What is the most likely diagnosis for a patient with a history of blunt trauma to the eye, decreased visual acuity, smaller pupil, and circumcorneal (inflammation of the cornea) hyperemia?

Traumatic Iritis (Anterior Uveitis)

The most likely diagnosis is traumatic iritis (anterior uveitis), given the history of blunt ocular trauma one week ago, smaller pupil (miosis), circumcorneal hyperemia (ciliary flush), photophobia, and pain. 1, 2, 3

Key Diagnostic Features Supporting Traumatic Iritis

The clinical presentation is classic for post-traumatic anterior segment inflammation:

• Miotic pupil (smaller on affected side) results from ciliary muscle spasm and is pathognomonic for iritis 1, 2
• Circumcorneal hyperemia (ciliary flush) indicates inflammation of the anterior uveal tract, distinguishing this from simple conjunctivitis 2
• Photophobia and pain are cardinal symptoms of iritis, caused by ciliary muscle spasm and iris inflammation 1, 2
• Timing (one week post-trauma) is consistent with traumatic iritis, which can develop days after blunt injury 4, 3
• Preserved visual acuity (20/25) suggests the inflammation has not yet caused significant complications like corneal edema or posterior synechiae 1

Critical Examination Findings to Confirm

While slit-lamp examination would be definitive, the suboptimal fundoscopic exam due to pupillary constriction and photophobia further supports iritis as the diagnosis 2. You should specifically look for:

• Anterior chamber cells and flare on slit-lamp examination (inflammatory cells and protein in aqueous humor) 1, 2
• Keratic precipitates on corneal endothelium 5
• Posterior synechiae (iris adhesions to lens) if inflammation is severe or prolonged 5, 1

Essential Concurrent Injuries to Rule Out

Blunt ocular trauma can cause multiple injuries simultaneously, and you must exclude sight-threatening complications 4, 3:

• Hyphema (blood in anterior chamber) - occurs in up to 30-40% of blunt trauma cases and can coexist with iritis 3, 6
• Traumatic mydriasis or iris sphincter rupture - check for iris transillumination defects 5
• Angle recession or secondary glaucoma - measure intraocular pressure, as elevated IOP requires different management 4, 6
• Lens subluxation or traumatic cataract - assess lens position and clarity 4
• Commotio retinae or retinal tears - dilated fundus exam is mandatory once inflammation controlled 3

Immediate Management Protocol

Treatment consists of topical cycloplegics and corticosteroids, which are imperative to prevent vision-threatening complications 1, 2:

• Cycloplegic agents (atropine 1% or homatropine 5% drops) to relieve ciliary spasm, reduce pain, and prevent posterior synechiae formation 1, 2, 3
• Topical corticosteroids (prednisolone acetate 1% every 1-2 hours initially) to suppress inflammation 1, 2, 3
• Close monitoring is required because corticosteroid overuse can cause elevated IOP and cataract formation 2

Critical Pitfalls to Avoid

• Do not assume all findings are from iritis alone - blunt trauma can cause angle damage, retinal tears, or globe rupture that may be obscured by anterior segment inflammation 4
• Do not delay dilated fundus examination - once inflammation is controlled, comprehensive peripheral retinal examination is mandatory to detect tears or detachment 4, 3
• Do not use corticosteroids without cycloplegics - posterior synechiae can form rapidly without adequate pupillary dilation 1, 2
• Do not miss secondary glaucoma - measure IOP at every visit, as both inflammation and steroid use can elevate pressure 4, 6

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