Diagnosis → Ophthalmology

Iridocyclitis

Etiology

Cause [nce][tdb][fvd]

• Noninfectious (immune-mediated HLA-B27–associated)

  • Arthritis

    • Axial spondyloarthritis/ankylosing spondylitis

    • Psoriatic arthritis

    • IBD-associated arthritis

    • Reactive arthritis

    • Juvenile idiopathic arthritis

  • Multiple Sclerosis

  • Sarcoidosis

  • Behçet disease

  • Idiopathic

• Infectious

  • Herpes simplex virus (HSV)

  • Varicella-zoster virus (VZV)

  • Cytomegalovirus (CMV)

  • Tuberculosis

  • Syphilis

  • Lyme disease

• Drugs: Immune checkpoint inhibitor–associated anterior uveitis

• Malignancy: Masquerade syndromes like lymphoma, leukemia, malignant melanoma

Pathophysiology [nce][fvd][qho]

1. Trigger and loss of ocular immune privilege

   • Infection

   • Autoimmunity

   • Immune-modulating drugs disrupt ocular immune privilege mechanisms (e.g., local immunosuppressive milieu in aqueous humor)

2. Breakdown of the blood–aqueous barrier

   • Increased vascular permeability in iris/ciliary body → protein exudation and leukocyte trafficking

3. Anterior chamber inflammatory cascade

   • Inflammatory cells/protein in aqueous humor → pain, photophobia, redness, hypopyon

4. Structural sequelae from ongoing/recurrent/chronic inflammation

   • Synechiae

   • Cataract

   • Secondary glaucoma/ocular hypertension

   • Macular edema

Risk factors [nce][tdb][fvd]

• HLA-B27 positivity

• Spondyloarthritis/IBD/psoriatic disease/reactive arthritis

• Juvenile idiopathic arthritis

• Smoking

• Immune checkpoint inhibitors

• Higher infectious exposure burden (TB, syphilis and Lyme in endemic regions)

Complications [nce][fvd]

• Corneal scar

• Non-resolving hypopyon

• Synechiae

• Macular edema

• Cataract

• Glaucoma

• Iris atrophy

• Optic nerve damage / optic disc swelling

• Vitreous hemorrhage

• Retinal detachment

• Vision loss

• Occlusio pupillae

• Festooned pupil

• Seclusio pupillae

• Endophthalmitis

• Strabismus

Epidemiology

Incidence per 100.000 [6sm][9vk]

Default

Approach

Approach [nce][tdb][fvd]

• Confirm anterior uveitis on slit lamp:

  • Anterior chamber cells and flare

  • Keratic precipitates

  • Hypopyon

  • Synechiae

  • No primary corneal abrasion/keratitis or posterior uveitis

• Intraocular pressure

• Dilated fundus exam

• OCT (optical coherence tomography) macula scan

• Infectious exclusion often prioritized: syphilis, TB; Lyme in endemic areas

• Consider sarcoidosis evaluation: Chest imaging ± ACE

• Anterior Chamber Tap for aqueous PCR if suspecting viral anterior uveitis

• Syphilis Serology

• HIV Serology

• HLA-B27 screening

Treatment

1. Topical corticosteroid: Prednisolone 1% (taper over weeks guided by AC cells) [nce]

2. Cycloplegic Atropine 1%: Dilate the pupil, pain control, prevent/break synechiae

3. Intraocular pressure management

4. Refractory or high-risk disease: if inadequate control with topical therapy

   • Periocular/intraocular corticosteroid if complications

   • Systemic corticosteroids or vitreous implants for severe, bilateral, recurrent, or posterior spillover disease

   • Steroid-sparing systemic immunomodulatory therapy

5. HLA-B27–associated (SpA-associated)

   • If frequent recurrences/severe disease --> biologic DMARDs (anti-TNF, IL-6)

6. Viral anterior uveitis (HSV/VZV/CMV)

   • Add systemic antiviral therapy

7. Immune checkpoint inhibitor–associated anterior uveitis

   • Severe cases may require systemic corticosteroids and prompt discontinuing ICI per oncology guidance

   • Methotrexate can be considered if poor response to systemic steroids

Differential diagnoses

Conjunctivitis, Corneal abrasion, Corneal ulcer, Endophthalmitis, Episcleritis, Foreign body, Glaucoma, Keratitis, Lymphoma, Retinitis, Scleritis, Subconjunctival hemorrhage, Trauma