Iridocyclitis

In this article:

• Iridocyclitis Treatment
• Intraocular treatments
• Complications
• Iridocyclitis Problem in Children
• References

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Iridocyclitis Treatment

Any inflammation in the eye should be treated by the doctor, who will oversee the process of recovery. if your condition is severe (acute eye pain and redness, or signs of systemic infection), it is a good idea to go the nearest emergency room. In the chronic eye conditions, it is necessary to have a regular ophthalmologist who knows you well, and can act on time to treat a vision-threatening complication.

The acute iridocyclitis treatment is primarily aimed at infection, reducing inflammation and pain and preventing complications. First-line treatment involves topical cycloplegics (dilate the pupil, prevent ciliary body and pupillary spasm) and topical steroids (decrease inflammation). 

You should be referred to an ophthalmologist within 24 to 48 hours. Corticosteroids should be initiated only in conjunction with approval of an ophthalmologist because uveitis is a diagnosis of exclusion.

Steroids need to be administered with caution, as they have significant adverse effects potentially worsening condition:

• increased intraocular pressure
• cataract formation
• steroid-induced glaucoma
• worsening herpes keratitis

Approximately half of the patients with uveitis need treatment beyond corticosteroid treatment to prevent vision loss.

Anticholinergics block nerve impulses to the ciliary muscles and pupillary sphincter to decrease photophobia and pain. Homatropine is agent of choice for uveitis.

Tumor Necrosis Factor Blockers. Infliximab or adalimumab may be used as second-line treatment for patients with vision-threatening chronic uveitis caused by seronegative spondyloarthropathy.

To have the best prognosis, urgent appointment with an ophthalmologist within 24 hours is crucial. If the patient comes to the ER, an ophthalmologist on-call can help with diagnosis and treatment recommendations.

Monitoring should include repeat slit-lamp and intraocular pressure checks every few days. When the condition is stable, follow-up is recommended every 1-6 months.

Intraocular treatments

Periocular and intravitreal steroid injections, including steroid implants, may be given to rapidly and consistently control inflammation in non-infectious conditions or infectious conditions under appropriate anti-microbial cover.

Intravitreal antimicrobial injections may be used, such as clindamycin for toxoplasma, and antifungals such as voriconazole for candida to achieve higher intraocular concentrations a better therapeutic response. Intravitreal immunosuppressants such as sirolimus may also be used in the treatment of non-infectious uveitis. 

Surgical aspiration may be useful in lens-induced (phakoanaphylactic) cases or cases associated with large anterior chamber granulomas.

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Complications

The prognosis becomes worse if there is an acute rise in intraocular pressure secondary to pupillary block, inflammation, or topical corticosteroid. Incorrectly treating with steroids is dangerous; the clinician should be sure of the diagnosis prior to start steroids. A rise in intraocular pressure can result in optic nerve atrophy and catastrophic permanent vision loss.

Depending on the cause, most patients respond well to treatment and retain full vision. However, at least 10-30% of patients may need treatment beyond steroids to prevent vision loss.

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Iridocyclitis Problem in Children

Because of their varied spectrum of clinical presentation and difficulty in management, pediatric uveitis remains a challenge to the ophthalmologist. Variations in clinical presentation, difficulties in eye examination, extended burden of the inflammation over quality of life, limited treatment modalities, risk of amblyopia are the main challenges in the management of pediatric uveitis. Pediatric uveitis is a cause of significant ocular morbidity and severe vision loss is found in 25-33% of such cases. 

One of the most significant cause of the iridocyclitis in children is Juvenile Rheumatoid Arthritis. The disease is chronic and does not present with acute symptoms or vision problem in children. If left untreated, Uveitis is a sight-threatening disease that can lead to visual impairment and blindness. 

Prompt diagnosis and treatment are very important in addition to the collaboration of specialists such as ophthalmologists and rheumatologists. Many treatment options may be associated to side effects; therefore, clinicians should follow a stepladder approach starting with the least aggressive treatments to induce remission of inflammation. 

The use of biologics has greatly improved the outcome of noninfectious uveitis both in pediatric patients and adults. Randomized controlled trials have confirmed the efficacy of adalimumab, while for other agents data are still scarce

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References

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Kaufman AR, Myers EM, Moster ML, Stanley J, Kline LB, Golnik KC. Herpes Zoster Optic Neuropathy. J Neuroophthalmol. 2018 Jun;38(2):179-189. [PubMed]

Krishna U, Ajanaku D, Denniston AK, Gkika T. Uveitis: a sight-threatening disease which can impact all systems. Postgrad Med J. 2017 Dec;93(1106):766-773. [PubMed]

Okuma H, Hashimoto K, Wang X, Ohkiba N, Murooka N, Akizuki N, Inazawa T, Ogawa Y. Systemic Sarcoidosis with Thyroid Involvement. Intern Med. 2017 Aug 15;56(16):2181-2186. [PMC free article] [PubMed]

Reddy AK, Engelhard SB, Shah CT, Sim AJ, Thorne JE. Medical Malpractice in Uveitis: A Review of Clinical Entities and Outcomes. Ocul Immunol Inflamm. 2018;26(2):242-248. [PubMed]

Granulomatous Uveitis. Elnahry AG, Elnahry GA.2021 Apr 25. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan–.PMID: 34033343 Free Books & Documents. Review.

Evidence-Based Treatment for Uveitis. Gamalero L, Simonini G, Ferrara G, Polizzi S, Giani T, Cimaz R.Isr Med Assoc J. 2019 Jul;21(7):475-479.PMID: 31507124 Free article. Review.

Pediatric uveitis: An update. Majumder PD, Biswas J.Oman J Ophthalmol. 2013 Sep;6(3):140-50. doi: 10.4103/0974-620X.122267.PMID: 24379547 Free PMC article. Review.

Controversies in intraocular lens implantation in pediatric uveitis. Phatak S, Lowder C, Pavesio C.J Ophthalmic Inflamm Infect. 2016 Dec;6(1):12. doi: 10.1186/s12348-016-0079-y. Epub 2016 Mar 24.PMID: 27009616 Free PMC article. Review.