Ophthalmology & Rheumatology & Internal Medicine & Family Medicine
Iritis / Anterior uveitis
Iritis - the clinical term for isolated inflammation of the iris - and anterior uveitis - a more precise anatomopathological term encompassing inflammation of the iris (iritis) and ciliary body (iridocyclitis) - are the most common ocular inflammatory entities, accounting for 50-75 % of all uveitis. Anterior uveitis is defined by the presence of inflammatory cells and flare (protein) in the anterior chamber of the eye, as assessed by the ophthalmologist using a slit lamp. It typically manifests as a clinical triad: unilateral eye pain (deep eye pain) + photophobia + perikeratic redness (perikeratic circle - vasodilation of limbal vessels) ± reduced visual acuity. Prevalence is estimated at 4-8 cases per 100,000 inhabitants per year. The main identifiable cause is HLA-B27 spondyloarthropathy (ankylosing spondylitis + psoriatic arthritis + reactive arthritis + IBD-associated), which accounts for 30-50 % of recurrent anterior uveitis. In the majority of cases (50-60 %), anterior uveitis is idiopathic. Other causes include sarcoidosis, tuberculosis, Behçet's syndrome, toxoplasmosis, Fuchs syndrome (chronic unilateral asymptomatic), and viral causes (HSV + VZV + CMV). Treatment is based on topical corticosteroids (eye drops) and cycloplegic mydriatic agents (atropine + tropicamide) to relieve ciliary spasm, prevent synechiae and reduce inflammation. Early recognition and prompt treatment are essential to prevent complications (glaucoma + cataract + irreversible posterior synechiae + permanent loss of vision).
Pathophysiology, etiologies, and clinical presentation
- Anatomy of the Uvea and Pathophysiological Mechanisms of Anterior Uveitis anatomy of the uvea and classification of uveitis: uvea = vascular tunica of the eye → composed of 3 parts: iris (anterior) + ciliary body (intermediate) + choroid (posterior) → SUN classification (Standardization of Uveitis Nomenclature - Jabs 2005 - American Journal of Ophthalmology) according to location: anterior uveitis: anterior chamber + iris + anterior ciliary body → iritis + iridocyclitis → intermediate uveitis: vitreous + posterior ciliary body + pars plana → pars planite → posterior uveitis: retina + choroid → chorioretinitis + retinitis → pan-uveitis: all layers of the uvea; immunological mechanisms of uveitis: anterior uveitis is predominantly of immune mechanism: non-infectious uveitis (70-80 %): autoimmune or dysimmune mechanism → CD4+ + CD8+ T lymphocytes → activation by ocular antigens (retinal + iris antigens) → type IV hypersensitivity reaction + complement activation → HLA-B27 spondyloarthropathies → iris has similar molecular structures to HLA-B27 → antigenic cross-reactivity (molecular mimicry) → inflammatory + infectious uveitis (20-30 %): direct invasion of iris + ciliary body by pathogens → HSV + VZV + CMV + Toxoplasma gondii + Mycobacterium tuberculosis + Treponema pallidum (syphilis) + Borrelia burgdorferi (Lyme) + rubella virus → ocular hypertension (OHT) often associated with viral uveitis (CMV + HSV + VZV) → antiviral treatment + corticosteroids + important differential features according to mechanisms: HLA-B27 uveitis: unilateral + acute + fibrinogenic + recurrent + alternating + associated with spondylar arthritis → sarcoidosis: bilateral + chronic + granulomatous (retrodescemetic sheep fat precipitates) + herpetic uveitis: unilateral + ocular hypertonia + dendritic keratitis possible → atrophied iris sector + Fuchs syndrome : Fuchs' iridocyclitis → unilateral + chronic + asymptomatic + cells in anterior chamber + stellate precipitates + iridis heterochromia (iris lighter on affected side) + cataract + glaucoma → cause: intraocular rubella (Roman 2006 - American Journal of Ophthalmology) → mechanisms of complications: posterior synechiae (iris - lens) → pupillary obstruction → glaucoma by pupillary blockage + iris bomb → secondary glaucoma → trabeculitis hypertonia (acute uveitis - increased resistance to aqueous humor outflow) → posterior subcapsular cataract → prolonged local corticosteroid therapy + chronic inflammation → cystoid macular edema (complication of chronic uveitis - decreased vision)
- Etiologies and detailed clinical presentation: Etiologies of anterior uveitis by frequency: idiopathic (50-60 %): no identifiable cause despite comprehensive workup → HLA-B27 positive in 30-50 % of these cases → good prognosis if promptly treated + HLA-B27 spondyloarthropathies (25-40 % of recurrent anterior uveitis): ankylosing spondylitis (AS): HLA-B27 association + most classic uveitis → unilateral + acute + fibrinogen + intense photophobia + frequent recurrences (alternating sides) + reactive arthritis (Reiter): after urogenital or digestive infection → uveitis + urethritis + arthritis (Reiter's triad) + psoriatic arthritis (RPso) + IBD-associated (Crohn's + UC): uveitis + IBD → often HLA-B27 positive + sarcoidosis: 2nd cause of non-infectious uveitis → bilateral + chronic + granulomatous (mutton fat KP - retrodescemetic sheep fat precipitates) + bulging iris + iris nodules (Busacca + Koeppe) + elevated angiotensin-converting enzyme (ACE) + Behçet syndrome: mouth ulcers + uveitis (often posterior → retinal vasculitis) + genital + cutaneous lesions → severe bilateral uveitis → international Behçet criteria + viral: herpes simplex (HSV): keratitis + uveitis + hypertonia → treatment: aciclovir + dexamethasone → ophthalmic shingles (VZV) + CMV : Posner-Schlossman endotheliitis + ocular hypertension → topical ganciclovir → ocular toxoplasmosis: more often posterior uveitis → but can give anterior uveitis by spillover + ocular tuberculosis: granulomatous + posterior uveitis + chorioretinitis + syphilis: great mimic → all types of uveitis → TPHA + VDRL serology + Lyme disease: Borrelia + uveitis + IBD + JIA (Juvenile Idiopathic Arthritis): asymptomatic chronic iridocyclitis in children → beware of silent synechiae → ANA positive; clinical manifestations: deep ocular pain (deep pain - ciliary pain → periorbital irradiation) + intense photophobia + miosis (pupil small + irregular if synechiae) + perikeratic conjunctival hyperhemia (perikeratic circle - limbal deep vessels - unlike superficial conjunctivitis) + decreased visual acuity (if significant flare + synechiae + complications) + tearing → slit-lamp examination by ophthalmologist: anterior chamber tyndall (flare = proteins + cells) → scoring according to SUN: 0 to 4+ → retrodescemetic precipitates (KP): fine = non-granulomatous → sheep fat = granulomatous (sarcoidosis + tuberculosis) → posterior synechiae (iris adheres to lens) → ocular hypertonia → fundus + OCT + angiography
Diagnosis, treatment, and etiological management
| Aspect / Domain | Data, criteria and procedures | Key studies and recommendations |
|---|---|---|
| Local treatment — ophthalmic corticosteroids and mydriatics Dexamethasone — prednisolone acetate — atropine — tropicamide — cyclopentolate — synechiae prevention — ocular hypertension — instillation schedule — tapering — severe uveitis |
Topical treatment of anterior uveitis - reference treatment: ophthalmic corticosteroids (eye drops): prednisolone acetate 1 % (Pred Forte): most potent glucocorticoid available in eye drop form → best corneal penetration → schedule according to severity: mild to moderate uveitis (tyndall 1+-2+): 1 drop every 2h for the first 2-3 days → then reduction according to response → severe uveitis (tyndall 3+-4+): 1 drop every hour for the first 24-48h → then gradual reduction → total duration: 4-8 weeks for acute uveitis → SLOW, gradual decrease (risk of rebound if stopped too quickly) → rule: wait for complete resolution of the flare (cells + proteins) before accelerating the decrease → dexamethasone eye drops (Maxidex 0.1 %): effective but corneal penetration slightly inferior to prednisolone acetate → or loteprednol (Lotemax 0.5 %): esterified glucocorticoid → less conversion → less ocular hypertonia → preferred in mild uveitis or patients at risk of glaucoma → complications of local corticosteroid treatment: ocular hypertonia: monitor IOP at D7-J14 → if IOP >25 mmHg → add ocular hypotensor (dorzolamide + or timolol) + consider switching to loteprednol → posterior subcapsular cataract: prolonged local corticosteroid therapy → annual monitoring by ophthalmologist → mydriatic-cycloplegic agents: mechanism: paralysis of pupillary sphincter + ciliary muscle → pupillary dilatation → prevention of posterior synechiae (lens iris) + relief of ciliary spasm (main source of pain) → atropine 1 %: long-acting (7-14 days) → severe uveitis + synechiae already present → short-acting cycloplegics: cyclopentolate 1 % (Cyclogyl - duration 24h) → tropicamide 1 % (duration 6h) → for mild to moderate uveitis → homatropine 2-5 %: intermediate duration (2-3 days) → usual protocol in daily practice : prednisolone acetate 1 % × 1 drop every 2h (D1-J3) + tropicamide 1 % × 3/d or cyclopentolate 1 % × 2/d → reassessment at D7 → if improvement → reduction to × 4/d of prednisolone + maintenance of mydriatic → if rebound → intensification + periocular corticoids (subconjunctival or subtenone injection of triamcinolone or betamethasone) : if insufficient response to eye drops → good intraocular penetration → indications: severe uveitis + insufficient compliance with eye drops + uveitis in children | Jabs 2005 — American Journal of Ophthalmology (SUN criteria): standardization of uveitis classification and monitoring + grading of tyndall → world reference + Pavesio 2003 — British Journal of Ophthalmology: corticosteroid eye drops + anterior uveitis → prednisolone acetate 1 % = gold standard + efficacy + London 2003 — American Journal of Ophthalmology: mydriatics + uveitis → prevention of synechiae → review of indications + protocols + Nussenblatt 2010 — Uveitis: Fundamentals and Clinical Practice (4th edition): treatment of uveitis → corticosteroids + mydriatics + protocols + AAO (American Academy of Ophthalmology) 2021: preferred practice pattern for anterior uveitis → treatment + monitoring → Wakefield 2008 — Ophthalmology: prevention of synechiae + flare control + monitoring parameters + EULAR 2018 recommendations for management of uveitis: treatment algorithm + monitoring |
| Etiological assessment and systemic treatments HLA-B27 — spondyloarthritis — sarcoidosis — ACE — lysozyme — sacroiliac radiography — infectious workup — syphilis — tuberculosis — Behçet's — immunosuppressants — anti-TNF — adalimumab — methotrexate |
Etiological work-up for anterior uveitis - indications and algorithm: systematic work-up recommended for all anterior uveitis: HLA-B27 (typing) : if positive → work-up for spondyloarthropathy (sacroiliac radiographs + spine + sacroiliac MRI if clinical) → CBC + CRP + ESR → systemic inflammation → ACE (angiotensin-converting enzyme) + serum lysozyme → if elevated + bilateral + granulomatous uveitis → sarcoidosis → complete with: chest X-ray (hilar adenopathies + infiltrates) + TAP scan if normal chest X-ray → +/- bronchial or conjunctival biopsy → RPR or VDRL + TPHA (FTA-ABS) : syphilis → great imitator → do not miss → QuantiFERON-TB or IDR 5 U → tuberculosis → anterior chamber puncture + PCR if viral infectious uveitis suspected (HSV + VZV + CMV) → toxoplasma IgG + IgM if posterior uveitis involved → ANA (antinuclear antibodies) + FR : if JIA suspected in children → full rheumatological workup if associated arthritis → if first acute unilateral anterior uveitis + young patient + no bilateral or granulomatous involvement → workup often limited to HLA-B27 + infectious serologies + CBC → if atypical + recurrent + granulomatous → full workup + oriented; systemic treatment - indications: uveitis not controlled by eye drops alone (≥3 months of optimal local treatment) + bilateral vision-threatening uveitis + uveitis associated with systemic disease requiring systemic treatment + severe ocular complications (refractory CMO) → insufficient eye drops → oral corticosteroids (prednisone 0.5-1 mg/kg/d → gradual decrease) : severe + bilateral uveitis + or while awaiting effect of immunosuppressants → adverse effects: Cushing's + T2DM + osteoporosis → corticosteroid-sparing immunosuppressants: methotrexate (7.5-25 mg/week PO or SC): most commonly used → chronic or recurrent non-infectious uveitis → Gangaputra 2009 - American Journal of Ophthalmology: methotrexate + chronic uveitis → efficacy + tolerance → mycophenolate mofetil (CellCept 1-3 g/d): alternative to methotrexate → azathioprine (Imuran 1-2 mg/kg/d) → uveitis associated with chronic inflammatory diseases + cyclosporine (2.5-5 mg/kg/d): severe uveitis + Behçet (reduction in ocular episodes by 50 %) → nephrotoxic → limit over time + anti-TNF-α (biotherapies): adalimumab (Humira): only anti-TNF approved by FDA (2016) and Health Canada for chronic non-infectious uveitis + Jaffe 2016 - NEJM (VISUAL I + II trials): adalimumab + non-infectious uveitis → reduced risk of treatment failure by 50 % in VISUAL I (active uveitis) + 68 % in VISUAL II (inactive uveitis) → seminal reference → dosage: 40 mg SC every 2 weeks → infliximab IV (Behçet's uveitis ++) → etanercept: less effective (not recommended for uveitis) → secukinumab (Cosentyx - anti-IL-17) + ixekizumab (Taltz): new options in uveitis associated with HLA-B27 spondyloarthropathies → positive data + methylprednisolone IV (bolus): severe threatening uveitis + or corticoresistance → 500-1,000 mg/d × 3 days | Jaffe 2016 — NEJM (VISUAL I + II trials RCT): adalimumab + non-infectious uveitis → risk reduction of failure 50% (VISUAL I) + 68% (VISUAL II) → FDA approval 2016 + Health Canada → foundational reference for anti-TNF in uveitis + Gangaputra 2009 — American Journal of Ophthalmology: methotrexate + chronic uveitis → efficacy + tolerance + Nussenblatt 2010: immunosuppressants in uveitis + EULAR 2018 uveitis recommendations: classification + treatment + indications for biotherapies + AAO 2021 Preferred Practice Pattern: uveitis → workup + treatment + follow-up + Bodaghi 2016 — Rheumatic Diseases Clinics: uveitis associated with spondyloarthritis + anti-TNF + HLA-B27 → recommendations + Caspi 2010 — Journal of Autoimmunity: immunological mechanisms of uveitis → autoimmunity + molecular mimicry + EULAR 2019 (Rosenbaum — Annals of the Rheumatic Diseases): guidelines for uveitis associated with spondyloarthritis → adalimumab + secukinumab |
| Specific uveitis — HLA-B27, JIA, sarcoidosis, and Fuchs' syndrome Ankylosing spondylitis - uveitis HLA-B27 - JIA asymptomatic iridocyclitis - child monitoring - Fuchs - intraocular rubella - CMV - ocular sarcoidosis - bilateral Behçet's - prognosis |
HLA-B27 uveitis and spondyloarthropathies - specific features: epidemiology: 30-50 % of recurrent acute anterior uveitis = HLA-B27 positive → HLA-B27 present in 6-8 % of the general population + in 75-90 % of AS → but prevalence uveitis in AS: 25-40 % over the course of life → typical clinical picture: abrupt onset (hours) + intense pain + photophobia + perikeratic circle + miosis + hypopyon possible (liquid level of cells in anterior chamber - sign of severity) → unilateral + alternates both eyes with each recurrence → duration: 6-8 weeks without treatment → resolution under local treatment 3-5 weeks → frequent recurrences (on average 2-3/year) → Zeboulon 2008 - Annals of the Rheumatic Diseases: HLA-B27 + uveitis + spondyloarthropathy → association + characteristics + prognosis → treatment: corticosteroid eye drops + mydriatics → rapid resolution with early treatment → if frequent recurrences (>3/year) + associated systemic diseases → adalimumab → secukinumab if spondyloarthritis in parallel; JIA (Juvenile Idiopathic Arthritis) - asymptomatic chronic iridocyclitis: characteristics: child + ANA positive + oligoarthritis (<5 joints) + young age of onset (<6 years) + girl → ASYMPTOMATIC uveitis: no pain + no redness → detected only during systematic slit-lamp screening → severe consequences if undetected → synechiae + cataract + glaucoma + low vision → OBLIGATORY SURVEILLANCE: ophthalmological every 3 months (JIA type oligoarthritis + ANA+) → slit lamp screening → treatment if cells detected → corticosteroid eye drops + if resistant or uncontrolled → methotrexate + adalimumab → Foeldvari 2021 - Annals of the Rheumatic Diseases: adalimumab + JIA uveitis → reduced risk of relapse → recommendation; ocular sarcoidosis: features: bilateral + granulomatous + chronic → sheep fat KP + Busacca nodules (middle of iris) + Koeppe (pupillary margin) + trabeculitis → anterior synechiae + OHT → fundus : candlestick retinal vasculitis → systemic workup: ACE + lysozyme + TAP radiography → biopsy if necessary → treatment: local corticoids + if systemic: prednisone + methotrexate → adalimumab if corticoresistant; Fuchs syndrome - Fuchs heterochromic iridocyclitis: features: unilateral + chronic + asymptomatic (no pain or photophobia) → detected incidentally or during a drop in visual acuity (cataract) → diffuse stellate KP + fine cells in the anterior chamber + iris lighter on the affected side (iridis heterochromia) → no synechiae + early cataract + secondary glaucoma → association with intraocular rubella documented (Roman 2006 - AJO) → treatment: no specific treatment of inflammation → cataract surgery when necessary → treatment of glaucoma → herpetic uveitis (HSV + VZV + CMV): unilateral + frequent ocular hypertonia + possible keratitis (HSV + VZV) → CMV : Posner-Schlossman endotheliitis → significant OHT + discrete KP → anterior chamber PCR (puncture) → treatment: antivirals (oral aciclovir 400 mg × 5/d for HSV + VZV → ganciclovir for CMV) + local corticoids under antiviral cover + hypotonisers | Zeboulon 2008 – Annals of the Rheumatic Diseases: HLA-B27 + uveitis + AS → association + clinical characteristics + Foeldvari 2021 – Annals of the Rheumatic Diseases: adalimumab + uveitis JIA → reduced relapses → recommended + Roman 2006 – American Journal of Ophthalmology: intraocular rubella + Fuchs' syndrome → confirmed viral etiology → Jabs 2005 – AJO SUN criteria: classification + grading + standardized terminology → international reference + Caspi 2010 – Journal of Autoimmunity: uveitis mechanisms + Bodaghi 2016 – Rheumatic Diseases Clinics: systemic uveitis + sarcoidosis + Behçet's + Rosenbaum 2016 – Nature Reviews Rheumatology: comprehensive review of uveitis + mechanisms + treatment + AAO 2021 + EULAR 2019: recommendations for monitoring JIA + uveitis + treatment + Nussenblatt 2010: treatment of uveitis according to etiology + severity |
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Anterior uveitis is an ophthalmic emergency—any red, painful eye with photophobia should be evaluated by an ophthalmologist within 24 hours to rule out uveitis: Early treatment with topical corticosteroids and mydriatics prevents irreversible synechiae, glaucoma, and cataracts. JIA iridocyclitis is particularly insidious because it is asymptomatic—only regular slit-lamp examination can detect it before irreversible ocular damage occurs. Any recurrent uveitis should prompt investigation for HLA-B27 spondyloarthritis.
Situations requiring urgent ophthalmological consultation (within 24 hours)
Unilateral painful red eye + photophobia + decreased visual acuity + circumcorneal injection + miosis (small pupil) in a patient with a history of spondylarthritis or HLA-B27 → acute anterior uveitis → urgent ophthalmology consultation within 24 hours → slit lamp → if confirmed → prednisolone acetate 1 % + cyclopentolate/tropicamide → DO NOT initiate eye drops without confirmed diagnosis (risk of masking acute glaucoma or herpes keratitis).
Hypopyon visible to the naked eye (white fluid level in the lower anterior chamber) + severe pain + intense photophobia → severe anterior uveitis with hypopyon → ophthalmologic emergency within hours → atropine 1% % + prednisolone acetate 1% % every hour → urgent etiological workup (HLA-B27 + syphilis serology + QuantiFERON) → hospitalization according to etiology.
Child 2-8 years old with arthritis (oligoarthritis) + positive ANA with no eye symptoms → systematic screening for JIA iridocyclitis → slit lamp every 3 months → do not wait for symptoms — JIA uveitis is ASYMPTOMATIC → regular ophthalmological screening is essential even in the absence of any complaints.
Known anterior uveitis with sudden increase in intraocular pressure (>30 mmHg) + pain + colored halos around lights + nausea → acute ocular hypertension with uveitis → ophthalmologic emergency → ocular hypotensives (dorzolamide + timolol + acetazolamide if severe) + inflammation control → exclude angle-closure glaucoma (iris bombé → laser iridotomy).
Consult at Clinique Omicron
Clinique Omicron physicians recognize the clinical signs of anterior uveitis (red, painful eye + photophobia + perilimbal flush), refer urgently to an ophthalmologist, prescribe the initial etiological workup (HLA-B27 + infectious serologies + CBC + ACE + QuantiFERON), and ensure coordination with rheumatologists for uveitis associated with spondyloarthropathies. Consultations are available at several service locations in Quebec and via telemedicine. To make an appointment, visit cliniqueomicron.ca.
The content of this page is for informational purposes only and does not substitute for the advice of an ophthalmologist or rheumatologist. Any painful red eye or decrease in vision should be evaluated by an ophthalmologist as soon as possible.
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