Managing trauma-induced anterior uveitis

The question:

‘Recently, a patient presented at my practice with unilateral, trauma-induced acute anterior uveitis. Dilated examination revealed a few inflammatory cells in the anterior chamber, however the vitreous and fundus were healthy. I’m interested in hearing how you would manage this patient?’

OT’s panel says...

Ceri Smith-Jaynes (CSJ): The first thing I would do is establish what happened and when. Are we talking squash ball at high-speed, or someone’s finger poked in their eye? A history would include questions about vision, pain, photophobia and diplopia.

Also, I’d ask about previous iritis and health conditions, for instance, what if this wasn’t caused by the trauma? Is the anterior chamber reacting because of a corneal abrasion or a biff on the sclera?

Farah Topia (FT): You might want to ask specifically about any auto immune conditions or prior infections. The onset and the duration of symptoms is important in trying to ascertain the underlying cause. If it’s not trauma related, an underlying systemic disease has to be considered, particularly if the patient mentions previous episodes. A full history is key and as Ceri has said, if it does seem to be trauma related, the type of trauma will help give an idea of what else you need to be looking out for.

The onset and the duration of symptoms is important in trying to ascertain the underlying cause

CSJ: Intraocular pressure (IOP) is important for two reasons: it can go up or down in trauma, and if I do end up prescribing a steroid, I’ll want a baseline measurement.

FT: The IOP is also helpful to rule out angle closure as a differential diagnosis.

CSJ: I assume we checked motility, looked at the pupils, and measured visual acuity before dilating.

FT: Even if the trauma is to one eye, it’s important to check both eyes as the inflammatory response can affect both.

CSJ: I’d have a look for any synechiae or even the imprint of the iris in the anterior lens from the force of a blow. I’d also check for hyphaema, keratic precipitates and hypopyon.

I like to use the Standardisation of Uveitis Nomenclature (SUN) Working Group grading scheme to record cells or flare, so I can quantify any improvement (or the ophthalmologist can, if I am referring).

In my area, we have an agreement with the local eye clinic that independent prescribers will assess iritis, start treatment and refer to the hospital for follow-up. I’d give the eye clinic a call first, but if there is no corneal abrasion, it’s likely I’d prescribe 1% cyclopentolate three times a day and 1% prednisolone four times a day and refer on for follow-up in a few days. The patient may need to take their usual over-the-counter painkillers.

Traumatic iritis tends to respond more quickly to steroids and can be tapered more quickly than usual acute iritis. I’m not able to do gonioscopy, which I think is important in some trauma cases to rule out angle recession, so I’d be glad for the ophthalmologist’s view. They can be on the lookout for trauma induced glaucoma and take a second look for any retinal breaks too.

If there is no corneal abrasion, it’s likely I’d prescribe 1% cyclopentolate three times a day and 1% prednisolone four times a day and refer on for follow-up in a few days

FT: I agree with Ceri’s management. If there is trauma involved, you have to consider other pathology compared to a simple anterior uveitis. With anything impacting the eye, you should counsel the patient on retinal detachment signs and symptoms just so they know what to look out and what to do if their symptoms change.

CSJ: Oh, and don’t forget to give the patient advice about eye protection before they leave.

Kevin Wallace: I agree with Ceri and Farah’s comprehensive options already presented and would manage my patient in the same way. I am glad that the patient was dilated, as it’s important to assess the internal eye in cases of a significant impact.

It is always good practice to finish by recommending appropriate safety eyewear to reduce the chance of this sort of injury happening again.

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