What is the treatment for iritis, particularly in patients with underlying systemic conditions such as ankylosing spondylitis or inflammatory bowel disease?

Treatment of Iritis

All patients with acute iritis must receive immediate topical corticosteroids (prednisolone acetate 1% or dexamethasone) prescribed by an ophthalmologist, as this is the only first-line therapy proven to prevent vision-threatening complications including glaucoma, cataracts, and permanent vision loss. 1

Immediate Management Algorithm

Step 1: Urgent Ophthalmology Referral

• Every patient with suspected iritis requires urgent ophthalmology evaluation within 24-48 hours for proper diagnosis, severity assessment, and treatment selection 1, 2, 3
• Ophthalmologists possess specialized expertise in diagnosing iritis severity and selecting optimal topical treatments that primary care cannot replicate 1

Step 2: First-Line Topical Therapy

• Topical corticosteroids (prednisolone acetate 1% or dexamethasone) are the definitive treatment of choice for both acute and chronic anterior uveitis 1, 3
• NSAIDs may serve only as adjunctive therapy when added to corticosteroids to allow steroid dose reduction, but never use NSAIDs as monotherapy 1

Step 3: Dosing Strategy to Minimize Complications

• Keep topical corticosteroid doses at ≤3 drops daily whenever possible to minimize cataract risk during extended treatment 1
• Doses ≤2 drops daily demonstrate 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

Management of Recurrent Iritis

Patient-Initiated Treatment Protocol

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

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

Systemic Treatment Hierarchy

1. Methotrexate is the preferred initial disease-modifying agent for moderate to severe disease, achieving remission in approximately 52% of patients 1, 3
2. For inadequate response to methotrexate, add monoclonal antibody TNF inhibitors (adalimumab or infliximab) 1, 3

Special Populations: Ankylosing Spondylitis and Inflammatory Bowel Disease

TNF Inhibitor Selection in Recurrent Iritis

• For patients with ankylosing spondylitis and recurrent iritis, use infliximab or adalimumab instead of etanercept to decrease recurrences of iritis 4, 3
• Four observational studies and pooled analyses demonstrate that infliximab or adalimumab are associated with lower rates of iritis than etanercept 4
• Adalimumab reduces uveitis recurrence rates by 30% compared to etanercept 3
• Data on adalimumab are less extensive than data on infliximab 4

TNF Inhibitor Selection in Inflammatory Bowel Disease

• Strongly recommend using TNF inhibitor monoclonal antibodies (infliximab or adalimumab) over etanercept in patients with ankylosing spondylitis and inflammatory bowel disease 4
• Pooled analyses indicate lower risks of either flare or new onset of inflammatory bowel disease with infliximab than with etanercept 4
• Adalimumab is also associated with lower risks, although these associations are not as strong as those of infliximab 4
• Infliximab, unlike etanercept, is effective in treating clinical symptoms, inducing and maintaining remission, and mucosal healing in inflammatory bowel disease 5
• Infliximab is currently the drug of choice for treatment of patients with active ankylosing spondylitis associated with inflammatory bowel disease 5

NSAID Use in Inflammatory Bowel Disease

• No particular NSAID is recommended as the preferred choice to decrease the risk of worsening inflammatory bowel disease symptoms 4
• Short courses of treatment with celecoxib may have less potential for harm than other NSAIDs, though evidence is limited 4

Critical Pitfalls to Avoid

Medication Errors

• Never use etanercept in patients with uveitis history—it is explicitly contraindicated and may paradoxically worsen or trigger new uveitis episodes 1, 3
• 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

Monitoring Failures

• Regular ophthalmologic monitoring is essential to detect subclinical progression of posterior uveitis, which can be asymptomatic yet still progress to irreversible vision loss 3
• Steroid dependency occurs in up to 84% of cases with persistent iritis, requiring careful monitoring and potential escalation to systemic therapy 6