Basics
Description
- 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 spondylitis
- Reiter syndrome
- Sarcoidosis
- Beh žet disease
- Inflammatory bowel disease
- Juvenile rheumatoid arthritis
- Kawasaki syndrome
- Interstitial nephritis
- IgA nephropathy
- Drug reactions
- Sj Âgren syndrome
- Psoriatic arthritis
- Infectious conditions include the following:
- Viral:
- Rubella
- Measles
- Adenovirus
- Herpes simplex virus
- Herpes zoster virus
- HIV
- Mumps
- Varicella
- Cytomegalovirus
- West Nile virus
- Bacterial:
- Tuberculosis
- Syphilis
- Pertussis
- Brucellosis
- Lyme disease
- Chlamydia
- Rickettsia
- Gonorrhea
- Leprosy
- Fungal:
- 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
Diagnosis
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"Ł 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-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. á
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, 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:
- Systemic steroids
- Sulfadiazine
- Vitamin A
- Reiter syndrome:
- Treat urethritis (and sexual contacts).
- Beh žet 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 á
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:
- Keratitis
- Herpes simplex conjunctivitis
- Bacterial conjunctivitis
- Acute angle-closure glaucoma
- Traumatic globe rupture
Additional Reading
- Bertolini áJ, Pelucio áM. The red eye. Emerg Med Clin North Am. 1995;13:561-579.
- Dargin áJM, Lowenstein áRA. The painful eye. Emerg Med Clin North Am. 2008;26:199-216, viii.
- Kunimoto áDY, Kanitkar áKD, Makar áM. The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Diseases. 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2004.
- Leibowitz áHM. The red eye. N Engl J Med. 2000;343:345-351.
- Ventura áA, Hayden áB, Taban áM, et al. Ocular inflammatory diseases. Ultrasound Clin. 2008;3(2):245-255.
- Weinberg áRS. 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)