What are the symptoms and treatment options for iridocyclitis?

Symptoms of Iridocyclitis

Iridocyclitis (anterior uveitis) typically presents with eye pain, photophobia, blurred vision, and redness, though it can be asymptomatic in chronic cases, particularly in children with juvenile rheumatoid arthritis. 1, 2

Clinical Presentation

Symptomatic Acute Iridocyclitis

• Eye pain and photophobia are the hallmark symptoms of acute iridocyclitis 2, 3
• Blurred vision occurs due to inflammatory cells and protein in the anterior chamber 2
• Redness from conjunctival and episcleral vascular congestion 1
• Tearing and light sensitivity accompany the inflammatory response 3

Asymptomatic Chronic Iridocyclitis

• Most children with JRA-associated uveitis are completely asymptomatic despite active inflammation 1
• The inflammation is detected only by slit-lamp examination, not by direct ophthalmoscopy 1
• Chronic cases in leprosy have insidious onset with minimal clinical signs in early stages except on slit-lamp examination 4

Physical Examination Findings

Slit-Lamp Biomicroscopy Findings

• Inflammatory cells and increased protein (flare) in the anterior chamber are diagnostic 1, 2
• Keratic precipitates (inflammatory deposits on the corneal endothelium) may be present 4
• Posterior synechiae (iris adhesions to the lens) indicate more severe or chronic disease 3
• Iris atrophy can develop in chronic cases like Fuchs heterochromic iridocyclitis 5, 6

Associated Ocular Signs

• Mid-dilated or irregular pupil from iris inflammation and synechiae formation 1
• Conjunctival injection (redness) without exudate 1
• Band keratopathy in chronic cases, particularly with JRA 1, 3

Context-Specific Presentations

Kawasaki Disease

• Mild acute iridocyclitis or anterior uveitis detected by slit lamp 1
• Resolves rapidly and rarely associated with photophobia or eye pain 1
• Accompanied by bilateral bulbar conjunctival injection without exudate 1

Immune Checkpoint Inhibitor Therapy

• Dry eye and uveitis are the most commonly reported ocular adverse events, with incidence between 1% and 24% 1
• Presentation varies from asymptomatic (grade 1) to vision-threatening (grade 3-4) 2

HLA-B27 Associated Disease

• Typically episodic and self-limiting acute anterior uveitis 7
• May be associated with genital lesions suggesting Behçet's syndrome or spondyloarthritis 7

Critical Diagnostic Pitfalls

Missed Diagnosis in Children

• Unlike joints, ocular involvement in JRA is most often asymptomatic yet can cause serious vision loss 1
• Regular scheduled slit-lamp examinations are essential for early detection 1
• Direct ophthalmoscopy cannot detect early iridocyclitis 1

Fuchs Heterochromic Iridocyclitis

• Misdiagnosed more than any other form of uveitis, particularly in brown-eyed individuals where heterochromia may not be apparent for years 6
• May present with unrecognized variants including Koeppe nodules and transient synechiae 6

Herpetic Iridocyclitis

• Can occur without active corneal inflammation, making diagnosis challenging 8
• Requires specific antiviral treatment rather than corticosteroids alone 8

Treatment Overview

Immediate Management

• Urgent ophthalmology evaluation and topical corticosteroids (prednisolone acetate 1% or dexamethasone) are necessary to prevent vision-threatening complications 2, 3, 9
• Cycloplegics to prevent posterior synechiae formation 10

Monitoring Requirements

• If symptoms fail to improve after 2 days, re-evaluation is mandatory 9
• Patients on topical corticosteroids require monitoring for elevated intraocular pressure and cataract formation 9

Complications Without Treatment

• Glaucoma, cataracts, band keratopathy, phthisis bulbi, and permanent vision loss are major complications 1, 2
• Iridocyclitis in JRA remains a leading cause of blindness in the United States despite improved outcomes 1