Traumatic Iritis

Non-granulomatous inflammation of the iris and ciliary body (anterior uveitis) after blunt trauma, caused by breakdown of the blood aqueous barrier and release of prostaglandins and other mediators.

• Onset within 24 to 72 hours of injury; self-limiting in 1 to 2 weeks with treatment. It often accompanies abrasion, hyphaema, angle recession, or retinal injury.
• Traumatic mydriasis or miosis commonly coexists; sphincter tears and iridodialysis may occur.
• Rare complications: posterior synechiae, secondary glaucoma, cystoid macular oedema, and chronic uveitis.

• Photophobia, aching pain, tearing, blurred vision, deep ocular redness (ciliary flush).
• Anterior chamber cells and flare, miotic or irregular pupil (reflex miosis or sphincter damage), keratic precipitates (fine), reduced intraocular pressure (ciliary body shock) or raised pressure, and sluggish pupillary reaction.
• Look for associated injuries: hyphaema, angle recession, lens subluxation, vitreous cells, retinal tears, commotio retinae, choroidal rupture, and optic nerve injury.

• Slit lamp for cells and flare (grade by number of cells in a 1 by 1 mm beam), keratic precipitates, pupil, iris tears, lens; fluorescein for corneal injury.
• Intraocular pressure measurement (when globe is closed), gonioscopy at follow up for angle recession, and dilated fundus examination with scleral depression for tears and dialysis (delay if hyphaema or pain prevents).
• Exclude infection and non-traumatic uveitis when the history is unclear: inflammation persisting beyond 4 weeks requires systemic workup.

• Cycloplegic: cyclopentolate 1 percent twice to three times daily (or atropine 1 percent once or twice daily for severe cases) for relief of ciliary spasm and prevention of posterior synechiae; continue until the chamber is quiet.
• Topical corticosteroid: prednisolone acetate 1 percent every 2 to 4 hours while awake, tapered over 2 to 3 weeks (four times daily for 1 week, three times daily for 4 to 5 days, twice daily for 4 to 5 days, then once daily for a further week); difluprednate 0.05 percent four times daily as an alternative.
• Analgesia: paracetamol 1 g four times daily, oral NSAID (ibuprofen 400 mg three times daily) if no hyphaema; sunglasses.
• Intraocular pressure surveillance during steroid treatment; treat elevation with timolol 0.5 percent twice daily or dorzolamide 2 percent three times daily.
• Review at 2 to 3 days, 1 week, 2 weeks, then at 4 weeks for gonioscopy and dilated retinal examination; repeat the retinal examination at 3 months.
• Counsel on warning symptoms (flashes, floaters, field loss) and delayed glaucoma.