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Iritis, Emergency Medicine

Basics

Description

- Malignancies include the following: - Leukemia - Lymphoma - Multiple sclerosis - Malignant melanoma

- Other causes include the following: - Cocaine use - Exposure to pesticides - Corneal foreign body - Blunt trauma

- 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)

- Sarcoidosis: - STI: - Rapid plasma reagin or VDRL test - Fluorescent treponemal antibody absorption test - Appropriate cultures

- Treat secondary glaucoma. - Supportive measures: - Warm compresses - Dark glasses - Analgesia

- Inflammatory bowel disease: - Systemic steroids - Sulfadiazine - Vitamin A

  • Inflammation of anterior uveal tract
  • Iritis and anterior uveitis are synonymous.
  • Uveitis secondary to trauma is also called traumatic iritis.

Etiology

  • Most cases are idiopathic, but may be traumatic or associated with numerous infectious and noninfectious systemic diseases.
  • May be acute or chronic.
  • Noninfectious systemic diseases include the following:Ankylosing spondylitisReiter syndromeSarcoidosisBeh Еѕet diseaseInflammatory bowel diseaseJuvenile rheumatoid arthritisKawasaki syndromeInterstitial nephritisIgA nephropathyDrug reactionsSj Г‚gren syndromePsoriatic arthritis
  • Infectious conditions include the following:Viral:RubellaMeaslesAdenovirusHerpes simplex virusHerpes zoster virusHIVMumpsVaricellaCytomegalovirusWest Nile virusBacterial:TuberculosisSyphilisPertussisBrucellosisLyme diseaseChlamydiaRickettsiaGonorrheaLeprosyFungal:
  • Malignancies include the following:LeukemiaLymphomaMultiple sclerosisMalignant melanoma
  • Other causes include the following:Cocaine useExposure to pesticidesCorneal foreign bodyBlunt trauma

Diagnosis

Signs and Symptoms

  • Acute presentation:Ocular pain, red eyePhotophobia (consensual)LacrimationDecreased visual acuity (usually mild)Cells and flare in anterior chamber; hypopyonPosterior synechiae (adhesions of iris to lens)MiosisLow intraocular pressure (occasionally may be high)Injection of perilimbal vessels (ciliary flush)
  • Chronic presentation:Recurrent episodesFew 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"ЕЃ 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:Purified protein derivative (PPD)
  • Sarcoidosis:
  • Ankylosing spondylitis:
  • Inflammatory bowel disease:
  • Reiter syndrome:HLA-B27Cultures of conjunctiva and urethra
  • Psoriatic arthritis:
  • Lyme disease:
  • Juvenile rheumatoid arthritis:Antinuclear antibodyRheumatoid factor
  • Sarcoidosis:
  • STI:Rapid plasma reagin or VDRL testFluorescent treponemal antibody absorption testAppropriate cultures

Imaging

  • Ankylosing spondylitis:Sacroiliac spine radiograph
  • Sarcoidosis:
  • TB:

Diagnostic Procedures/Surgery

US biomicroscopy can be used to help to diagnose pathologies. ГЎ

Differential Diagnosis

  • Acute angle-closure glaucoma
  • Conjunctivitis
  • Corneal abrasion
  • Corneal foreign body
  • Episcleritis
  • Intraocular foreign body
  • Keratitis
  • Posterior segment tumor

Treatment

Initial Stabilization/Therapy

  • Goal:Reduce inflammation and prevent complications
  • Cycloplegic agent (short-acting):Decreases pain, photophobiaPrevents 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 compressesDark glassesAnalgesia
  • Identification of cause:Initiate appropriate management.
  • Ankylosing spondylitis:Systemic anti-inflammatory agentsPhysical therapy
  • Inflammatory bowel disease:Systemic steroidsSulfadiazineVitamin A
  • Reiter syndrome:Treat urethritis (and sexual contacts).
  • Beh Еѕet 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:Tylenol or tylenol with codeine
  • Cycloplegics not recommended in children <6 yr:May cause systemic anticholinergic toxicity with blurred vision, flushing, tachycardia, hypotension, and hallucinations.

Follow-Up

Disposition

Admission Criteria

Not indicated unless significant systemic illness ГЎ

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:

Pearls and Pitfalls

  • If topical anesthesia relieves pain, probably not iritis.
  • Must be differentiated from other, vision-endangering forms of eye pain:KeratitisHerpes simplex conjunctivitisBacterial conjunctivitisAcute angle-closure glaucomaTraumatic globe rupture

Additional Reading

  • Bertolini ГЎJ, Pelucio ГЎM. The red eye. Emerg Med Clin North Am. 1995;13:561-579.
  • Dargin ГЎJM, Lowenstein ГЎRA. The painful eye. Emerg Med Clin North Am. 2008;26:199-216, viii.
  • Kunimoto ГЎDY, Kanitkar ГЎKD, Makar ГЎM. The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Diseases. 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2004.
  • Leibowitz ГЎHM. The red eye. N Engl J Med. 2000;343:345-351.
  • Ventura ГЎA, Hayden ГЎB, Taban ГЎM, et al. Ocular inflammatory diseases. Ultrasound Clin. 2008;3(2):245-255.
  • Weinberg ГЎRS. Uveitis. Ophthalmol Clin North Am. 1999;12:71-79.

See Also (Topic, Algorithm, Electronic Media Element)

Codes

ICD9

  • 364.00 Acute and subacute iridocyclitis, unspecified
  • 364.3 Unspecified iridocyclitis
  • 364.10 Chronic iridocyclitis, unspecified
  • 054.44 Herpes simplex iridocyclitis
  • 364.02 Recurrent iridocyclitis

ICD10

  • H20.00 Unspecified acute and subacute iridocyclitis
  • H20.9 Unspecified iridocyclitis
  • H20.10 Chronic iridocyclitis, unspecified eye
  • B00.51 Herpesviral iridocyclitis
  • H20.029 Recurrent acute iridocyclitis, unspecified eye

SNOMED

  • 65074000 Iritis (disorder)
  • 29050005 Acute iritis (disorder)
  • 398155003 Chronic anterior uveitis (disorder)
  • 420485005 herpetic iridocyclitis (disorder)
  • 417020006 Traumatic iritis
  • 6869001 Recurrent iridocyclitis (disorder)