What is the treatment for iritis?

Treatment of Iritis

All patients with acute iritis should be treated by an ophthalmologist with topical corticosteroids (prednisolone acetate 1% or dexamethasone) as first-line therapy to prevent vision-threatening complications including glaucoma, cataracts, and permanent vision loss. 1

Immediate Management

Specialist Referral

• Urgent ophthalmology evaluation is mandatory for proper diagnosis, severity assessment, and selection of appropriate local treatments 1, 2
• Ophthalmologists have specialized expertise in diagnosing iritis, evaluating episode severity, and selecting optimal topical treatments 1

First-Line Topical Therapy

• Topical corticosteroids (prednisolone acetate 1% or dexamethasone) are the treatment of choice for both acute and chronic anterior uveitis 1, 3, 2, 4
• Prednisolone acetate ophthalmic suspension 1% is FDA-approved for steroid-responsive inflammation of the conjunctiva, cornea, and anterior segment 4
• Typical dosing: Start with 1-2 drops every hour during Week 1, then taper to every 2 hours during Week 2, four times daily during Week 3, and once daily for final 3 days 5

Adjunctive Therapy

• Cycloplegic agents should be used concurrently to reduce pain, prevent posterior synechiae formation, and improve patient comfort 6
• NSAIDs may have an adjunctive role when added to corticosteroids, allowing steroid dose reduction, but should never be used as monotherapy 1

Monitoring During Topical Therapy

Dose Optimization

• Keep topical corticosteroid doses ≤3 drops daily when possible to minimize cataract risk during extended treatment 1
• Doses ≤2 drops daily have shown zero incidence of cataract formation per eye-year of follow-up 1
• High-dose topical steroids (>3 drops daily) significantly increase cataract and glaucoma risk independent of inflammation severity 1

Follow-up Schedule

• Patients with controlled uveitis on stable therapy require monitoring at least every 3 months 3, 2
• When tapering or discontinuing topical corticosteroids, ophthalmologic examination must occur within 1 month after each change 3, 2

Recurrent Iritis Management

At-Home Treatment for Recurrent Episodes

• Patients with recurrent iritis should receive prescriptions for topical corticosteroids for prompt at-home initiation when typical symptoms develop 1
• This approach decreases episode severity and duration while reducing likelihood of ocular complications 1
• This strategy is restricted to patients with prior episodes who are knowledgeable about iritis symptoms and must include a care plan requiring prompt ophthalmologic examination 1

Systemic Therapy for Prevention

• For patients requiring systemic therapy to prevent recurrent episodes, use adalimumab or infliximab—never etanercept 1, 2
• Adalimumab and infliximab reduce uveitis recurrence rates by 30% compared to etanercept in observational studies 2
• Etanercept may paradoxically worsen or trigger new uveitis episodes and is explicitly contraindicated for patients with uveitis history 2

Escalation to Systemic Immunosuppression

Indications for Systemic Therapy

• Initiate systemic immunosuppression when topical steroids are insufficient to eliminate inflammation or when doses required create unacceptable risks (cataracts, glaucoma) 1
• Immediate systemic therapy is indicated if poor prognostic factors are present at first visit: posterior synechiae, band keratopathy, glaucoma, cataract, poor initial vision, hypotony, macular edema, or dense vitreous opacification 1
• Lower threshold for systemic therapy in patients with multiple risk factors for visual loss 1

Systemic Treatment Algorithm

• Methotrexate is the preferred initial disease-modifying agent for moderate to severe disease, achieving remission in approximately 52% of patients 2
• For inadequate response to methotrexate, add monoclonal antibody TNF inhibitors (adalimumab or infliximab) 1, 2
• Infliximab provides complete remission in 30-85% of patients with rapid inflammation reduction within 2 weeks 2
• Adalimumab demonstrates superior efficacy to infliximab for maintaining remission over 3-year treatment periods 1

Severe Refractory Disease

• Combination immunosuppressive therapy may be required for severe cases: intravenous cyclophosphamide (1,500 mg/month), high-dose prednisone (60 mg/day), and cyclosporine (5 mg/kg/day) 7
• Systemic corticosteroids alone (prednisone 20-60 mg/day) can be used for rapid control of severe uveitis or macular edema, but are not preferred in children due to growth suppression and osteopenia risks 1

Critical Pitfalls to Avoid

• Never delay ophthalmology referral—undiagnosed or improperly treated iritis leads to glaucoma and vision loss 6
• Never use etanercept in patients with uveitis history—it is explicitly contraindicated and may worsen disease 1, 2
• Never exceed 3 drops daily of topical corticosteroids chronically without compelling indication due to exponential cataract risk 1
• Never use NSAIDs as monotherapy—they are only adjunctive to corticosteroids 1
• Regular monitoring is essential as posterior uveitis can progress asymptomatically to irreversible vision loss 2