Iridocyclitis (anterior uveitis) is a combined inflammatory lesion affecting the iris (iris) and the ciliary body of the eye. In acute iridocyclitis, there is swelling, redness and pain in the eye, lacrimation, discoloration of the iris, narrowing and deformation of the pupil, formation of hypopion, precipitates, decreased visual acuity. Diagnosis includes examination, palpation, biometrics and ultrasound of the eye, visual acuity testing, measurement of intraocular pressure, clinical laboratory, immunological studies. Conservative treatment is based on anti-inflammatory, antibacterial and antiviral therapy, the appointment of antihistamines, hormonal, detoxification drugs, mydriatics, immunomodulators, vitamins.
Iridocyclitis, iritis, cyclitis, keratouveitis belong in ophthalmology to the so–called anterior uveitis – inflammation of the vascular membrane of the eye. Due to the close anatomical and functional interaction of the iris and the ciliary (ciliary) body, the inflammatory process, having begun in one of these parts of the vascular membrane of the eye, spreads very quickly to the other and proceeds in the form of iridocyclitis.
Iridocyclitis is diagnosed in people of any age, but more often in patients from 20 to 40 years old. According to the course of the disease, acute and chronic iridocyclitis are distinguished; by the nature of inflammatory changes – serous, exudative, fibrinous-plastic and hemorrhagic; by etiology – infectious, infectious-allergic, allergic non-infectious, post-traumatic, unclear etiology, as well as caused by systemic and syndromic diseases. The duration of acute form is 3-6 weeks, chronic – several months; the disease and relapses, as a rule, occur in the cold season.
The causes of iridocyclitis are diverse, may be endogenous or exogenous. Often, iridocyclitis develops due to traumatic damage to the eye (wounds, contusions, ophthalmic operations), inflammation of the iris (keratitis). Iridocyclitis can be caused by transferred viral, bacterial or protozoal diseases (influenza, measles, HSV, staphylococcal and streptococcal infections, tuberculosis, gonorrhea, chlamydia, toxoplasmosis, malaria, etc.), as well as existing foci of chronic infection in the nasopharynx and oral cavity (sinusitis, tonsillitis).
The cause of iridocyclitis may be rheumatoid conditions (rheumatism, Still’s disease, autoimmune thyroiditis, Bechterev’s disease, Reiter and Sjogren syndromes), metabolic disorders (gout, diabetes), systemic diseases of unknown etiology (sarcoidosis, Behcet’s disease, Vogt-Koyanagi-Harada syndrome). The prevalence of iridocyclitis among patients with rheumatic and infectious diseases is about 40% of cases.
The appearance of iridocyclitis is facilitated by the developed vascular network of the eye and the increased susceptibility of the iris and ciliary body to antigens and CEC coming from extra-ocular foci of infection or non-infectious sources of sensitization.
With the development of iridocyclitis, in addition to direct damage to the vascular membrane of the eye by microbes or their toxins, its immunological damage occurs with the participation of inflammatory mediators. Inflammation is accompanied by the phenomena of immune cytolysis, vasculopathy, dysfermentosis, microcirculation disorders followed by scarring and dystrophy.
An important role in the development of iridocyclitis belongs to provoking factors — endocrine and immune disorders, stressful situations, hypothermia, excessive physical exertion.
The degree of severity and features of the course of iridocyclitis depend on the nature and duration of exposure to the antigen, the level of permeability of the hematophthalmic barrier, genotype and immune status of the organism. With iridocyclitis, unilateral eye damage is usually observed. The first signs of acute iridocyclitis are general redness and pain in the eye, with a characteristic significant increase in pain when pressing on the eyeball. Patients with iridocyclitis have photophobia, lacrimation, a slight (within 2-3 lines) decrease in visual acuity, the appearance of a “fog” in front of their eyes.
The course of iridocyclitis is characterized by a noticeable change in the color of the inflamed iris (greenish or rusty-red) and a decrease in the clarity of its pattern. There may be a moderately pronounced corneal syndrome, pericorneal injection of the vessels of the eyeball. Serous, fibrinous or purulent exudate may be detected in the anterior chamber of the eye. When the purulent exudate settles at the bottom of the anterior chamber of the eye, a hypopion is formed in the form of a gray or yellow-green stripe; when the vessel ruptures in the anterior chamber, a blood accumulation — hyphema is detected.
The inflammatory process in the ciliary body when the exudate settles on the surface of the lens and the fibers of the vitreous body can lead to their clouding and to a decrease in visual acuity.
On the posterior surface of the cornea with iridocyclitis, grayish-white precipitates appear from point deposits of cells and exudate, with the resorption of which pigmented lumps are noted for a long time. Swelling of the iris tissues and its close contact with the anterior capsule of the lens in the presence of exudate leads to the formation of posterior adhesions (synechiae), causing irreversible constriction (myosis) and deformation of the pupil, deterioration of its reaction to light. With the fusion of the iris and the anterior surface of the lens, a circular spike is formed throughout. With an unfavorable course of iridocyclitis, synechiae create a risk of developing blindness due to complete overgrowth of the pupil.
Often, intraocular pressure in iridocyclitis is below normal due to inhibition of the secretion of moisture of the anterior chamber. Sometimes, with acute onset of iridocyclitis with pronounced exudation or fusion of the pupillary edge of the iris with the lens, an increase in intraocular pressure is observed.
Different types of iridocyclitis have their own clinical features. Viral iridocyclites are characterized by a torpid course, the formation of serous or serous-fibrinous exudate and light precipitates, increased intraocular pressure.
Tuberculous iridocyclitis proceeds with mild symptoms, manifested by the presence of large “sebaceous precipitates”, yellowish tubercles (tubercles) on the iris, opalescence of the moisture of the anterior chamber, the formation of powerful posterior stromal synechiae, blurred vision or complete overgrowth of the pupil.
Autoimmune iridocyclitis is characterized by a severe recurrent course against the background of exacerbations of the underlying disease with frequent complications (cataracts, secondary glaucoma, keratitis, scleritis, eyeball atrophy). Each relapse is more severe than the previous one and often leads to blindness.
With traumatic iridocyclitis, sympathetic inflammation of a healthy eye (sympathetic ophthalmia) may develop. Iridocyclitis in Reiter’s syndrome, caused by chlamydia infection, is accompanied by conjunctivitis, urethritis and joint damage with minor manifestations of inflammation of the vascular membrane.
The diagnosis of iridocyclitis is established by the results of a comprehensive examination: ophthalmological, laboratory diagnostic, radiological, consulting of the patient by narrow specialists.
Initially, an ophthalmologist conducts an external examination of the eyeball, palpation, and collection of anamnestic data. To clarify the diagnosis of iridocyclitis, visual acuity is checked, intraocular pressure is measured by contact or non-contact tonometry, biomicroscopy of the eye, revealing damage to the ocular structures, ultrasound of the eye with a one-dimensional or two-dimensional image of the eyeball. The ophthalmoscopy procedure for iridocyclitis is often difficult due to the inflammatory changes in the anterior parts of the eye.
To clarify the etiology of iridocyclitis, general and biochemical blood and urine tests, coagulogram, rheum tests to detect systemic diseases, allergy tests (local and general reactions to the introduction of streptococcus allergens, staphylococcus, specific antigens: tuberculin, toxoplasmin, etc.), PCR and ELISA diagnostics of the inflammatory pathogen (including syphilis, tuberculosis, herpes, chlamydia, etc.).
To assess the immune status, the level of serum immunoglobulins in the blood IgM, IgG, IgA, as well as their content in the lacrimal fluid is studied.
Depending on the features of the clinical picture of iridocyclitis, consultation and examination by a rheumatologist, phthisiologist, dentist, otorhinolaryngologist, allergist, dermatovenerologist are necessary. It is possible to conduct radiography of the lungs and paranasal sinuses.
Differential diagnosis of iridocyclitis and other diseases accompanied by swelling and redness of the eyes, such as acute conjunctivitis, keratitis, acute attack of primary glaucoma, is carried out.
Treatment of iridocyclitis should be timely and, if possible, aimed at eliminating the cause of its occurrence.
Conservative treatment of iridocyclitis is focused on preventing the formation of posterior synechiae, reducing the risk of complications and includes emergency measures and planned therapy. In the first hours of the disease, instillation of pupil dilating agents (mydriatics), NSAIDs, corticosteroids, and antihistamines are indicated in the eye.
Planned treatment of iridocyclitis is carried out in a hospital setting, it is based on local and general antiseptic, antibacterial or antiviral therapy, the introduction of anti-inflammatory nonsteroidal and hormonal drugs (in the form of eye drops, parabulbar, subconjunctival, intramuscular or intravenous injections. Corticosteroids are widely used in the treatment of toxic-allergic and autoimmune iridocyclitis.
With iridocyclitis, detoxification therapy is carried out (with severe inflammation – plasmapheresis, hemosorption), instillation of solutions of mydriatics that prevent the fusion of the iris with the lens. Antihistamines, multivitamins, immunostimulants or immunosuppressors are prescribed (depending on the underlying disease), local proteolytic enzymes for resorption of exudate, precipitates and adhesions. Physiotherapy procedures are often used for iridocyclitis: electrophoresis, magnetotherapy, laser therapy.
Iridocyclitis of tuberculosis, syphilitic, toxoplasmosis, rheumatic etiology requires specific therapy under the supervision of appropriate specialists.
Surgical treatment of iridocyclitis is carried out if it is necessary to separate the adhesions or (dissection of the anterior and posterior synechiae of the iris), in case of secondary glaucoma. In case of severe complication of purulent iridocyclitis with lysis of the membranes and contents of the eye, surgical removal of the latter (enucleation, evisceration of the eye) is indicated.
Prognosis and prevention
The prognosis of iridocyclitis with timely, adequate and carefully conducted treatment is quite favorable. Complete recovery after treatment of acute iridocyclitis is noted in about 15-20% of cases, in 45-50% of cases – the disease takes a subacute recurrent course with more erased relapses, which often coincide with exacerbations of the underlying disease (rheumatism, gout).
Iridocyclitis can turn into a chronic form with a persistent decrease in vision. In neglected and untreated cases of iridocyclitis, dangerous complications develop that threaten vision and the existence of the eye: chorioretinitis, fusion and overgrowth of the pupil, secondary glaucoma, cataract, vitreous deformity and retinal detachment, vitreous abscess, endophthalmitis and panophthalmitis, subatrophy and atrophy of the eyeball.
Prevention of iridocyclitis consists in timely treatment of the underlying disease, rehabilitation of foci of chronic infection in the body.