EENT · PANCE / PANRE

Anterior Uveitis (Iritis)

Painful red eye with photophobia, miotic pupil, and cells/flare in the anterior chamber; treat with cycloplegic and topical steroid; investigate for HLA-B27 disease.

Also known as: anterior uveitis, iritis, iridocyclitis, acute anterior uveitis, HLA-B27 uveitis

Overview

Inflammation localized primarily to the anterior segment of the uveal tract — the iris (iritis) and ciliary body (iridocyclitis). Classified by onset (acute, recurrent, chronic), laterality, and granulomatous vs nongranulomatous appearance. Most common form of uveitis (about 75% of cases).

Epidemiology

Incidence 8-12 per 100,000 per year. Peak age 20-50, slight male predominance. HLA-B27 is positive in about 50% of acute anterior uveitis cases; the lifetime risk in HLA-B27 carriers is 1-2%.

🔒 Free preview limit reached

Keep reading — start your free trial

You've read your 2 free diagnosis previews. Create your free account to unlock the full Anterior Uveitis (Iritis) outline — plus all 514 diagnoses, 3,500+ board-style questions, flashcards, and an AI tutor. Your 7-day free trial includes everything, and there's no credit card required.

Start your 7-day free trial → Sign in

Free to start · No credit card · Cancel anytime

Risk factors

HLA-B27 positivity
Ankylosing spondylitis, reactive arthritis, psoriatic arthritis, IBD-associated arthritis
Juvenile idiopathic arthritis (especially ANA-positive oligoarticular form)
Sarcoidosis, tuberculosis, syphilis, herpesvirus infection (HSV, VZV, CMV)
Behcet disease
Ocular trauma, recent intraocular surgery (sterile postoperative uveitis)
Idiopathic (about one-third of cases)

Pathophysiology

Breakdown of the blood-aqueous barrier permits leukocyte and protein leak into the anterior chamber. Inflammatory mediators released by ciliary body and iris produce ciliary spasm (pain, miosis, photophobia), exudation of cells (cells in AC) and protein (flare), and may deposit on the corneal endothelium (keratic precipitates). Chronic or recurrent inflammation causes posterior synechiae (iris adhesions to lens) and secondary glaucoma.

Clinical presentation

Symptoms

Unilateral (usually) eye pain, photophobia, blurred vision, tearing
Headache or brow ache
Reduced visual acuity, often mildly to moderately impaired
Recurrent episodes in HLA-B27-related disease — often the SAME eye or alternating
Associated systemic features may include low back pain (AS), arthritis, mucosal ulcers, GI symptoms, dermatitis

Signs / physical exam

Circumlimbal (ciliary) flush — perilimbal redness with deeper vessel injection
Miotic pupil from ciliary spasm; may be irregular if posterior synechiae
Slit-lamp: cells and flare in the anterior chamber (graded 1+ to 4+); hypopyon in severe disease (especially Behcet, HLA-B27)
Keratic precipitates on the corneal endothelium — fine (nongranulomatous) or mutton-fat large/greasy (granulomatous, suggesting sarcoid, TB, syphilis)
IOP may be low (decreased aqueous production from ciliary body inflammation) or elevated (trabeculitis or pupillary block)
Posterior synechiae — iris adhesions to anterior lens capsule; pupil shape becomes irregular with dilation

Classic findings

Painful red eye with photophobia, ciliary flush, miotic pupil, and cells/flare on slit-lamp examination.

Differential diagnosis

Acute angle-closure glaucoma — Severe pain, headache, nausea, halos around lights; fixed mid-dilated pupil; markedly elevated IOP; corneal edema; emergency
Bacterial keratitis — Pain, photophobia, mucopurulent discharge, corneal infiltrate with epithelial defect; fluorescein staining; contact lens user
Herpes simplex keratitis — Dendritic corneal lesion on fluorescein; decreased corneal sensation; antiviral therapy
Conjunctivitis — Discharge, papillary or follicular reaction, no anterior chamber cells, no photophobia (or mild)
Episcleritis / scleritis — Sectoral redness, deep ache (scleritis); scleritis often associated with systemic disease and threatens vision
Endophthalmitis — Acute severe pain and vision loss after surgery or trauma; hypopyon, vitritis; emergency
Posterior uveitis or panuveitis — Floaters, decreased vision; cells in vitreous; chorioretinal lesions on fundus exam

Diagnostic workup

Diagnostic criteria

Clinical diagnosis by slit-lamp findings (cells and flare in the anterior chamber). Standardization of Uveitis Nomenclature (SUN) grading is used for cell and flare quantification.

Labs

First episode of unilateral acute anterior uveitis without systemic features may need NO workup
If recurrent, bilateral, granulomatous, or with systemic features: CBC, ESR, CRP, ACE, lysozyme, HLA-B27, RPR/treponemal, QuantiFERON-TB, ANA, urinalysis, Lyme serology if exposure
Chest X-ray or CT chest for sarcoid and TB screening
Sacroiliac imaging or MRI if back pain to assess for ankylosing spondylitis
Anterior chamber tap with PCR (HSV, VZV, CMV) for atypical or chronic cases

Imaging

Slit-lamp examination — primary diagnostic modality; documents cells, flare, KPs, synechiae
Dilated fundoscopy to assess posterior involvement
Anterior segment OCT for monitoring inflammation in select cases
Goldmann tonometry — important to monitor for steroid-induced or inflammatory IOP elevation

Diagnostic algorithm

Feature	Anterior uveitis	Acute angle-closure glaucoma	Conjunctivitis	Bacterial keratitis
Pain	Moderate, deep	Severe + headache/nausea	Mild gritty	Severe + photophobia
Pupil	Miotic / irregular	Mid-dilated, fixed	Normal	Normal
Cornea	Clear ± KPs	Hazy edematous	Clear	Infiltrate ± epithelial defect
IOP	Low, normal, or high	Markedly elevated	Normal	Normal
AC cells	Present	May be present	Absent	May be present
Discharge	None (tearing)	None	Mucoid/purulent	Mucopurulent
First step	Slit lamp + cycloplegic + topical steroid + ophtho	Lower IOP + ophthalmology emergency	Hygiene ± topical antibiotic	Topical fluoroquinolone + ophtho

Quick differentiation of the painful red eye.

Treatment

First-line

Topical cycloplegic — cyclopentolate 1%, homatropine 5%, or atropine 1% — to relieve ciliary spasm and prevent posterior synechiae
Topical corticosteroid — prednisolone acetate 1% every 1-2 hours initially, tapered over weeks; difluprednate 0.05% is an alternative potent steroid
Treat underlying cause if identified (antivirals for HSV/VZV uveitis, antibiotics for syphilis, anti-TB for tuberculosis)
Urgent ophthalmology referral within 24 hours
Monitor IOP at every visit — both inflammatory glaucoma and steroid-induced ocular hypertension can occur

Second-line / adjunct

Periocular or intravitreal corticosteroid injection (triamcinolone, dexamethasone implant) for severe or non-responsive disease
Systemic corticosteroid for bilateral severe or sight-threatening inflammation
Immunomodulatory therapy (methotrexate, azathioprine, mycophenolate, cyclosporine) for chronic recurrent disease
TNF-alpha inhibitors (adalimumab is FDA-approved for noninfectious uveitis; infliximab off-label) for HLA-B27-related, JIA-associated, or Behcet uveitis
Laser or surgical synechiolysis for refractory synechiae

Complications

Posterior synechiae with pupillary block and secondary angle-closure glaucoma
Cataract (from inflammation and from chronic steroid use)
Glaucoma (inflammatory, steroid-induced, or angle-closure)
Cystoid macular edema
Band keratopathy in chronic disease
Hypotony with phthisis in chronic uncontrolled inflammation
Vision loss

PANCE pearls

Cells in the anterior chamber on slit-lamp examination clinch the diagnosis — no cells, no uveitis.
Always dilate the pupil with a cycloplegic — both for synechiae prevention and to allow posterior segment examination.
Recurrent acute anterior uveitis, especially in young men with low back pain, should prompt HLA-B27 testing and rheumatology referral.
Granulomatous (mutton-fat) keratic precipitates suggest sarcoid, TB, or syphilis — workup mandatory.
Monitor intraocular pressure at every visit; both the inflammation and the steroids can drive glaucoma.
Never give topical steroids for a red eye unless cornea has been examined with fluorescein to exclude dendritic HSV keratitis.

References

AAO PPP — American Academy of Ophthalmology Preferred Practice Pattern: Uveitis
SUN — Standardization of Uveitis Nomenclature (SUN) Working Group recommendations (Jabs et al., Am J Ophthalmol 2005)
AUSCON / FOSTER — Foster CS, Kothari S, Anesi SD et al. The Ocular Immunology and Uveitis Foundation preferred practice patterns of uveitis management

Practice EENT questions on FirstPassPA

Turn this outline into retention. 3,500+ board-style questions with an AI tutor that explains every answer — free to start, no card required.

Start studying free → Browse all 514 diagnoses

Educational use only. This outline is a study aid for PA students and is not medical advice or a substitute for clinical judgment. FirstPassPA is an independent study tool and is not affiliated with, endorsed by, or sponsored by NCCPA. PANCE® and PANRE® are registered trademarks of the National Commission on Certification of Physician Assistants.