What is the appropriate emergency department management for a patient presenting with acute anterior uveitis characterized by eye pain, photophobia, redness, decreased vision and anterior chamber cells/flare?

Emergency Department Management of Acute Anterior Uveitis

Initiate treatment immediately with prednisolone acetate 1% eyedrops (1-2 drops per affected eye, initially every 1-2 hours while awake for severe inflammation) plus a cycloplegic agent (cyclopentolate 1% or homatropine 5% three times daily), and arrange urgent ophthalmology follow-up within 24-48 hours. 1

Immediate Assessment and Red Flags

When a patient presents with eye pain, photophobia, redness, and blurred vision, you must rapidly distinguish true anterior uveitis from less serious conditions:

• Confirm the diagnosis by identifying anterior chamber cells and flare on slit-lamp examination—this is the diagnostic hallmark 1, 2
• Look for keratic precipitates on the corneal endothelium, which are inflammatory deposits characteristic of uveitis 1
• Rule out episcleritis, which presents with mild discomfort, hyperemia, itching/burning, but notably lacks significant pain, photophobia, or visual changes 2, 3
• Any visual disturbance, moderate-to-severe pain, or photophobia warrants urgent ophthalmologic referral to prevent progression to permanent vision loss 2, 3

The critical distinction: episcleritis is relatively painless with no visual changes, while anterior uveitis causes significant pain, photophobia, and decreased vision 2, 4.

Initial Emergency Department Treatment

Start topical corticosteroids immediately once the diagnosis is confirmed—do not wait for ophthalmology consultation if the diagnosis is clear:

• Prednisolone acetate 1% is the first-line agent 1
• Initial dosing: 1-2 drops per affected eye every 1-2 hours while awake for moderate-to-severe inflammation, then taper based on response 1
• Higher frequencies may be needed initially for severe inflammation, though this increases risk for ocular complications 5

Add a cycloplegic agent concurrently to prevent posterior synechiae formation and reduce pain 1:

• Cyclopentolate 1% or homatropine 5% three times daily
• This prevents iris adhesions to the lens (posterior synechiae), a sight-threatening complication

Disposition and Follow-up

Arrange ophthalmology follow-up within 24-48 hours for all patients with confirmed anterior uveitis 1, 3:

• Slit-lamp examination by an ophthalmologist is essential to confirm diagnosis, assess severity, and monitor for complications 3
• Patients requiring topical corticosteroids need ophthalmologic monitoring within 1 month after each change in therapy 5, 1
• The goal is to discontinue topical corticosteroids within 3 months due to risks of glaucoma and cataracts 5

When to Consider Systemic Therapy (Not Typically in ED)

While not initiated in the emergency department, you should be aware that systemic therapy becomes necessary if 1:

• Inflammation cannot be controlled within 3 months
• Patient requires more than 1-2 drops per day of prednisolone acetate 1% at 3 months to maintain control
• Recurrent flares occur during topical steroid taper
• Bilateral disease is present
• Complications develop (posterior synechiae, cystoid macular edema)

Methotrexate is the first-line systemic agent, followed by monoclonal TNF inhibitors (adalimumab or infliximab) for refractory cases 5, 1, 4.

Special Considerations

HLA-B27-associated anterior uveitis (often seen with ankylosing spondylitis) is typically episodic and self-limiting 5, 6:

• These patients often respond well to topical treatment alone
• Recurrent episodes may eventually require systemic therapy for prevention 1

Infectious uveitis must be ruled out before initiating corticosteroids 4:

• Consider toxoplasmosis, herpes, tuberculosis, or HIV if clinical features suggest infection
• Infectious uveitis requires systemic antimicrobial treatment, not just corticosteroids 4

Common Pitfalls to Avoid

Do not misdiagnose as conjunctivitis—this is the most common error in primary care 7:

• Conjunctivitis lacks the triad of significant pain, photophobia, and decreased vision
• Mean delay to appropriate treatment when misdiagnosed by primary care is 9.2 days versus 4.3 days for direct presentations 7

Do not prescribe topical antibiotics alone—this represents inappropriate management and delays definitive treatment 7.

Do not use difluprednate as first-line therapy—prednisolone acetate 1% is conditionally recommended over difluprednate 5.