How is iritis assessed and treated?

Assessment and Treatment of Iritis

Iritis should be managed by an ophthalmologist to decrease severity, duration, and complications of episodes, with prompt treatment using topical glucocorticoids as first-line therapy. 1

Diagnosis of Iritis

Proper assessment of iritis requires specialized equipment and expertise:

• Slit lamp examination: Essential for diagnosis to detect cells and flare in the anterior chamber 2
• Key symptoms to identify:
  • Red eye
  • Photophobia
  • Eye pain
  • Decreased visual acuity 3

Treatment Algorithm

Acute Iritis Management

1. Immediate ophthalmology referral:

   • All patients with suspected iritis require evaluation by an ophthalmologist 1
   • This is a strong recommendation based on expert consensus (100% agreement) despite very low-quality evidence 1

2. First-line treatment:

   • Topical glucocorticoids to control inflammation 1
   • Mydriatic/cycloplegic agents (e.g., atropine 1% ophthalmic solution) 2-3 times daily to:
     • Prevent synechiae formation
     • Reduce pain by paralyzing the ciliary muscle
     • Continue until inflammation resolves (typically 5-7 days) 4, 3

3. Monitoring:

   • Regular follow-up with ophthalmologist
   • Assessment of anterior chamber cells and flare
   • Monitoring of intraocular pressure 4

Management of Recurrent Iritis

1. Preventive strategy:

   • For patients with recurrent episodes, provide prescription for topical glucocorticoids for at-home use 1
   • Patient education about symptoms of iritis recurrence
   • Instructions to initiate treatment at first sign of symptoms 1
   • Immediate ophthalmology follow-up after self-initiated treatment 1

2. Systemic therapy for frequent recurrences:

   • For patients with ankylosing spondylitis and frequent iritis recurrences:
     • TNF inhibitors (infliximab or adalimumab) are recommended over etanercept 1
     • This recommendation is based on observational studies showing lower rates of iritis with infliximab/adalimumab compared to etanercept 1

3. Severe refractory cases:

   • May require combination immunosuppressive therapy in certain autoimmune conditions 5
   • Options include oral prednisone, methotrexate, cyclophosphamide, or cyclosporine in severe cases 5

Special Considerations

Medication-Induced Iritis

• Cidofovir (antiviral) can cause iritis in up to 26% of patients 6, 7
• Onset typically occurs after 4-5 doses 7
• Management includes:
  • Topical corticosteroids
  • Consideration of medication discontinuation if severe 6

Complications to Monitor

• Synechiae formation (adhesions between iris and lens)
• Secondary glaucoma
• Persistent visual acuity decrease 3, 7
• Hypotony (abnormally low intraocular pressure) 7

Important Caveats

• Prescription for at-home treatment should be restricted to:

  • Patients with recurrent episodes only
  • Those knowledgeable about iritis symptoms
  • Within a care plan that includes prompt ophthalmologic examination 1

• Administration technique matters:

  • Pull down lower eyelid to create a pocket
  • Apply one drop into affected eye
  • Apply gentle pressure to inner corner of eye for 1-2 minutes to reduce systemic absorption 4

• Risk groups requiring special attention:

  • Children with juvenile idiopathic arthritis (JIA) - iritis often asymptomatic 2
  • Patients with autoimmune conditions like Sjögren's syndrome 5
  • Elderly patients (more sensitive to anticholinergic side effects) 4

By following this structured approach to iritis assessment and management, clinicians can minimize complications and improve outcomes for patients with this potentially sight-threatening condition.