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Acute Iritis (Anterior Uveitis)

What is Acute Iritis?

Acute iritis, also called acute anterior uveitis, is a sudden‑onset inflammation of the iris (the colored part of the eye) and the adjacent ciliary body. The inflammation is located in the front (anterior) segment of the eye, which is why it is often referred to as “anterior uveitis.” The condition can develop within hours to a few days and, if untreated, may lead to complications such as cataract, glaucoma, or permanent vision loss.

Most patients describe a rapid change in vision accompanied by eye pain, light sensitivity, and a feeling of something “in the eye.” While a single episode may be isolated, many people experience recurrent attacks.

Common Causes

Acute iritis is usually the result of an underlying systemic or ocular trigger. The most frequent causes include:

• Autoimmune disorders – e.g., ankylosing spondylitis, Behçet’s disease, sarcoidosis, rheumatoid arthritis.
• Infectious agents – herpes simplex virus (HSV), varicella‑zoster virus (VZV), cytomegalovirus (CMV), syphilis, tuberculosis, or Lyme disease.
• Trauma – blunt or penetrating eye injury can rupture the blood‑aqueous barrier and provoke inflammation.
• Intra‑ocular surgery – cataract extraction, laser procedures, or vitrectomy may trigger postoperative iritis.
• Systemic inflammatory diseases – inflammatory bowel disease (Crohn’s, ulcerative colitis), psoriasis, or juvenile idiopathic arthritis.
• HLA‑B27 positivity – the genetic marker HLA‑B27 is strongly associated with recurrent anterior uveitis.
• Medications – certain drugs such as bisphosphonates, sulfonamides, or diethylstilbestrol have been reported to cause a drug‑induced uveitis.
• Masquerade syndromes – intra‑ocular tumors (e.g., lymphoma, melanoma) can mimic iritis.
• Idiopathic – up to 30 % of cases have no identifiable cause after thorough work‑up.

Associated Symptoms

Patients with acute iritis often experience a cluster of symptoms that develop together:

• Eye pain – deep, aching pain that worsens with eye movement.
• Photophobia – intolerance to bright light.
• Redness – typically a dull, circumferential redness of the sclera (ciliary injection) rather than the bright “bird’s‑eye” injection seen in conjunctivitis.
• Blurred vision – due to corneal edema, inflammatory cells in the anterior chamber, or the development of posterior synechiae.
• Floaters – small dark specks that seem to drift in the visual field.
• Decreased depth perception – especially if the inflammation is intense.
• Eye pressure changes – either elevated (risk for secondary glaucoma) or lowered intra‑ocular pressure.

When to See a Doctor

Because untreated iritis can cause permanent damage, prompt evaluation is essential. Seek professional care if you notice:

• Moderate to severe eye pain that does not improve with over‑the‑counter pain relievers.
• Sudden onset of redness and light sensitivity.
• Blurred or double vision that persists beyond a few hours.
• Symptoms following eye injury, eye surgery, or a recent systemic infection.
• Recurrent episodes of similar eye inflammation.
• Any history of autoimmune disease, recent travel to areas with endemic infections (e.g., TB, Lyme), or known HLA‑B27 positivity.

Even if symptoms appear mild, an ophthalmic exam is warranted to rule out complications.

Diagnosis

Diagnosis is primarily clinical, performed by an ophthalmologist or optometrist with specialized equipment.

1. Detailed History

• Onset, duration, and progression of symptoms.
• Recent infections, surgeries, trauma, or new medications.
• Systemic disease history (autoimmune, infectious, inflammatory).

2. Slit‑Lamp Examination

A magnified microscope (slit‑lamp) allows the clinician to view the structures of the anterior segment:

• Presence of cells and flare (protein leakage) in the anterior chamber.
• Degree of **ciliary injection** (redness around the cornea).
• Any **posterior synechiae** – adhesions between the iris and the lens.
• Corneal edema or keratic precipitates (tiny deposits on the back of the cornea).

3. Intra‑ocular Pressure (IOP) Measurement

Inflammation can either raise or lower IOP; measuring it helps detect secondary glaucoma early.

4. Ancillary Tests (if indicated)

• Fundus examination – to assess the posterior segment for peripheral uveitis.
• Laboratory work‑up – HLA‑B27 typing, rheumatoid factor, ANA, ACE level, lysozyme, syphilis serology (RPR/VDRL), TB interferon‑gamma release assay, and Lyme serology when systemic disease is suspected.
• PCR or culture of aqueous humor – rare, used for suspected infectious etiologies.
• Imaging – orbital ultrasound or OCT (optical coherence tomography) if posterior involvement is suspected.

Treatment Options

Treatment aims to reduce inflammation, relieve symptoms, prevent complications, and address any underlying cause.

1. Topical Corticosteroids

First‑line therapy for most cases:

• Prednisolone acetate 1 % drops, usually initiated every 1–2 hours and tapered over weeks.
• Alternative agents include difluprednate 0.05 % or loteprednol etabonate (lower risk of IOP rise).

2. Cycloplegic / Mydriatic Agents

These dilate the pupil and relieve ciliary spasm, helping prevent posterior synechiae:

• Atropine 1 % (long‑acting) or cyclopentolate 1 % (short‑acting).

3. Non‑steroidal Anti‑Inflammatory Drugs (NSAIDs)

Topical NSAIDs (e.g., ketorolac 0.5 %) can be added for pain control and to reduce steroid load.

4. Systemic Therapy (when needed)

• Oral corticosteroids – for severe or bilateral disease, or when topical therapy is insufficient.
• Immunomodulatory agents – methotrexate, mycophenolate mofetil, or biologics (e.g., adalimumab) for recurrent disease linked to autoimmune disorders.
• Antiviral or antibacterial agents – when a specific infectious cause is identified (e.g., acyclovir for HSV, doxycycline for Lyme).

5. Home Care & Symptomatic Relief

• Cold compresses for pain (10‑15 minutes, several times daily).
• Avoid bright lights; wear sunglasses with UV protection.
• Do not wear contact lenses until cleared by the ophthalmologist.
• Maintain good hand hygiene to prevent secondary infection.

6. Follow‑up

Patients are usually re‑examined within 24‑48 hours after initiating therapy to assess response, adjust medication, and monitor intra‑ocular pressure.

Prevention Tips

While not all episodes are preventable, several strategies can lower the risk of recurrence:

• Control systemic disease – keep rheumatologic or inflammatory conditions well‑managed with the help of your primary physician.
• Regular eye examinations – especially for individuals with known HLA‑B27 positivity, ankylosing spondylitis, or a history of prior uveitis.
• Avoid eye trauma – wear protective eyewear during sports or high‑risk occupations.
• Limit exposure to known triggers – for example, avoid prolonged use of certain medications (e.g., bisphosphonates) without medical supervision.
• Prompt treatment of infections – seek care for bacterial or viral eye infections early to prevent spread to the anterior chamber.
• Adhere to treatment regimens – never stop steroid drops abruptly; taper as instructed to prevent rebound inflammation.

Emergency Warning Signs

If you develop any of the following, seek emergency eye care (ER or urgent ophthalmology) immediately:

• Sudden, severe eye pain that worsens despite medication.
• Rapid loss of vision or new “black spots” in your visual field.
• Marked increase in eye redness with a hazy or “cloudy” cornea.
• Persistent vomiting, headache, or neurological symptoms accompanying eye pain (possible meningitis or severe infection).
• Signs of elevated intra‑ocular pressure: halos around lights, persistent headache, or nausea.

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References:

• Mayo Clinic. “Uveitis.” https://www.mayoclinic.org
• Cleveland Clinic. “Anterior Uveitis (Iritis).” https://my.clevelandclinic.org
• American Academy of Ophthalmology. “Uveitis Preferred Practice Pattern.” 2023.
• National Eye Institute (NEI). “Uveitis.” https://nei.nih.gov
• World Health Organization. “WHO Guidelines on the Management of Uveitis.” 2022.

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