, reactive arthritis (Reiter syndrome), sarcoidosis, Behçet disease, inflammatory bowel disease, juvenile rheumatoid arthritis, Kawasaki syndrome, interstitial nephritis, IgA nephropathy, Sjögren syndrome, and psoriatic arthritis. Infectious causes include viral pathogens such as herpes simplex virus, herpes zoster virus, cytomegalovirus, HIV, rubella, measles, mumps, varicella, adenovirus, and West Nile virus; bacterial causes such as tuberculosis, syphilis, Lyme disease, chlamydia, gonorrhea, brucellosis, pertussis, rickettsial infections, and leprosy; and less commonly fungal infections. Other associations include leukemia, lymphoma, multiple sclerosis, malignant melanoma, cocaine use, pesticide exposure, corneal foreign bodies, and blunt ocular trauma.
Diagnosis and clinical presentation
Acute iritis typically presents with ocular pain, a red eye, photophobia (often consensual), tearing, and mildly decreased visual acuity. On examination, characteristic findings include ciliary flush (perilimbal injection), miosis, inflammatory cells and protein “flare” in the anterior chamber, and sometimes hypopyon. Posterior synechiae, which are adhesions between the iris and the lens, may develop. Intraocular pressure is often low but can occasionally be elevated. Chronic iritis may present with recurrent episodes and few acute symptoms, making diagnosis more challenging.
Essential workup and evaluation
A thorough history and review of systems are critical, as up to half of patients have an associated systemic disease. Slit-lamp examination is diagnostic and reveals leukocytes (“cells”) and protein leakage (“flare”) in the anterior chamber; these findings are best appreciated with a short, wide beam of light. Intraocular pressure should be measured. Relief of pain with topical anesthetic suggests a superficial process and makes iritis less likely.
Diagnostic tests and interpretation
Routine laboratory testing is usually not required in the emergency setting. Further outpatient evaluation should be guided by clinical suspicion and coordinated with ophthalmology and other specialists. Targeted testing may include inflammatory markers, HLA-B27 typing, autoimmune serologies, tuberculosis screening, syphilis testing, Lyme serologies, ACE levels, or imaging such as chest radiography or sacroiliac joint films, depending on suspected systemic disease. Ultrasound biomicroscopy may assist in selected cases.
Differential diagnosis
Conditions that can mimic iritis include acute angle-closure glaucoma, conjunctivitis, corneal abrasion or foreign body, episcleritis, keratitis, intraocular foreign body, posterior segment tumors, and traumatic globe rupture. These must be carefully excluded because management differs significantly.
Treatment and emergency management
The primary goals of treatment are to reduce inflammation, relieve pain, prevent posterior synechiae, and preserve vision. Cycloplegic agents are the cornerstone of initial therapy, as they decrease ciliary muscle spasm, relieve pain and photophobia, and prevent synechiae formation. Topical corticosteroids may be indicated but should only be started in consultation with an ophthalmologist because of the risk of worsening infectious keratitis, particularly herpes simplex virus infection. Secondary glaucoma should be treated if present. Supportive care includes warm compresses, dark glasses, and appropriate analgesia. Identification and treatment of any underlying systemic or infectious cause are essential.
Medications
Cyclopentolate 1–2% is commonly used for mild to moderate inflammation, typically one drop three times daily. Homatropine 2–5% may be used for moderate inflammation. Atropine 1% is reserved for moderate to severe cases and should only be used with ophthalmology guidance. Prednisolone acetate 1% topical drops may be used for inflammation under ophthalmologic supervision. Analgesics such as acetaminophen or acetaminophen with codeine may be given for pain control.
Pediatric considerations
Cycloplegic agents are generally not recommended in children under 6 years of age because of the risk of systemic anticholinergic toxicity, which may cause flushing, tachycardia, hypotension, blurred vision, and hallucinations.
Disposition and follow-up
Hospital admission is rarely required unless there is a significant associated systemic illness. All patients with suspected iritis should be referred to an ophthalmologist within 24 hours for confirmation of diagnosis, monitoring, and adjustment of therapy. Referral to rheumatology, gastroenterology, or other specialists may be necessary when a systemic disease is identified.
Pearls and pitfalls
If topical anesthetic relieves eye pain, iritis is unlikely. Iritis must be distinguished from other causes of painful red eye that can rapidly threaten vision, including keratitis, herpes simplex conjunctivitis, bacterial conjunctivitis, acute angle-closure glaucoma, and globe rupture. Early recognition and appropriate referral are critical to preventing complications and vision loss.
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