What is the treatment for iritis (inflammation of the iris)?

Treatment of Iritis

All patients with acute iritis must 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, 2

Immediate Management

• Urgent ophthalmology referral is mandatory for proper diagnosis, severity assessment, and selection of appropriate local treatments. 1, 2
• Ophthalmologists possess specialized expertise in diagnosing iritis, evaluating episode severity, and selecting optimal topical treatments that non-specialists lack. 1
• The FDA has approved prednisolone acetate ophthalmic suspension 1% specifically for steroid-responsive inflammation of the palpebral and bulbar conjunctiva, cornea, and anterior segment of the globe. 3

First-Line Topical Therapy

• Topical corticosteroids (prednisolone acetate 1% or dexamethasone) are the treatment of choice for both acute and chronic anterior uveitis. 2, 4, 5
• Combine topical corticosteroids with cycloplegic agents to prevent synechiae formation and reduce pain. 6, 7, 8
• Initial dosing should be aggressive: prednisolone acetate 1% every 1-2 hours while awake for the first 24-48 hours to achieve rapid control of inflammation. 6
• NSAIDs may serve an adjunctive role when added to corticosteroids, allowing steroid dose reduction, but never use NSAIDs as monotherapy. 2

Tapering Strategy

• 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. 6
• Keep topical corticosteroid doses ≤3 drops daily when possible to minimize cataract risk during extended treatment. 2, 4
• Doses ≤2 drops daily have demonstrated zero incidence of cataract formation per eye-year of follow-up. 2, 4
• High-dose topical steroids (>3 drops daily) significantly increase cataract and glaucoma risk independent of inflammation severity. 2
• Limit topical glucocorticoids to ≤3 months due to risk of glaucoma and cataracts. 6

Management of Recurrent Iritis

• Patients with recurrent iritis should receive prescriptions for topical corticosteroids for prompt at-home initiation when typical symptoms develop. 1, 2, 4
• This approach decreases episode severity and duration while reducing likelihood of ocular complications. 1, 2
• This strategy should be restricted to patients with recurrent episodes who are knowledgeable about iritis symptoms. 1
• Prescription of topical glucocorticoids for at-home use must be done within a care plan that includes prompt ophthalmologic examination. 1

Monitoring Requirements

• Ophthalmologic examination within 2-7 days of initiating treatment is necessary to assess response and check for complications including elevated intraocular pressure, posterior synechiae, or worsening inflammation. 6
• If requiring >1-2 drops/day of prednisolone acetate for >2-3 months to maintain control, consider systemic therapy. 6

When to Escalate to Systemic Immunosuppression

• Initiate systemic immunosuppression when topical steroids are insufficient to eliminate inflammation or when doses required create unacceptable risks (cataracts, glaucoma). 2, 4
• 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. 2
• If inflammation persists or worsens despite 1-2 weeks of topical corticosteroids, consider periocular or systemic corticosteroids. 6

Systemic Treatment Algorithm

• Methotrexate is the preferred initial disease-modifying agent for moderate to severe disease, achieving remission in approximately 52% of patients. 2, 4, 5
• For inadequate response to methotrexate, add monoclonal antibody TNF inhibitors (adalimumab or infliximab). 2
• In patients with recurrent iritis, infliximab or adalimumab are preferred over etanercept to decrease recurrences. 1
• Adalimumab extended time to treatment failure to 24 weeks versus 13 weeks with placebo and reduced frequency of treatment failure from 78.5% to 54.5%. 5

Critical Pitfalls to Avoid

• Never use etanercept in patients with uveitis history—it is explicitly contraindicated and may worsen disease. 2, 4
• Never exceed 3 drops daily of topical corticosteroids chronically without compelling indication due to exponential cataract risk. 2, 4
• Never use NSAIDs as monotherapy—they are only adjunctive to corticosteroids. 2
• Inadequate initial treatment with topical corticosteroids increases risk of posterior synechiae formation and chronic inflammation. 6
• Undiagnosed or improperly treated iritis can lead to glaucoma and loss of vision. 7
• Development of posterior synechiae, cystoid macular edema, or other complications warrants urgent ophthalmology consultation. 6