SIGNS AND SYMPTOMS 
- Acute presentation:
- Ocular pain, red eye
- Photophobia (consensual)
- Lacrimation
- Decreased visual acuity (usually mild)
- Cells and flare in anterior chamber; hypopyon
- Posterior synechiae (adhesions of iris to lens)
- Miosis
- Low intraocular pressure (occasionally may be high)
- Injection of perilimbal vessels (ciliary flush)
- Chronic presentation:
- Recurrent episodes
- Few or no acute symptoms
ESSENTIAL WORKUP
- History and review of systems:
- Up to 50% may be associated with systemic disease.
- Slit-lamp exam:
- Inflammatory cells (leukocytes) or "flare" in the anterior chamber are diagnostic.
- Flare is a homogeneous fog secondary to protein leakage into aqueous humor.
- Use short, wide beam to best appreciate cells and flare.
- Cellular deposits with more severe inflammation
- Intraocular pressure measurement
- If topical anesthesia relieves pain, probably not iritis.
DIAGNOSIS TESTS & INTERPRETATION
- None usually indicated
- Tailored outpatient workup if history, signs, and symptoms point strongly to a certain cause (with referral to ophthalmology, rheumatology, or internal medicine)
Lab
- TB:
- Sarcoidosis:
- Ankylosing spondylitis:
- Inflammatory bowel disease:
- Reiter syndrome:
- HLA-B27
- Cultures of conjunctiva and urethra
- Psoriatic arthritis:
- Lyme disease:
- Juvenile rheumatoid arthritis:
- Antinuclear antibody
- Rheumatoid factor
- Sarcoidosis:
- STI:
- Rapid plasma reagin or VDRL test
- Fluorescent treponemal antibody absorption test
- Appropriate cultures
Imaging
- Ankylosing spondylitis:
- Sacroiliac spine radiograph
- Sarcoidosis:
- TB:
Diagnostic Procedures/Surgery
US biomicroscopy can be used to help to diagnose pathologies.
DIFFERENTIAL DIAGNOSIS
[Outline]
INITIAL STABILIZATION/THERAPY
- Goal:
- Reduce inflammation and prevent complications
- Cycloplegic agent (short-acting):
- Decreases pain, photophobia
- Prevents development of posterior synechiae
ED TREATMENT/PROCEDURES
- Cycloplegia
- Topical steroids if indicated:
- Use with caution, in consultation with ophthalmologist.
- May cause significant complications (i.e., progression of herpes simplex virus keratitis)
- Treat secondary glaucoma.
- Supportive measures:
- Warm compresses
- Dark glasses
- Analgesia
- Identification of cause:
- Initiate appropriate management.
- Ankylosing spondylitis:
- Systemic anti-inflammatory agents
- Physical therapy
- Inflammatory bowel disease:
- Reiter syndrome:
- Behçet disease:
- Systemic steroids or immunosuppressive agents
- Infectious causes:
- Appropriate management of underlying infection
MEDICATION
- Cycloplegic:
- Cyclopentolate 1–2% for mild to moderate inflammation: 1 drop TID (lasts up to 24 hr)
- Homatropine 2% or 5% for moderate inflammation: 1 drop TID (lasts up to 3 days)
- Atropine 1% for moderate to severe inflammation (should only be used in consultation with ophthalmologist): 1 drop TID (lasts 7–14 days)
- Topical steroid (should only be used in consultation with ophthalmologist):
- Prednisolone acetate 1%: 1 drop q1–6h, depending on severity
- Analgesic:
Pediatric Considerations
- Cycloplegics not recommended in children < 6 yr:
- May cause systemic anticholinergic toxicity with blurred vision, flushing, tachycardia, hypotension, and hallucinations.
[Outline]
DISPOSITION
Admission Criteria
Not indicated unless significant systemic illness
Issues for Referral
- Iritis:
- Refer to ophthalmologist within 24 hr for follow-up care and possible steroid therapy.
- Inflammatory bowel disease:
- Reiter syndrome:
- Psoriatic arthritis:
- Juvenile rheumatoid arthritis:
- Bertolini J, Pelucio M. The red eye. Emerg Med Clin North Am. 1995;13:561–579.
- Dargin JM, Lowenstein RA. The painful eye. Emerg Med Clin North Am. 2008;26:199–216, viii.
- Kunimoto DY, Kanitkar KD, Makar M. The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Diseases. 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2004.
- Leibowitz HM. The red eye. N Engl J Med. 2000;343:345–351.
- Ventura A, Hayden B, Taban M, et al. Ocular inflammatory diseases. Ultrasound Clin. 2008;3(2):245–255.
- Weinberg RS. Uveitis. Ophthalmol Clin North Am. 1999;12:71–79.
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