Acute Iritis

This 31-year-old white female first presented in 2018 with complaints of pain, redness, and light sensitivity in her right eye. She was immediately started on a topical steroid and cycloplegic eyedrops. Her condition improved slowly over the next few weeks but did not resolve completely. She was then referred to a large, specialty ophthalmology clinic associated with a prominent medical school.

Switching her to Durezol (difluprednate 0.05%, Alcon) helped to control the iritis, which eventually resolved. Due to her relatively young age and to the severity of the condition, blood work was ordered. The results were positive for the HLA-B27 marker and possibly ankylosing spondylitis. The latter corresponded with her complaints of lower back pain. Later, it was revealed that she also suffered from Hashimoto’s thyroiditis. A moderate but definite association has linked thyroid disease and uveitis.¹

This patient presented recently with the same complaints of iritis but with more severe symptoms (Figure 1). She had resumed using the Durezol but not the cycloplegics. The anterior chamber was notable for 3+ cells and flare as well as for a prominent fibroid membrane. These membranes have previously been reported as a transient complication of phacoemulsification with implantation of a posterior chamber intraocular lens (7.6% in one study).² The patient was immediately started on homatropine 5% three times daily as well as on a new bottle of Durezol to be used every three hours while awake. Subsequent follow up by the ophthalmology service reported resolution of the condition as well as of the membrane.

Anterior uveitis or iritis is an inflammatory condition of the anterior uveal tract that may include the iris and ciliary body. It may be classified as acute or chronic as well as granulomatous or non-granulomatous.³ While many consider iritis easier to treat compared to panuveitis, serious complications may nevertheless occur. Cystoid macular edema, cataract, and glaucoma, especially in a steroid responder, are possible sequelae.³

Patients will typically present with complaints of light sensitivity, pain, and hyperemia, although the latter may be a light ciliary flush as opposed to the “beet-redness” of bacterial infection. Circumlimbal injection is more common.³

Cells present in the anterior chamber are considered a hallmark of iritis, as “up to 75% of patients with bacterial keratitis will not have anterior chamber inflammation.”⁴ These cells are primarily leukocytes but may also be neutrophils as well.³

References

1. Borkar DS, Homayounfar G, Tham VM, et al. Association Between Thyroid Disease and Uveitis: Results From the Pacific Ocular Inflammation Study. JAMA Ophthalmol. 2017 Jun;135;594-599.
2. Nishi O. Fibrinous membrane formation on the posterior chamber lens during the early postoperative period. J Cataract Refract Surg. 1988 Jan;14;73-77.
3. Guney E, Tugal-Tutkun T. Symptoms and Signs of Aterior Uveitis. US Ophthal Rev. 2013 Jan;6:33-37.
4. Gilani CJ, Yang A, Yonkers M, Boysen-Osborn M. Differentiating Urgent and Emergent Causes of Acute Red Eye for the Emergency Physician. West J Emerg Med. 2017 Apr;18:509–517.