Author:
ReneMack
YasuharuOkuda
Description
- Inflammation of anterior uveal tract
- Iritis, anterior uveitis, and iridocyclitis are synonymous
- Iritis secondary to trauma is also called traumatic iritis
- Acute and chronic presentations
Etiology
- Most cases are idiopathic, but may be traumatic or associated with numerous infectious and noninfectious systemic diseases
- Most prevalent in 30-50-yr old patients
- M:F distribution is equal
- May be acute or chronic
- HLA B27 haplotype causative in up to 50% of cases
- Ankylosing spondylitis
- Inflammatory bowel disease
- Reactive Arthritis/Reiter syndrome
- Psoriatic arthritis
- Other noninfectious systemic diseases include the following:
- Rheumatoid arthritis
- Sarcoidosis
- Behçet disease
- Juvenile rheumatoid arthritis
- Kawasaki syndrome
- Interstitial nephritis
- IgA nephropathy
- Multiple sclerosis
- Drug reactions
- Sjögren syndrome
- Infectious conditions include the following:
- Viral:
- Herpes simplex virus, type 1 (most common)
- Rubella
- Measles
- Adenovirus
- Epstein-Barr virus
- Herpes zoster virus
- HIV
- Mumps
- Varicella
- Cytomegalovirus
- West Nile virus
- Chikungunya
- Dengue
- Zika
- Bacterial:
- Tuberculosis
- Syphilis
- Pertussis
- Brucellosis
- Lyme disease
- Chlamydia
- Rickettsia
- Gonorrhea
- Leprosy
- Leptospirosis
- Cat scratch disease
- Fungal
- Malignancies include the following:
- Leukemia
- Lymphoma
- Multiple sclerosis
- Malignant melanoma
- Retinoblastoma
- Other causes include the following:
- Cocaine use
- Exposure to pesticides
- Corneal foreign body
- Blunt trauma
- Postoperative complication
Signs and Symptoms
History
- May be due to trauma or spontaneous onset
- Acute presentation:
- Unilateral ocular pain
- Red eye (conjunctivitis)
- Photophobia
- Usually present for evaluation within hours to days of onset
- Lacrimation but usually no discharge
- Blurry vision/decreased visual acuity
- Chronic presentation:
- Recurrent episodes
- Few or no acute symptoms
- Bilateral ocular involvement
Physical
- Diffuse conjunctival injection with prominence of perilimbal vessels (ciliary flush)
- Irregular, poorly reactive pupil
- Consensual photophobia
- Cells and flare in anterior chamber
- Topical anesthesia likely not effective for pain relief
- Synechiae (adhesions of iris to lens or cornea) may be seen in chronic disease
- Miosis due to spasm of the iris and ciliary muscles
- Low intraocular pressure (occasionally may be high) due to ciliary body malfunction and decreased aqueous production
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
- Visual acuity
- Pupillary reflex exam
- Fluorescein staining for possible corneal insult or infection
Diagnostic Tests & Interpretation
- None usually indicated especially if:
- First occurrence
- Unilateral
- Healthy individual
- Noncontributory H&P
- Tailored outpatient workup if history, signs, and symptoms point strongly to a certain cause (with referral to ophthalmology, rheumatology, or internal medicine)
Lab
- PCR and ELISA testing of any cultures
- TB:
- Purified protein derivative (PPD)
- 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
- Anterior chamber paracentesis
Differential Diagnosis
- Acute angle-closure glaucoma
- Conjunctivitis
- Corneal abrasion
- Corneal foreign body
- Episcleritis
- Intraocular foreign body
- Keratitis
- Posterior segment tumor
Initial Stabilization/Therapy
- Goal
- Reduce inflammation
- Provide pain relief
- Prevent complications
ED Treatment/Procedures
- Topical steroids:
- Most helpful but begin use after consultation with ophthalmologist
- May cause significant complications (i.e., progression of herpes simplex virus keratitis)
- Cycloplegics:
- Provide pain control by relieving ciliary spasm
- Prevents development of posterior synechiae
- Treat secondary glaucoma
- Supportive measures:
- Dark glasses
- Oral analgesia
- Identification of cause and initiate appropriate management:
- Noninfectious systemic disease
- Infectious
- Malignant
- Traumatic
Medication
First Line
- Topical corticosteroid (should only be used after consultation with ophthalmologist):
- Prednisolone acetate 1%: 2 drops every 15-30 min × 4, then q6h for 2-3 d
Second Line
- Cycloplegic/mydriatic:
- Homatropine 5%: 1 drop q6h for up to 4 d
- Cyclopentolate 1%: 1 drop q8h for up to 4 d
- Analgesia:
- Oral nonsteroidal anti-inflammatory (NSAID)
- Tylenol
- Narcotic pain relievers
Pediatric Considerations |
- Cycloplegics not recommended in children <6 yr:
- May cause systemic anticholinergic toxicity with blurred vision, flushing, tachycardia, hypotension, and hallucinations
- Codeine not recommended for children, <12 yr
|
Pregnancy Prophylaxis |
| Codeine not recommended during pregnancy and breastfeeding |
Disposition
Admission Criteria
Not indicated unless significant systemic illness
Issues for Referral
- Idiopathic iritis:
- Refer to ophthalmologist within 24 hr for follow-up care and possible steroid therapy
- If not likely to be idiopathic cause, follow up with the appropriate consultation specialty
- BealC, GiordanoB. Clinical evaluation of red eye in pediatric patients . J Pediatr Health Care. 2016;30(5):506-514.
- DeibelJ, CowlingK. Ocular inflammation and infection . Emerg Med Clin N Am. 2013;31(2):387-397.
- TarffA, BehrensA. Ocular emergencies: Red eye . Med Clin N Am. 2017;101(3):615-639.
- WallsRM, HockbergerRS, Gausche-HillM, eds. Rosen's Emergency Medicine: Concepts and Clinical Practice. 9th ed.Philadelphia, PA: Elsevier; 2018.
See Also (Topic, Algorithm, Electronic Media Element)