AKT · Ophthalmology/Cornea & ant. segment

Anterior uveitis (iritis)

Inflammation of the iris/ciliary body (idiopathic or HLA-B27 / systemic associations)

Overview

Inflammation of the anterior uveal tract (iris ± ciliary body). Acute anterior uveitis presents with a painful, photophobic red eye with reduced vision; strongly associated with HLA-B27 disease (ankylosing spondylitis, IBD, reactive arthritis, psoriatic arthritis). Managed by ophthalmology with topical steroids and cycloplegia.

Recognise

Painful red eye with photophobia (including consensual photophobia), watering and blurred vision
Circumcorneal ('ciliary') injection, small/irregular pupil, anterior-chamber cells and flare; keratic precipitates; hypopyon if severe
Posterior synechiae (iris stuck to lens) → irregular pupil; associations: HLA-B27, sarcoidosis, IBD, JIA (often painless/white in children)

Red flags

New/recurrent uveitis, severe pain, marked visual loss or raised IOP → urgent same-day ophthalmology
Child with JIA: uveitis is often asymptomatic and white-eyed → screening slit-lamp checks (can blind silently)

Differentials & how to tell them apart

Acute angle-closure glaucomafixed mid-dilated pupil, hazy cornea, very high IOP, haloes, nausea

Conjunctivitisdischarge, no true pain/photophobia, normal vision and pupil

Scleritisboring pain that wakes the patient, deep violaceous injection not blanching with phenylephrine

Microbial keratitiscorneal infiltrate with an epithelial defect

Anterior uveitis — keratic precipitates on the corneal endothelium
Imrankabirhossain / CC BY-SA 4.0 — Wikimedia Commons

Investigations

Slit-lamp (cells/flare, KPs, synechiae). Investigate for systemic cause if recurrent/bilateral/granulomatous (HLA-B27, CXR/ACE for sarcoid, syphilis/TB serology).

Management

Same-day ophthalmology → topical steroid + cycloplegic

1Urgent same-day ophthalmology. Topical corticosteroid to control inflammation plus a cycloplegic (cyclopentolate/atropine) to relieve pain and prevent posterior synechiae.Gate: Do NOT start topical steroids in primary care — exclude an infective (herpetic) cause first; uveitis is a slit-lamp diagnosis, so refer rather than treat blind
2Recurrent/bilateral/posterior or granulomatous → investigate and treat the systemic cause (HLA-B27 work-up, sarcoid/TB/syphilis); chronic disease may need systemic steroids/DMARDs/biologics.

Topical corticosteroid (e.g. prednisolone/dexamethasone) — mainstay — specialist-directed to suppress inflammation

Cycloplegic/mydriatic (cyclopentolate/atropine) — relieves ciliary spasm pain and prevents/breaks posterior synechiae

Treat the systemic association — DMARDs/biologics for chronic or JIA-associated disease

Key points

Painful photophobic red eye + small/irregular pupil + AC cells = anterior uveitis. Think HLA-B27 (back pain, IBD, psoriasis). In a child with JIA it is silent and white — screened, not symptomatic.

Monitor & prognosis

Slit-lamp until quiet; watch IOP (steroid response) and synechiae.

Good if treated; recurrent disease and complications (glaucoma, cataract, CMO) with delay.

Source: NICE CKS Uveitis; College of Optometrists CMG