Anterior uveitis has been a major part of my practice for my whole career. These seven steps are a culmination of 25 years of insights I’ve gleaned from managing hundreds of iritis patients and working directly with top specialists in the field.
1. Rule Out Keratouveitis
If the cornea is involved (as in an infiltrative keratitis) with the presence of an iritis, be suspicious for a microbial cause. In cases of bacterial, viral—such as herpes simplex (HSV)—or fungal keratitis, steroids are contraindicated even though an iritis is present. The iritis is secondary to the infection and usually subsides once the antimicrobial agents have cleared it. Looking for corneal involvement or keratouveitis can help you spot an infectious cause, thus completely changing your treatment approach.
2. Investigate Previous Surgery
Along the same lines, if a patient presents with a significant anterior chamber reaction after an ocular surgery such as cataract surgery or corneal transplant, consider endophthalmitis. I’ve seen glaucoma patients present with a significant iritis and hypopyon, and after raising the upper eyelid, I discovered a trabeculectomy bleb. In these glaucoma procedures, shunts and tubes create a path to the anterior chamber (AC) and could lead to endophthalmitis. Once again, the treatment approach is completely different and requires a referral to a retina specialist.
3. Check IOP
While most cases of iritis result in the ciliary body producing less aqueous and lowering pressures, some causes of uveitis are predisposed to a trabeculitis and can cause a significant rise in IOP. These include herpes zoster ophthalmicus (HZO) and HSV or even the presence of fibrin in the AC. I’ve seen cases of HZO uveitis present with pressures above 50mm Hg, which can cause a vascular occlusion that potentially can lead to an AION or a CRAO.
4. Consider a Systemic Work-up
While I don’t believe you need to order labs on every iritis patient, there are times when it’s warranted, including severe presentations such as a hypopyon, significant fibrin in the AC (not caused by trauma), synechia, bilateral presentation or recurrence.
5. Treat Aggressively
Now that you’ve completed the above, you have no reason not to be aggressive in your treatment. I recommend treating every iritis, even grade 1, with topical steroids every one or two hours while awake. The exception would be use of difluprednate, which is twice as strong—an initial QID dosing is sufficient.
Consider adding an overnight steroid, such as loteprednol, in more severe presentations. I’ve seen synechia break quicker, fibrin resolve, hypopyon improve dramatically and IOP from a trabeculitis lower with this simple addition.
It’s also important to cycloplege these patients, as it can alleviate pain, restore the blood-aqueous barrier and prevent synechiae. Try to avoid atropine if there is potential for synechia, as it can result in synechia lock because of its slow acting profile. Other effective aggressive options include a Medrol Dosepak when necessary. I particularly like Acthar Gel (injections) in cases that are recalcitrant, rebound often or are steroid responders.
6. Treat and Taper Beyond Cells and Flare
After treatment with a proper but slow taper, continue to maintain a steroid QD for an additional five days after there are no more cells or flare. This seems like an odd rule, but I’ve seen rebound iritis where I stopped the steroid prior to this additional treatment. It can take three to five days after the last cell has disappeared to completely restore the blood-aqueous barrier.
7. Examine the Posterior Segment
Most cases of anterior uveitis are diagnosed without observing the posterior segment, but it can provide great insights. Sometimes, it’s actually a vitritis that spills over into the AC. I’ve seen cotton wool spots, chorioretinitis and even a retinal detachment that presented with an anterior iritis.
Following these “rules” will allow you to manage this condition like a specialist, while also protecting you and the patient!
Dr. Karpecki is medical director for Keplr Vision and the Dry Eye Institutes of Kentucky and Indiana. He is the Chief Clinical Editor for Review of Optometry and chair of the New Technologies & Treatments conferences. A fixture in optometric clinical education, he consults for a wide array of ophthalmic clients, including ones discussed in this article. Dr. Karpecki's full list of disclosures can be found here.