Iritis, or anterior uveitis, is the most common form of ocular inflammation encountered. It is a common cause of a painful red eye.

Inflammation of the iris may appropriately be termed iritis, whereas inflammation of the iris and the ciliary body is called iridocyclitis. Iritis may be subdivided into 2 broad categories: granulomatous and nongranulomatous. The exact pathophysiology is not known. Inflammation of the iris and the ciliary body causes a breakdown of the blood ocular barrier. This condition allows both protein and W !s to extravasate into the a"ueous, resulting in the typical iritis signs of cell and flare. #re"uently, the cause is idiopathic, but certain ocular and systemic diseases may be the underlying cause of the iritis. In"uire about the patient$s complete medical history, to include all medical conditions, surgeries, medications, and ocular history %eg, history of iritis&. 'erform a detailed review of systems. This is critical, as the history and the review of systems in many cases will suggest a diagnosis. !ritical review "uestions include, but are not limited to, asking about recent ocular trauma, back stiffness, arthritis, rashes, shortness of breath, swollen lymph nodes, diarrhea, blood in stools, recent insect bites, sexually transmitted diseases %(T)s&, and tuberculosis %T & exposure. In"uire about the onset of the symptoms. *ost cases of acute anterior uveitis begin with the sudden onset of redness, pain, and photophobia. #amily history is important as well. In"uire if there is a family history of uveitis or other symptoms in family members that might suggest associated diseases, such as a spondyloarthropathy or other human leukocyte antigen %+,-&. 2/ processes. In"uire in particular about the following symptoms: )ull, aching eye pain occurs and may worsen when one touches the eye through the eyelid. 'ain may be referred to the temple or periorbital region. 'ain is usually abrupt in onset. 'hotosensitivity to light, especially sunlight, worsens the patient$s discomfort. 0edness with no mucopurulent discharge is seen. 'atients rarely have a watery discharge or tearing. *ild blurring of vision may be noted. *ost cases are unilateral. 'hysical 1ision: 1isual acuity is usually normal or only slightly decreased. Intraocular pressure %I2'& is often lower in the eye with iritis when compared to the fellow eye. This is secondary to a decrease in a"ueous production by the inflamed ciliary body. +owever, in some cases, the I2' may be elevated as a result of altered a"ueous outflow. !on3unctiva: Typically, the eye has a perilimbal in3ection termed ciliary flush. ,ess commonly, generali4ed redness of the bulbar con3unctiva may be present.

!ornea: 5eratic precipitates %5's& may be present. These clusters of W !s collect on the endothelium. In nongranulomatous iritis, they tend to be small and are usually located over the inferior half of the cornea. (tellate.shaped 5's, uniformly spread over the endothelium, are typical of #uchs heterochromic iridocyclitis. !orneal stromal edema may be present. -nterior chamber: #lares, cells, and6or hypopyon may be present. - flare, resulting from extra protein in the a"ueous, is usually present and can be graded as follows: 7 8 !ompletely absent 9: 8 arely present 2: 8 *oderate ;: 8 *arked %iris and lens detail ha4y& <: 8 Intense %formed fibrin in a"ueous& !ells, the hallmark of iritis, are present in the a"ueous. They should be graded by severity under high.magnification slit lamp examination in a 9 = ;.mm field of light, as follows: Trace 8 9.> cells 9: 8 ?.9> cells 2: 8 9?.2> cells ;: 8 2?.>7 cells <: 8 *ore than >7 cells +ypopyon, if present, is highly suggestive of diseases associated with +,-. 2/@ with ehcet disease@ or, less commonly, with an infection.associated iritis. Iris: 'osterior synechiae may be present. Inflammatory nodules are usually not present in nongranulomatous iritis. (ector atrophy of the iris, if present, suggests herpes 4oster as the etiology of the inflammation. +eterochromia and loss of iris detail %eg, blurring of stroma& are suggestive of #uchs heterochromic iridocyclitis. ,ens and anterior vitreous: ,enticular precipitates may be present on the anterior lens capsule. 'osterior subcapsular cataracts may be present if the patient has had repeated episodes of iritis. !ells are commonly seen in the anterior vitreous. They represent either an iridocyclitis or a spillover of cells from the anterior chamber into the retrolental space. 2ccasionally, patients with +,-. 2/ disease have an intense vitritis, papillitis, and cystoid macular edema. *edical !are !ycloplegia: - long.acting cycloplegic agent, such as cyclopentolate or homatropine, should be used to help relieve both pain and photophobia and to prevent the formation of posterior synechiae. !orticosteroids: Topical corticosteroids are the mainstays of therapy and should be used aggressively during the initial phases of therapy. - subcon3unctival in3ection of depot.steroids %eg, !elestone& may be used if the patient poorly complies with topical therapy or if the iritis is not responding to topical corticosteroids alone. In severe cases of iritis, the addition of oral corticosteroids to the treatment regimen may be necessary. Topical a"ueous suppressant: If I2' is elevated, a topical a"ueous suppressant should be used.

Topical corticosteroids and a cycloplegic agent should be started immediately, unless an infectious etiology is suspected. If the eye is not ade"uately responding to topical therapy within a week to 97 days, the addition of either oral corticosteroids or a periocular in3ection of corticosteroids to the treatment regimen may be necessary. The in3ection of steroids may be contraindicated in a known steroid responder or in a patient with an already elevated I2'.

-nterior uveitis ackground 'atients with anterior uveitis present with a wide range of symptoms. These symptoms vary from a mild blurring of the vision with an otherwise normal.looking eye %ie, AI-& to severe pain, photophobia, and loss of vision associated with intense in3ection and hypopyon. #actors other than ocular signs and symptoms can help in diagnosing anterior uveitis. The onset, duration, and severity of any symptom, as well as unilaterality or bilaterality of the disease, should be known. The patient$s age, racial background, and ocular history should be taken into consideration. - detailed history and review of systems are of immeasurable value in the diagnostic approach to patients with uveitis. -n important element of any classification system for uveitis is defining what part of the eye is involved. The presence of white cells confined solely to the anterior chamber is called iritis. When the cellular activity involves the retrolental vitreous, the inflammatory process is believed to include the ciliary body and iris and is known as iridocyclitis. !orneal or scleral involvement plus anterior chamber inflammation is called keratouveitis or sclerouveitis, respectively. *ultiple etiologies exist for anterior uveitis. *ost types of anterior uveitis are sterile inflammatory reactions, as opposed to many of the posterior uveitic syndromes that are caused by infections. The percentage of idiopathic anterior uveitis ranges from approximately ;BC to greater than /7C@ this is by far the most common cause of anterior uveitis./, B The next most common etiology is the sudden.onset +,-. 2/ positive or +,-. 2/Dassociated disease. *c!annel reports that both community.based patients and university.based patients have similar incidence rates %about 9/C&. -fter that, differences exist in the probability of the various etiologies depending on the clinical setting. #or community. based patients, trauma is the third most common cause of anterior uveitis %>./C&@ trauma was not observed in the university setting. While herpes simplex virus is uncommon in community.based patients %9.EC&, it was the third most likely diagnosis in the university setting %92.<C&. 1aricella.4oster infection occasionally was observed in both settings %>.?C&.

(ymptoms 'ain, redness, and photophobia comprise the classic presentation of acute anterior uveitis. The pain usually is described as a dull ache in and around the eye, but anterior uveitis can cause little or no discomfort. 1ision can be normal or slightly decreased. 2ften, the eye is extremely sensitive to light %photophobia&. The patient may notice redness in one or both eyes or no change at all in the look of the eye. (igns The con3unctiva classically shows perilimbal in3ection %known as ciliary flush&. The cornea may have keratic precipitates, which are clusters of W !s collected on the endothelium. The type of keratic precipitate can provide a clue to the classification of anterior uveitis. *utton.fat keratic precipitates are characteristic of granulomatous uveitis. )iffuse stellate keratic precipitates classically are seen in #uchs heterochromic iridocyclitis. Interstitial keratitis commonly is seen in patients with syphilis and herpetic disease. y definition, the anterior chamber has variable amounts of white cells floating in the a"ueous. 2ften, protein also is visible in the anterior chamber as flare. If enough white cells deposit on the bottom of the chamber, a hypopyon results. This finding is suggestive of +,-. 2/ disease, ehFet disease, or endophthalmitis. The intraocular pressure %I2'& is often low in acute cases of anterior uveitis %with the exception of herpetic uveitis& but may be elevated in chronic cases. The iris can provide additional information about the possible etiology or chronicity of the disease. ,ong.standing inflammation can cause posterior synechiae. Inflammatory nodules on the iris suggest granulomatous uveitis. +eterochromia is the classic finding in #uchs heterochromic iridocyclitis. -trophy of the iris may point to herpes 4oster as the infection responsible for the inflammation. The lens may show signs of cataractous change, which may suggest repeated bouts of iritis, or inflammatory precipitates may be present on the anterior lens capsule. The anterior vitreous may have some cells that have Gspilled overG from the anterior chamber. (ome +,-. 2/ diseases have varying amounts of vitritis and posterior pole involvement.

Traditionally, medical management consisted of topical or systemic corticosteroids and often cycloplegics. In patients with severe cases of uveitis who were unresponsive to steroids or in those patients with complications associated with the usual therapy, immunosuppressants can be used. Immunosuppressive agents should be considered as first.line therapy in patients with ehFet disease involving the posterior segment, Wegener granulomatosis, and necroti4ing scleritis. These diseases often are associated with life.threatening systemic vasculitis, and available evidence suggests that treatment with immunosuppressive agents can improve outcomes in these diseases.

Immunomodulatory therapy often is used in situations where long.term treatment with systemic corticosteroids is necessary, such as serpiginous choroiditis, birdshot choroiditis, 15+ disease, sympathetic ophthalmia, and AI-. The newest entries into the therapeutic arena for uveitis are medications that target specific mediators of the immune response. -lthough these medications have been studied primarily in patients with rheumatoid arthritis and !rohn disease, similarities in the disease pathogenesis have stimulated interest in using these drugs for the treatment of various ocular inflammatory diseases. In particular, molecules that block the tumor necrosis factor alpha %eg, etanercept, infliximab& and the interleukin.2 receptor %eg, dacli4umab& have been found to effectively modulate the immune response in patients with uveitis. -lthough none of these molecules has been studied in rigorous randomi4ed controlled trials, in recent years, they have played an important role in the management of sight.threatening uveitis. In particular, infliximab has found a place in the treatment of refractory uveitis, but its favorable effects have been mitigated by a relatively high incidence of drug toxicity. -nother new treatment modality is the use of intraocular pharmacotherapy via intravitreal in3ection and surgically placed implants. (everal reports have confirmed the treatment benefit of intravitreal triamcinolone %usually < mg in 7.9 cc& for the management of refractory !*H. Infortunately, the intravitreal half.life of triamcinolone is relatively short, and multiple in3ections may be necessary. !ataract formation and elevated I2' are common, and the risk of endophthalmitis %usually sterile& is approximately 7.9C. 0eports are emerging regarding the off.label use of the full.length humani4ed anti. 1HJ# monoclonal antibody bevaci4umab in the treatment of refractory !*H and neovascular complications of uveitis. +owever, as with triamcinolone, serial in3ections may be necessary, and the long.term tolerability and safety of this medication is unknown. - sustained.release fluocinolone implant %0etisert& was recently #)- approved for the treatment of refractory noninfectious uveitis. The drug is released for ;7 months and effectively controlled inflammation in nearly all eyes in the phase ; study, allowing for the tapering of systemic steroids and immunomodulatory agents. !ataract formation is a near certainty in phakic eyes, and the risk of glaucoma is nearly ?7C. !areful patient selection is a must. )rug !ategory: !ycloplegics . (ymptoms and complications of inflammation can be tempered with topical cycloplegic agents. oth short.acting drops %eg, cyclopentolate& and long.acting drops %eg, atropine& can be used to decrease photophobia caused by ciliary spasm and to break up or prevent the formation of posterior synechiae.

)rug !ategory: !orticosteroids . Inhibit arachidonic acid release from phospholipids, inhibit the transcription and action of cytokines, and limit . and T.cell activity. Indicated in inflammatory diseases of a noninfectious cause. Three routes of

administration are available: topical, periocular, and systemic. The best route and dose is determined for each patient, but the minimum amount needed to control inflammation should be used to reduce complications. ecause of serious adverse effects, especially with high doses and long.term use, immunosuppressive agents commonly are used for chronic or sight.threatening uveitis. Topical: #or anterior uveitis, topical steroid drops are used. )epending on the severity of the inflammation being treated, the fre"uency can range from hourly to every other day. 'rednisolone acetate 9C is preferred. (ince this agent is a precipitate, the patient must vigorously shake the bottle before use. (ometimes, steroids can cause ocular hypertension@ therefore, patients must be monitored at <. to ?.week intervals. 'eriocular: When a more posterior effect is necessary or when compliance is an issue, periocular corticosteroids can be administered. Hither a transseptal or a sub.Tenon approach works to deposit a long.lasting steroid %eg, triamcinolone acetonide& around the eye. Initially treating patients with a topical steroid for ;.< weeks prior to the administration of a long.acting depot steroid may help to identify those patients who are steroid responders. (ome evidence exists that deep transseptal in3ections cause less ocular hypertension than the sub.Tenon method. These in3ections should not be used in patients with infectious uveitis or scleritis because scleral thinning and possible perforation could result. (ystemic: When systemic disease is present that also re"uires treatment or for vision. threatening uveitis that is poorly responsive to other methods of delivery, oral or intravenous therapy is necessary. oth the short. and long.term adverse effects of corticosteroid use should be discussed with the patient and may re"uire the help of an internist. 'rednisone is the most commonly used oral corticosteroid.