Which slit-lamp finding is characteristic of traumatic iritis after blunt injury?

Mutton-fat keratic precipitates with iris nodules

Vitreous snowballs and snowbanking

Which pupil finding may be seen in traumatic iritis?

Miotic and sluggish, or dilated with tears Sphincter spasm causes miosis with a small, poorly reactive pupil, while a torn sphincter leaves a larger pupil.

A relative afferent defect in every case

Reacts to near but not to light

Tonic pupil with sectoral palsy

What does a finding of traumatic iritis imply about the eye examination?

It marks a significant blow; examine for other injuries Traumatic iritis is a marker of a significant blow, so hyphema, angle recession, lens injury, retinal damage, fractures and open globe must be sought.

The injury was trivial and needs no further tests

The posterior segment can be safely ignored

Systemic HLA-B27 testing is the priority

In traumatic iritis, when should the pupil be dilated to examine the retina?

Once open globe injury and hyphema are excluded Dilate once open globe injury and hyphema are excluded, then examine the retina for commotio retinae, choroidal rupture and tears.

Immediately, before any other examination

Only after the iritis has fully resolved

Never, because dilation worsens the iritis

Why are cycloplegic drops such as cyclopentolate 1 percent used in traumatic iritis?

To relieve ciliary spasm and prevent synechiae Cyclopentolate 1 percent two to three times a day relieves the painful ciliary spasm and prevents synechiae.

To heal a corneal abrasion faster

To prevent angle recession glaucoma

Which topical steroid regimen is used for traumatic iritis?

Prednisolone 1% four times daily, 1-2 week taper Prednisolone 1 percent four times a day, tapered over one to two weeks, is used along with cycloplegia and oral analgesia.

Dexamethasone 0.1% hourly for six weeks

Fluorometholone once weekly for one month

Loteprednol once daily for three months

When should topical steroids be withheld or covered in traumatic iritis?

With an epithelial defect and no antibiotic cover Steroids should be avoided when there is an active epithelial defect or infection without antibiotic cover.

When intraocular pressure is normal

When the pupil is small and miotic

When anterior chamber flare is present

Why is gonioscopy and long-term follow-up needed after traumatic iritis?

Angle recession glaucoma can develop years later Gonioscopy a few weeks after injury and follow-up for years are needed because angle recession glaucoma can develop long after the injury.

Sympathetic ophthalmia always follows blunt injury

Iritis recurs every year after trauma

Cataract develops in every injured eye

Why are squash balls and shuttlecocks classic causes of blunt injury leading to traumatic iritis?

Their size lets them strike the globe past the orbital rim Their size lets them reach the globe without being blocked by the orbital rim, so sport-standard protective eyewear is the best prevention.

They carry a high risk of infection

They always cause penetrating injury

They are usually thrown at close range

Traumatic Iritis: Diagnosis and Treatment

Traumatic iritis is inflammation of the iris and ciliary body that follows blunt trauma to the eye.

It is common after sports injuries, falls, and assaults, and it usually responds well to treatment.

The more important task is also to examine the eye for other injuries that can accompany it.

What Is Traumatic Iritis?

Blunt force transmits through the globe and damages the iris and ciliary body, which breaks down the blood-aqueous barrier.

Also, inflammatory cells and protein enter the anterior chamber and cause cell and flare.

The condition appears within a day or two of the injury and may also last for a week or more.

In addition, the ciliary muscle goes into spasm, causing pain, and the sphincter may go into spasm, causing miosis, or it may tear.

Clinical Features of Traumatic Iritis

Pain, photophobia, and tearing, often a deep aching pain
Blurred vision from ciliary spasm and cells in the anterior chamber
Circumlimbal injection (ciliary flush)
Cells and flare in the anterior chamber, and sometimes keratic precipitates
A small, poorly reactive pupil, or a larger one with sphincter tears
Normal or mildly reduced pressure, and sometimes a raised pressure

Also, the patient may recall a blow that happened one or two days earlier, and the symptoms may be delayed.

Test your knowledge 10 questions from this article

Examine for Other Injuries

Traumatic iritis is a marker of a significant blow, and the eye needs a thorough examination.

Hyphema: blood in the anterior chamber (see hyphema)
Corneal abrasion and edema (see corneal abrasion)
Sphincter tears and iridodialysis (see traumatic mydriasis and iridodialysis)
Lens subluxation, cataract, and a Vossius ring (see rosette-shaped cataract)
Angle recession, with a risk of glaucoma later (see angle recession glaucoma)
Commotio retinae, choroidal rupture, vitreous hemorrhage, and retinal tears (see commotio retinae and choroidal rupture)
Orbital fractures and open globe injury (see ruptured globe)

Dilate the pupil once you exclude open globe injury and hyphema and examine the retina with scleral depression.

Differential Diagnosis of Traumatic Iritis

Idiopathic or HLA-B27 anterior uveitis, which trauma can trigger or mimic (see acute anterior uveitis)
Herpetic uveitis, which can follow minor trauma
Sympathetic ophthalmia in penetrating injury, which is a later complication (see sympathetic ophthalmia)
Corneal abrasion with a reactive anterior chamber

Treatment for Traumatic Iritis

Cycloplegic drops, such as cyclopentolate 1 percent two to three times a day, to relieve ciliary spasm and prevent synechiae
Topical corticosteroid, such as prednisolone 1 percent four times a day, tapered over one to two weeks
Analgesia with oral agents as needed
Rest and avoidance of strenuous activity, with eye protection

Treat the pressure if it is high, using drops, and avoid steroids if there is an active epithelial defect without antibiotic cover.

Traumatic Iritis: Diagnosis and Treatment

Follow-Up

Review the patient within a few days to check the response, and again at one to two weeks.

Continue to monitor the intraocular pressure, since inflammation and angle damage can cause a rise.

Perform gonioscopy a few weeks after injury, and arrange regular follow-up for years, because angle recession glaucoma can develop long after the injury.

Also, warn the patient about the symptoms of retinal detachment and instruct them to report any visual change.

Pitfalls and Special Situations

Missing a hyphema or an open globe because the examiner hurried or used poor light
Treating with steroids when an epithelial defect or infection is present, without antibiotic cover
Failing to examine the posterior segment and the angle
Not arranging follow-up for angle recession and retinal tears
Ignoring a child who may not describe the symptoms, and consider abuse if the story does not fit

In patients with a large hyphema, the treatment changes: rest, head elevation, avoidance of aspirin, and monitoring of pressure (see hyphema).

Sports and Work Injuries

Squash balls, shuttlecocks, fists, and champagne corks are classic causes of blunt trauma, because their size allows them to strike the globe without being blocked by the orbital rim.

Protective eyewear that meets standards for the sport is the best prevention, so recommend such eyewear after any injury.

Recovery and Return to Activity

Most cases resolve within one to two weeks, with a gradual reduction in photophobia and pain.

The patient can return to normal activity once the eye is comfortable and the inflammation has resolved, but contact sports should wait until the examination is normal and the eye is cleared by the clinician.

Patients who have had significant trauma may need follow-up for years, because late complications occur.

Documentation

Record the mechanism of injury, the timing, the findings on each part of the eye, and the plan.

A clear record helps in later assessments for angle recession, cataract, and retinal problems, and it provides medico-legal protection.

References

Kuhn F, Morris R, Witherspoon CD, Mester V. The Birmingham Eye Trauma Terminology system (BETT). J Fr Ophtalmol. 2004;27:206-210.
Salmon JF. Kanski’s Clinical Ophthalmology: A Systematic Approach. 9th ed. Elsevier; 2020.
Yanoff M, Duker JS, eds. Ophthalmology. 5th ed. Elsevier; 2019.
American Academy of Ophthalmology. Basic and Clinical Science Course, Section 8: External Disease and Cornea. AAO; current edition.

Test yourself

A few questions straight from this article.

1 / 10 0 correct

Which slit-lamp finding is characteristic of traumatic iritis after blunt injury?
Inflammatory cells and protein enter the anterior chamber and cause cell and flare, with circumlimbal ciliary flush and sometimes keratic precipitates.
How long does it usually take for most cases of traumatic iritis to resolve with treatment?
Most cases resolve within one to two weeks, with a gradual reduction in photophobia and pain.
Which pupil finding may be seen in traumatic iritis?
Sphincter spasm causes miosis with a small, poorly reactive pupil, while a torn sphincter leaves a larger pupil.
What does a finding of traumatic iritis imply about the eye examination?
Traumatic iritis is a marker of a significant blow, so hyphema, angle recession, lens injury, retinal damage, fractures and open globe must be sought.
In traumatic iritis, when should the pupil be dilated to examine the retina?
Dilate once open globe injury and hyphema are excluded, then examine the retina for commotio retinae, choroidal rupture and tears.
Why are cycloplegic drops such as cyclopentolate 1 percent used in traumatic iritis?
Cyclopentolate 1 percent two to three times a day relieves the painful ciliary spasm and prevents synechiae.
Which topical steroid regimen is used for traumatic iritis?
Prednisolone 1 percent four times a day, tapered over one to two weeks, is used along with cycloplegia and oral analgesia.
When should topical steroids be withheld or covered in traumatic iritis?
Steroids should be avoided when there is an active epithelial defect or infection without antibiotic cover.
Why is gonioscopy and long-term follow-up needed after traumatic iritis?
Gonioscopy a few weeks after injury and follow-up for years are needed because angle recession glaucoma can develop long after the injury.
Why are squash balls and shuttlecocks classic causes of blunt injury leading to traumatic iritis?
Their size lets them reach the globe without being blocked by the orbital rim, so sport-standard protective eyewear is the best prevention.

Ahmed Ophthalmologist

Writes and reviews the clinical articles on Educate. Every post is checked against peer-reviewed sources before it goes live.