Traumatic iritis: Difference between revisions

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==Background==
==Background==
*Blunt trauma: contusion and spasm of ciliary body and iris
*Classically blunt trauma: contusion and spasm of ciliary body and iris
*Iridocyclitis because both the iris and the underlying ciliary body are inflamed
*May occur in any traumatic injury<ref>Augsburger JJ, Corrêa ZM. Chapter 19. Ophthalmic Trauma. In: Riordan-Eva P, Cunningham, Jr. ET, eds. Vaughan &amp;amp;amp;amp;amp;amp; Asbury's General Ophthalmology. 18th ed. New York, NY: McGraw-Hill; 2011:371-382.</ref>
*Iritis
*90% of uveitis is iritis, and traumatic iritis accounts for 20% of iritis<ref>Gutteridge IF, Hall AJ. Acute anterior uveitis in primary care. Clinical and Experimental Optometry. 2007. 90(2):70-82.</ref>
**HLA-B27 antigenic marker also strongly linked to spondyloarthritis such as ankylosing spondylitis


==Clinical Features==
==Clinical Features==
*Eye pain
*Often delayed presentation after traumatic event, typically 24-48 hrs
*[[Eye pain]], especially if not relieved by topical anesthetic<ref>Reidy JJ. Section 08: External Disease and Cornea. Basic and Clinical Science Course. San Francisco, CA: American Academy of Ophthalmology; 2012: 363.</ref>
*Decreased visual acuity in affected eye
*Decreased visual acuity in affected eye
*Photophobia (direct and consensual)
*Photophobia (direct and consensual)
*Sluggish pupil
*Sluggish pupil
*Cell & flare
*Hypopyon (severe cases): leukocytic exudate in anterior chamber
*Cell & flare (anterior chamber reaction)
**“Cell:” individual cells floating in the anterior chamber (look like dust specks)
**“Cell:” individual cells floating in the anterior chamber (look like dust specks)
**“Flare:" protein floating in the anterior chamber from inflamed blood vessels. (smoke)
**“Flare:" protein floating in the anterior chamber from inflamed blood vessels. (smoke)
*Hypopyon (severe cases): leukocytic exudate in anterior chamber
**May deposit onto corneal endothelium as keratic precipitates<ref>Bartley GB, Liesegang TJ. Essentials of Ophthalmology. Philadelphia, PA: JB Lippincott Company; 1992:156-157.</ref>
*Vossius' ring on anterior lens capsule
**Due to concussive force of posterior iris onto lens
**Depositing pigment in the pattern of a miosed pupil onto anterior lens
*IOP may be increased due to inflammation, damage to ciliary body, or circumferential synechial formation<ref>Trevor-Roper PD, Curran PV. The Eye and Its Disorders. Boston, MA: Blackwell Scientific Publications; 1984:489-507.</ref>


==Differential Diagnosis==
==Differential Diagnosis==
{{Unilateral red eye DDX}}
{{Unilateral red eye DDX}}
{{Acute vision loss noninflamed DDX}}


==Diagnosis==
==Evaluation==
*Clinical diagnosis
*Clinical diagnosis


==Treatment==
==Management==
#Cycloplegics (eg. homotyptine 5%, or cyclopentolate 2%, 3 times per day until ophthalmology follow-up): paralyzes the ciliary body resulting in a nonreactive, dilated pupil
#PO analgesia
#PO analgesia
#Steroids in consult with optho (rule out infection first)
#Cycloplegics paralyze the ciliary body resulting in a nonreactive and dilated pupil, preventing synechiae, progression of flare, ciliary spasm pain<ref>Alexander KL, Dul MW, Lalle PA, Magnus DE. Onofrey B. Optometric Clinical Practice Guideline: Care of the Patient with Anterior Uveitis. St. Louis, MO: American Optometric Association; 1994:3-29.</ref>
##[[Homatropine]] 5% BID-TID
##[[Cyclopentolate]] 2% TID
##[[Scopolamine]] 0.25% BID
#[[Corticosteroids#Ophthalmic Steroids|Topical steroids]] in consult with optho
##Rule out infection first and avoid corneal epithelial defect
##[[Prednisolone]] acetate 0.5-1% QID
#If secondary [[glaucoma]] as complication, may use [[timolol]] 0.5% BID if no contraindication


==Disposition==
==Disposition==
F/u with optho in 24-48 hours
*Follow up with optho in 24-48 hours, but 5-7 days may be acceptable on a case by case basis


==See Also==
==See Also==
*[[Red eye]]
*[[Eye pain]]


==References==
==References==
*PEER VIII Q&A
<references/>


[[Category:Ophtho]]
[[Category:Ophthalmology]]

Revision as of 06:26, 17 August 2017

Background

  • Classically blunt trauma: contusion and spasm of ciliary body and iris
  • May occur in any traumatic injury[1]
  • 90% of uveitis is iritis, and traumatic iritis accounts for 20% of iritis[2]

Clinical Features

  • Often delayed presentation after traumatic event, typically 24-48 hrs
  • Eye pain, especially if not relieved by topical anesthetic[3]
  • Decreased visual acuity in affected eye
  • Photophobia (direct and consensual)
  • Sluggish pupil
  • Hypopyon (severe cases): leukocytic exudate in anterior chamber
  • Cell & flare (anterior chamber reaction)
    • “Cell:” individual cells floating in the anterior chamber (look like dust specks)
    • “Flare:" protein floating in the anterior chamber from inflamed blood vessels. (smoke)
    • May deposit onto corneal endothelium as keratic precipitates[4]
  • Vossius' ring on anterior lens capsule
    • Due to concussive force of posterior iris onto lens
    • Depositing pigment in the pattern of a miosed pupil onto anterior lens
  • IOP may be increased due to inflammation, damage to ciliary body, or circumferential synechial formation[5]

Differential Diagnosis

Unilateral red eye

^Emergent diagnoses ^^Critical diagnoses

Acute Vision Loss (Noninflamed)

Emergent Diagnosis

Evaluation

  • Clinical diagnosis

Management

  1. PO analgesia
  2. Cycloplegics paralyze the ciliary body resulting in a nonreactive and dilated pupil, preventing synechiae, progression of flare, ciliary spasm pain[6]
    1. Homatropine 5% BID-TID
    2. Cyclopentolate 2% TID
    3. Scopolamine 0.25% BID
  3. Topical steroids in consult with optho
    1. Rule out infection first and avoid corneal epithelial defect
    2. Prednisolone acetate 0.5-1% QID
  4. If secondary glaucoma as complication, may use timolol 0.5% BID if no contraindication

Disposition

  • Follow up with optho in 24-48 hours, but 5-7 days may be acceptable on a case by case basis

See Also

References

  1. Augsburger JJ, Corrêa ZM. Chapter 19. Ophthalmic Trauma. In: Riordan-Eva P, Cunningham, Jr. ET, eds. Vaughan &amp;amp;amp;amp;amp; Asbury's General Ophthalmology. 18th ed. New York, NY: McGraw-Hill; 2011:371-382.
  2. Gutteridge IF, Hall AJ. Acute anterior uveitis in primary care. Clinical and Experimental Optometry. 2007. 90(2):70-82.
  3. Reidy JJ. Section 08: External Disease and Cornea. Basic and Clinical Science Course. San Francisco, CA: American Academy of Ophthalmology; 2012: 363.
  4. Bartley GB, Liesegang TJ. Essentials of Ophthalmology. Philadelphia, PA: JB Lippincott Company; 1992:156-157.
  5. Trevor-Roper PD, Curran PV. The Eye and Its Disorders. Boston, MA: Blackwell Scientific Publications; 1984:489-507.
  6. Alexander KL, Dul MW, Lalle PA, Magnus DE. Onofrey B. Optometric Clinical Practice Guideline: Care of the Patient with Anterior Uveitis. St. Louis, MO: American Optometric Association; 1994:3-29.