Traumatic iritis

Background

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

Clinical Features

• Often delayed presentation after traumatic event, typically within 3 days of blunt trauma
• Eye pain, especially if not relieved by topical anesthetic

Symptoms

• Blurry vision in affected eye
• Photophobia
• Floaters
• Tearing
• Perilimbal conjunctival injection, ciliary flush
• Decreased visual acuity
• Sluggish pupil affected eye
• Hallmark findings of consensual photophobia and “cell and flare” (anterior chamber) on slit limp examination
  • “Cell:” individual cells floating in the anterior chamber (look like dust specks)
  • “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

Complications:

• Synechiae formation
• 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

Differential Diagnosis

Unilateral red eye

• Nontraumatic
  • Acute angle-closure glaucoma^
  • Anterior uveitis
  • Conjunctivitis
  • Corneal erosion
  • Corneal ulcer^
  • Endophthalmitis^
  • Episcleritis
  • Herpes zoster ophthalmicus
  • Inflamed pinguecula
  • Inflamed pterygium
  • Keratoconjunctivitis
  • Keratoconus
  • Nontraumatic iritis
  • Scleritis^
  • Subconjunctival hemorrhage
• Orbital trauma
  • Caustic keratoconjunctivitis^^
  • Corneal abrasion, Corneal laceration
  • Conjunctival hemorrhage
  • Conjunctival laceration
  • Globe rupture^
  • Hemorrhagic chemosis
  • Lens dislocation
  • Ocular foreign body
  • Posterior vitreous detachment
  • Retinal detachment
  • Retrobulbar hemorrhage
    • Ocular compartment syndrome
  • Traumatic hyphema
  • Traumatic iritis
  • Traumatic mydriasis
  • Traumatic optic neuropathy
  • Vitreous detachment
  • Vitreous hemorrhage
  • Ultraviolet keratitis

^Emergent diagnoses ^^Critical diagnoses

Acute Vision Loss (Noninflamed)

• Painful
  • Arteritic anterior ischemic optic neuropathy
  • Optic neuritis
  • Temporal arteritis^†
• Painless
  • Amaurosis fugax
  • Central retinal artery occlusion (CRAO)^†
  • Central retinal vein occlusion (CRVO)^†
  • High altitude retinopathy
  • Open-angle glaucoma
  • Posterior reversible encephalopathy syndrome (PRES)
  • Retinal detachment^†
  • Stroke^†
  • Vitreous hemorrhage
  • Traumatic optic neuropathy (although may have pain from the trauma)

^†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
   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

• Red eye
• Eye pain