What medications are used to treat iritis?

Medications for Iritis Treatment

Topical corticosteroids are the first-line treatment for iritis, with prednisolone acetate 1% being the preferred agent, followed by systemic immunosuppressive therapy when topical treatment is insufficient to control inflammation. 1

First-Line Treatment

Topical Corticosteroids

• Prednisolone acetate 1% is conditionally recommended over difluprednate for active chronic anterior uveitis 2
• Dexamethasone is an alternative topical steroid option 3
• Dosing typically starts with frequent administration (every 1-2 hours) in severe cases, then tapered as inflammation resolves
• Low doses of topical corticosteroids (≤3 drops daily) can be used over moderate periods with a low risk of developing cataracts 2

Cycloplegic/Mydriatic Agents

• Atropine 1% ophthalmic solution 2-3 times daily (every 8-12 hours) 1
• Helps prevent synechiae formation (adhesions between iris and lens)
• Relieves pain by relaxing the ciliary muscle
• Reduces inflammation by stabilizing the blood-aqueous barrier

Second-Line Treatment

When topical steroids are insufficient (requiring 1-2 drops/day for ≥3 months) or in cases with sight-threatening complications:

Conventional Disease-Modifying Antirheumatic Drugs (DMARDs)

• Methotrexate (subcutaneous preferred over oral) 2
  • First-line systemic therapy for chronic uveitis
  • Particularly effective in JIA-associated uveitis

Biological DMARDs

• TNF inhibitors (monoclonal antibodies) 2
  • Adalimumab or infliximab are preferred over etanercept for recurrent iritis 2
  • Recommended when methotrexate is insufficient
  • For severe cases with sight-threatening complications, combination of methotrexate and a TNF inhibitor is recommended 2

Alternative Systemic Options (for refractory cases)

• Abatacept or tocilizumab as biologic options 2
• Mycophenolate, leflunomide, or cyclosporine as non-biologic alternatives 2, 4
• Cyclophosphamide may be needed in severe cases resistant to other therapies 4

Treatment Algorithm

1. Acute iritis with mild to moderate inflammation:

   • Topical prednisolone acetate 1% (4-8 times daily initially)
   • Cycloplegic agent (atropine 1%)
   • Taper topical steroids as inflammation resolves

2. Severe or sight-threatening iritis:

   • Intensive topical steroids (hourly initially)
   • Cycloplegic agent
   • Consider systemic steroids for rapid control

3. Chronic or recurrent iritis requiring long-term topical steroids:

   • Add methotrexate (preferably subcutaneous)
   • Taper topical steroids first before systemic therapy 2

4. Inadequate response to methotrexate:

   • Add TNF inhibitor (adalimumab or infliximab)
   • Consider escalating dose/frequency of TNF inhibitor before switching 2

5. Refractory cases (failed methotrexate and 2 TNF inhibitors):

   • Consider abatacept, tocilizumab, mycophenolate, leflunomide, or cyclosporine 2

Special Considerations

• For recurrent iritis: Provide prescription for topical steroids for at-home use at first sign of symptoms 2, 1
• NSAIDs: May have an adjunctive role in chronic iritis but not as monotherapy 2
• Nepafenac 0.1% has shown non-inferiority to prednisolone acetate 1% for controlling inflammation after laser peripheral iridotomy with less IOP elevation 5
• Monitoring: Regular follow-up with an ophthalmologist is essential to monitor:
  • Anterior chamber cells and flare
  • Intraocular pressure (steroid-induced glaucoma risk)
  • Development of cataracts
  • Macular edema

Potential Complications and Management

• Steroid-induced glaucoma: Monitor IOP regularly; consider IOP-lowering medications if needed
• Cataracts: Long-term steroid use increases risk; consider surgery if visually significant
• Synechiae: Proper use of cycloplegics helps prevent formation
• Macular edema: May require more aggressive systemic therapy
• Rebound inflammation: Avoid abrupt discontinuation of steroids; taper gradually

Common Pitfalls to Avoid

• Failure to refer to an ophthalmologist for proper diagnosis and management
• Inadequate initial treatment intensity or premature tapering
• Not monitoring for steroid-related complications
• Overlooking systemic associations (e.g., JIA, ankylosing spondylitis, Sjögren's syndrome)
• Continuing ineffective therapy without escalation when indicated

Remember that all cases of suspected iritis require immediate ophthalmology referral for proper diagnosis and management to prevent vision-threatening complications.