EM@3AM: Traumatic Iritis
- Jun 8th, 2024
- Eliza Szybka
- categories:
Authors: Eliza Szybka, DO (EM Resident Physician, Department of Emergency Medicine, Advocate Christ Medical Center, Oak Lawn IL); Michael Cirone, MD (@mcironeMD, Assistant Program Director, Advocate Christ Medical Center, Oak Lawn IL) // Reviewed by: Sophia Görgens, MD (EM Physician, Northwell, NY); Cassandra Mackey, MD (Assistant Professor of Emergency Medicine, UMass Chan Medical School); Brit Long, MD (@long_brit)
Welcome to EM@3AM, an emDOCs series designed to foster your working knowledge by providing an expedited review of clinical basics. We’ll keep it short, while you keep that EM brain sharp.
A 27-year-old male presents to the ED for left eye pain after being hit in the face with a spare car part while working under the hood of his car. He states his vision is slightly blurred, and he is experiencing significant pain. Physical exam reveals conjunctival injection, a red rim circumscribing his iris, and photophobia.
What is the diagnosis, and how do we manage it from the ED?
Answer: Traumatic Iritis
Epidemiology:
- There are approximately 55 million eye injuries worldwide annually. [1]
- Traumatic iritis accounts for about 20% of all iritis cases [2]
- Younger males are typically more affected than older populations or females.
- 95% occupational injuries occur in males [1].
- Incidence is 12 in 100,000 in the U.S. [2].
Anatomy review of the eye [6]:
Pathology:
- Trauma results in acute damage to the structures of the eye, particularly contusion and spasm of the ciliary body/iris.
- With cell death there is accumulation of cell products contributing to inflammation with resultant accumulation of proteins and debris in the eye [2].
- Classically, traumatic iritis is caused by blunt trauma, but it can be less obvious or missed in cases of car accidents, head trauma or presence of other distracting injuries [2].
- Symptoms can be delayed and present up to 3 days after initial injury, most commonly eye pain and photophobia [2][7].
Exam Findings:
- Check that the globe is intact when evaluating any patient with eye trauma.
- Signs of rupture include a flat anterior chamber, obvious deformity, teardrop shaped pupil, loss of visual acuity (defer tonometry in these cases) [7].
- Perform Seidel test.
- If there is any concern for globe injury, consult ophthalmology urgently.
- Check visual acuities: may be decreased on side of the injury [2].
- Slit lamp exam: classically will have “Cell and Flare” in cases of traumatic iritis [7].
- Caused by increase in leukocytes and protein in the aqueous humor [5].
- Measure intraocular pressure: often elevated [2].
- Photophobia; may have pain in affected eye when light is shone in un-affected eye.
- Localized circumlimbal injection, known as ciliary flush.
- Pain is typically not relieved by topical anesthetics.
- Hypopyon (leukocyte exudate in anterior chamber) may be present in severe cases.
Complications: injuries to assess for when evaluating a patient with suspected traumatic iritis.
- Hyphema: pooling of blood in the anterior chamber, seen on exam when patient is sitting up. High risk of re-bleeding and vision loss [7].
- Orbital wall fractures: palpate bony structures surrounding the eye, check extra ocular muscle movements to rule out entrapment, obtain CT imaging if suspected [7].
- Globe rupture: requires urgent surgical intervention and avoidance of unnecessary manipulation of the eye.
- Foreign bodies: may be obvious but often requires evaluation with fluorescence stain
- Corneal lacerations or abrasions: evaluate with fluorescence stain.
- Orbital hemorrhage: preseptal is less dangerous and more obvious on exam. Post septal (retrobulbar) is higher risk to vision and requires CT imaging to diagnose as well as thorough exam to check for proptosis, afferent pupillary defect, increased intraocular pressure [7].
Management:
- Consult ophthalmology for recommendations and to facilitate follow up (should be within 48 hours, then 5-7 days for dilated exam).
- PO pain medications typically are sufficient [4].
- If a hyphema is associated with injury, avoid NSAIDs to decrease risk of rebleeding [3].
- Cycloplegic agent: helps paralyze the ciliary body so that the pupil remains dilated and non-reactive [3].
- Assists with plain control.
- Prevents spasm.
- Can shorten duration of symptoms [5].
- Examples: Homatropine 1-2 drops of 2% solution, Cyclopentolate 1 drop of 1% in adults, 0.5% in children [4].
- Topical steroids: only if consulting ophthalmologist recommends [4].
- Feared side effects of topical steroids include glaucoma, increased risk of infections, and delayed healing [8].
Pearls:
- A full eye exam is the most crucial aspect of evaluating patients with traumatic eye injuries.
- Be concerned about traumatic iritis following ocular trauma in patients with vision changes, severe photophobia, and pain that does not improve with topical anesthetics.
- Consult ophthalmology before initiating topical steroid therapy due to side effects.
- Patients require follow up within 5-7 days for dilated eye exam.
A 32-year-old man presents to the emergency department with eye pain. His spouse noticed the right eye had become increasingly red over the past few days and encouraged him to be evaluated. About a week ago, he was robbed while leaving work, and the assailant struck him in the face with their fist. He reports his eye now hurts, and the pain is worse in bright environments. He does not have a foreign body sensation in the eye. He has a medical history of type 2 diabetes mellitus, anxiety, and Marfan syndrome. His only medication is metformin. His vital signs are a T of 37.2°C, HR of 96 bpm, BP of 116/70 mm Hg, RR of 18/min, and SpO2 of 97%. On exam, he has resolving ecchymosis around the right orbit. There is profound circumlimbal injection but no pupillary irregularity. With fluorescein staining, corneal abrasion and ocular leak are absent. There is scant tearing. His tonometry reading is normal. He adamantly refuses a slit lamp exam, stating he is claustrophobic. His vision is baseline at 20/30 in both eyes. Which of the following would be the most likely underlying pathophysiology of the condition causing his symptoms, given his presentation?
A) Dilation of conjunctival vessels resulting in hyperemia and edema
B) Infection leading to purulent inflammation of the intraocular fluids
C) Injury causing cell death that leads to the release of inflammatory cytokines
D) Irregularity and degeneration of the zonular fibers leading to lens displacement
Answer: C
Traumatic iritis is a common condition of inflammation in the anterior chamber. It is most frequently caused by blunt trauma, such as from a fist. The pathophysiology theorizes that traumatic injury causes cell death that leads to the release of inflammatory cytokines. Other causes of traumatic iritis include inflammatory diseases, infections, and idiopathic in nature. A slit lamp exam, which should have been pursued but was deferred in this case due to patient refusal, would show cells and flare within the anterior chamber. Specifically, leukocytes floating within the aqueous humor represent the cells, and the hazy aura of protein accumulation renders the flare appearance. Other common signs and symptoms typically progress rapidly over several days, including eye pain, photophobia, and localized circumlimbal injection (ciliary flush). Vision is rarely impacted. Treatment is aimed at resolving inflammation and relieving pain. Anti-inflammatory agents such as topical corticosteroids and a dilating agent such as cyclopentolate are commonly prescribed. Close follow-up within 48 hours with an ophthalmologist is appropriate for ongoing monitoring and care.
Dilation of conjunctival vessels resulting in hyperemia and edema (A) is the underlying pathophysiology of conjunctivitis, which can be brought on by infection or allergic reaction. This patient does not demonstrate diffuse dilation of conjunctival vessels but rather a ciliary flush, highly suggestive of iritis or anterior uveitis.
Infection leading to purulent inflammation of the intraocular fluids (B) describes endophthalmitis, which is often seen as a complication of a recent ocular procedure and is most commonly associated with signs and symptoms, including hypopyon and blurred vision.
Irregularity and degeneration of the zonular fibers leading to lens displacement (D) are characteristic of ectopia lentis, which can arise from mutations in genes such as FBN1 in Marfan syndrome. However, it would be expected to emerge with reduced visual acuity or other visual disturbances such as diplopia.
