Treatment of Traumatic Iritis with 2+ Cells, No Synechiae
For traumatic iritis with 2+ anterior chamber cells and no synechiae, initiate treatment with topical corticosteroids (prednisolone acetate 1%) dosed frequently (every 1-2 hours while awake initially) combined with a cycloplegic agent to prevent synechiae formation and reduce pain. 1, 2
Initial Treatment Regimen
Topical Corticosteroids
- Start prednisolone acetate 1% eye drops every 1-2 hours while awake for the first 24-48 hours 1
- For moderate inflammation (2+ cells = 11-20 cells per high-power field), this aggressive initial dosing achieves rapid control 1
- Topical corticosteroids are capable of achieving high tissue levels and are the preferred method of treatment 1
Cycloplegic Agents
- Add a cycloplegic agent (such as cyclopentolate 1% or homatropine 5%) three times daily 1, 2
- Cycloplegics decrease synechiae formation and reduce pain from ciliary spasm 1, 2
- This is particularly important given substantial anterior chamber inflammation 1
Tapering Strategy
Frequency Reduction
- Once inflammation begins to improve (typically 48-72 hours), taper prednisolone acetate to every 2-4 hours, then four times daily over 1-2 weeks 1
- The goal is to use topical glucocorticoids as short-term therapy ≤3 months due to risk of glaucoma and cataracts 1
- Monitor closely during taper, as rebound iritis can occur 3
Monitoring Requirements
- Ophthalmologic examination within 2-7 days of initiating treatment to assess response 1
- Check for development of complications including elevated intraocular pressure, posterior synechiae, or worsening inflammation 1
- If requiring >1-2 drops/day of prednisolone acetate for >2-3 months to maintain control, consider systemic therapy 1
Critical Pitfalls to Avoid
Steroid-Related Complications
- Monitor intraocular pressure at each visit, as corticosteroid-induced ocular hypertension can develop within 2 weeks 3
- Prednisolone acetate causes greater IOP elevation than alternatives (mean +2.6 mmHg at 2 weeks) 3
- Risk increases with doses >1-2 drops/day and duration >3 months 1
Inadequate Initial Treatment
- Do not underdose initially—2+ cells represents moderate inflammation requiring aggressive early treatment 1
- Insufficient initial control increases risk of posterior synechiae formation and chronic inflammation 1
Premature Discontinuation
- Do not stop treatment abruptly; gradual taper is essential to prevent rebound inflammation 3
- Rebound iritis occurred in 5.4% of patients stopping prednisolone without proper taper 3
Alternative Considerations
NSAID Monotherapy
- NSAIDs (nepafenac 0.1%) may be considered for mild traumatic iritis, but are generally inferior to corticosteroids for 2+ cells 3, 4
- One study showed nepafenac was noninferior to prednisolone for post-laser iritis, but this was in a less severe inflammatory setting 3
- For 2+ cells from trauma, corticosteroids remain the standard of care 1, 2
When to Escalate
- If inflammation persists or worsens despite 1-2 weeks of topical corticosteroids, consider periocular or systemic corticosteroids 1
- Development of posterior synechiae, cystoid macular edema, or other complications warrants urgent ophthalmology consultation 1
- Rare cases may develop delayed-onset posterior uveitis requiring systemic immunosuppression 5