Anterior Uveitis/Iritis: Symptoms and Treatment
Clinical Presentation
Anterior uveitis (iritis) classically presents with eye pain, blurred vision, photophobia, and eye redness, often with floaters. 1, 2 These symptoms distinguish it from less serious conditions like episcleritis, which typically presents with mild discomfort and hyperemia without significant pain or visual changes. 1
Key Symptoms to Identify:
- Eye pain (moderate to severe, distinguishing from episcleritis) 1
- Photophobia (light sensitivity) 1, 2
- Blurred vision 1, 2
- Eye redness (conjunctival hyperemia) 2
- Floaters 2
- Headache (may accompany ocular symptoms) 1
Clinical Examination Findings:
- Anterior chamber cells on slit-lamp examination (diagnostic hallmark) 1
- Aqueous flare 3
- Miosis (pupillary constriction) 3
- Decreased intraocular pressure 3
- Keratic precipitates (inflammatory deposits on corneal endothelium) 1
Treatment Algorithm
First-Line Treatment: Topical Corticosteroids
Prednisolone acetate 1% eyedrops are the first-line treatment for anterior uveitis, with initial dosing of 1-2 drops per eye per day or more frequently based on inflammation severity. 4, 5 This is the standard of care endorsed by the American College of Rheumatology. 4
Key treatment principles:
- Goal is to discontinue topical corticosteroids within 3 months due to risks of glaucoma and cataracts 1, 4
- Taper gradually as anterior chamber cellular reaction comes under control 4
- Add cycloplegic agents (such as atropine or cyclopentolate) to prevent posterior synechiae formation and reduce pain 1
When to Escalate to Systemic Therapy
If inflammation cannot be controlled within 3 months or reactivates during steroid taper, add systemic immunosuppression with methotrexate as first choice. 4 This threshold is critical—waiting longer risks permanent ocular complications including posterior synechiae, cataracts, glaucoma, and vision loss. 1, 2
Specific indications for systemic therapy:
- Requiring >1-2 drops/day of prednisolone acetate 1% at 3 months to maintain control 4
- Recurrent flares during topical steroid taper 4
- Bilateral disease (particularly in juvenile idiopathic arthritis-associated uveitis) 1
- Presence of complications (posterior synechiae, cystoid macular edema) 1
Second-Line Systemic Treatment: Biologics
For patients refractory to methotrexate, monoclonal TNF inhibitors (adalimumab or infliximab) are recommended. 1, 4 Adalimumab extended time to treatment failure to 24 weeks versus 13 weeks with placebo and reduced treatment failure from 78.5% to 54.5%. 2
Important distinction: Etanercept (a non-monoclonal TNF inhibitor) has no evidence supporting its use in uveitis and may paradoxically worsen disease. 1
Alternative Systemic Agents
For patients who cannot tolerate methotrexate or TNF inhibitors:
- Mycophenolate mofetil controlled inflammation in 70.9% of patients 2
- Azathioprine, cyclosporine are additional options 1
- Interferon alfa-2a demonstrated efficacy in refractory cases 1
Monitoring Requirements
During Active Treatment:
Ophthalmologic monitoring within 1 month after each change in topical corticosteroid therapy 1, 4 This frequent monitoring is essential to detect early complications or inadequate response.
On Stable Therapy:
Ophthalmologic examination every 3 months minimum for patients with controlled uveitis 1, 4
When Changing Systemic Therapy:
Ophthalmologic monitoring within 2 months of systemic therapy changes 6
Critical Pitfalls to Avoid
Never use topical NSAIDs as monotherapy—they have no demonstrable effect alone, though may serve as adjunctive therapy. 4
Do not delay systemic therapy beyond 3 months if topical steroids are insufficient—this risks irreversible structural damage including posterior synechiae, cataracts, and glaucoma. 1, 2
Distinguish from episcleritis, which may self-resolve and requires only supportive care (warm compresses, artificial tears, topical NSAIDs). 1 The presence of moderate-severe pain, photophobia, and visual changes indicates uveitis requiring aggressive treatment. 1
Urgent ophthalmology referral is mandatory for all cases of suspected anterior uveitis to confirm diagnosis with slit-lamp examination and assess severity. 1 Grade 2 (medical intervention required) warrants urgent referral; Grade 3-4 (posterior/panuveitis or vision 20/200 or worse) requires emergent referral. 1
Special Considerations
In HLA-B27 associated anterior uveitis, the condition is often episodic and self-limiting, with topical treatment frequently sufficient. 6 However, recurrent episodes may require systemic therapy for prevention. 6
In inflammatory bowel disease-associated uveitis, the condition may be independent of bowel disease activity and can precede intestinal symptoms. 1 Treatment should be guided by ophthalmology, not by IBD activity alone. 1
Periocular or intraocular corticosteroid injections may be considered at ophthalmologist discretion for refractory cases, though systemic therapy is generally preferred for bilateral or recurrent disease. 1, 4