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Inflammatory disorders (PEARLS)

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PANCE Inflammatory Disorders: Iritis (Anterior Uveitis), Scleritis, and Uveitis

Iritis (Anterior Uveitis) Scleritis Uveitis
Inflammation of the iris and ciliary body Inflammation of the sclera Inflammation of the uveal tract (iris, ciliary body, choroid)
Autoimmune: Ankylosing spondylitis, reactive arthritis, sarcoidosis

Infectious: HSV, syphilis, TB

 Autoimmune: Rheumatoid arthritis, lupus, granulomatosis with polyangiitis Autoimmune: Ankylosing spondylitis, reactive arthritis, IBD (HLA-B27)

Infectious: HSV, CMV, syphilis, TB
Eye pain, redness (ciliary flush), photophobia, blurred vision, small irregular pupil Severe deep eye pain worsened by eye movement, redness, tenderness on palpation Anterior: Pain, photophobia, redness

Posterior: Painless vision loss, floaters
Slit-lamp: Cells and flare in anterior chamber, keratic precipitates Clinical exam: Diffuse scleral redness, tender globe; slit-lamp confirms scleral inflammation Slit-lamp: Cells/flare (anterior), vitritis/choroiditis (posterior), keratic precipitates; Labs (HLA-B27, infectious screens)
Topical corticosteroids, cycloplegics, ophthalmology referral, systemic workup if recurrent Systemic NSAIDs (e.g., indomethacin), corticosteroids/immunosuppressants, ophthalmology & rheumatology referral Anterior: Topical steroids, cycloplegics

Posterior: Systemic steroids/immunosuppressants, treat underlying cause
Posterior synechiae, glaucoma, vision loss Vision impairment, scleral thinning/perforation Glaucoma, cataracts, permanent vision loss
Iritis
Patient will present as → a 32-year-old woman with a history of ankylosing spondylitis presenting with redness, eye pain, and photophobia in the right eye. She denies trauma or discharge but reports blurry vision. On examination, her right eye has a circumferential redness near the corneal limbus (ciliary flush), a small, irregularly shaped pupil, and cells and flare in the anterior chamber on slit-lamp examination. Iritis (anterior uveitis) is suspected, and she is urgently referred to an ophthalmologist for evaluation and management.

Iritis (anterior uveitis) is an inflammation of the iris, commonly associated with autoimmune diseases or infections, leading to ocular pain and visual impairment

  • Symptoms include eye pain, redness (particularly near the limbus), photophobia, blurred vision, and sometimes a small or irregular pupil
  • May occur in association with systemic conditions such as ankylosing spondylitis, reactive arthritis, sarcoidosis, or infections (e.g., herpes, syphilis, tuberculosis)
  • Physical exam findings include ciliary injection, a consensual photophobia response, and in severe cases, the presence of hypopyon or keratic precipitates on slit-lamp examination

DX: Diagnosis is clinical, often confirmed by slit-lamp examination showing inflammation in the anterior chamber (e.g., cells and flare)

TX: Referral to an ophthalmologist is essential for proper diagnosis and management

  • Topical corticosteroids (e.g., prednisolone drops) to reduce inflammation and cycloplegic agents (e.g., atropine) to relieve pain and prevent synechiae
  • Systemic workup may be necessary to identify underlying autoimmune or infectious causes in recurrent or bilateral cases
  • Complications include posterior synechiae, glaucoma, and vision loss if not treated promptly
Scleritis
Patient will present as → a 42-year-old female with rheumatoid arthritis presents with deep, aching pain in her right eye, worsening with movement, along with redness and blurred vision. Examination reveals diffuse redness involving the sclera with tenderness on palpation. Slit-lamp exam confirms scleral inflammation, consistent with diffuse anterior scleritis. Management includes systemic NSAIDs (e.g., indomethacin) and referral to a rheumatologist for possible immunosuppressive therapy. Follow-up with ophthalmology is necessary to monitor for complications.

Inflammation of the sclera (the white outer coating of the eye) associated with systemic immunologic disease, such as rheumatoid arthritis

  • It causes significant eye pain (severe, deep pain), redness, photophobia, and reduced vision; pain often worsens with eye movement

DX: On examination, there is ocular redness and pain on palpation of the eyeball. It can cause visual impairment

  • Labs should include screening for systemic immunologic diseases - ANCAs, ANA, CRP, ESR, Lyme, RA, ACE, RPR, etc.

TX: Refer the patient for prompt evaluation by an ophthalmologist

  • NSAIDs (e.g., indomethacin) are effective for mild cases like diffuse or nodular anterior scleritis
  • Glucocorticoids (e.g., prednisone 1 mg/kg/day) for severe cases or those unresponsive to NSAIDs
  • Immunosuppressive agents (e.g., methotrexate, mycophenolate mofetil, or cyclophosphamide) for necrotizing scleritis or systemic disease involvement
  • Biologic therapies (e.g., rituximab or TNF-alpha inhibitors) for refractory or severe cases
Uveitis
Patient will present as → a 32-year-old male presents with eye pain, redness, and blurred vision in his left eye for three days, along with photophobia and mild tearing. He reports chronic lower back pain that improves with activity. Exam reveals ciliary injection, a small, irregular pupil, and anterior chamber inflammation with keratic precipitates on slit-lamp examination. He is diagnosed with anterior uveitis, likely related to HLA-B27 seronegative spondyloarthropathy. Management includes topical corticosteroids, cycloplegics, and rheumatology referral. Follow-up is arranged to monitor for recurrence and complications.

Uveitis is inflammation of the uveal tract (iris, ciliary body, choroid) and can be associated with autoimmune, infectious, or idiopathic causes.

    • Anterior uveitis (iritis) – Most common; inflammation of the iris and ciliary body
    • Intermediate uveitis – Involves the vitreous
    • Posterior uveitis – Affects the retina and choroid
    • Panuveitis – Involves all layers of the uveal tract

Causes include autoimmune (ankylosing spondylitis, reactive arthritis, IBD – HLA-B27), infectious (HSV, CMV, syphilis, TB), or idiopathic.

Anterior uveitis presents with eye pain, photophobia, redness, blurred vision; posterior with painless vision loss and floaters.

DX:

  • Slit-lamp exam shows ciliary flush, hypopyon, choroiditis, retinal vasculitis (posterior uveitis)
    • Cells in the anterior chamber (hallmark of anterior uveitis)
    • Keratic precipitates (KP) (inflammatory deposits on the cornea)
  • Fundoscopy if posterior involvement is suspected
  • Labs (HLA-B27, syphilis, TB) if systemic cause suspected

TX:

  • Anterior uveitis: Topical corticosteroids (prednisolone), cycloplegics (atropine)
  • Posterior uveitis: Systemic corticosteroids/immunosuppressants
  • Treat underlying infection or systemic disease

Complications: If untreated, can lead to glaucoma, cataracts, permanent vision loss
Pterygium (ReelDx + Lecture) (Prev Lesson)
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