OP6.2 | Iridocyclitis: Complications, Investigations and Treatment — Summary & Reflection

KEY TAKEAWAYS

Complications of iridocyclitis arise from both the inflammation and its treatment. Anterior segment: posterior synechiae → seclusio pupillae → iris bombé → secondary angle-closure glaucoma; trabecular blockage → secondary open-angle glaucoma; steroid-induced IOP rise; complicated cataract (posterior subcapsular — from disease AND steroids); band keratopathy (JIA-association). Posterior segment: cystoid macular oedema (CMO — leading cause of vision loss, detected by OCT/FFA), epiretinal membrane, optic disc oedema. Investigations: tiered (HLA-B27, CXR, Mantoux/IGRA as first-line; ACE, ANA, VDRL, toxoplasma serology targeted; OCT/FFA for posterior complications). Treatment ladder: cycloplegia FIRST (atropine/homatropine → prevent synechiae) → topical prednisolone acetate (taper by frequency, not concentration; monitor IOP) → periocular steroids → systemic prednisolone → steroid-sparing agents (methotrexate, mycophenolate, azathioprine, ciclosporin) → biologics (adalimumab, infliximab). Complication management: secondary glaucoma — avoid prostaglandins, prefer beta-blockers/CAIs; iris bombé → laser peripheral iridotomy; cataract — operate during quiescence; CMO — periocular/intravitreal steroids, anti-VEGF in refractory cases.

REFLECT

Think back to the 22-year-old JIA patient in the opening scenario. Her uveitis was completely silent — no symptoms, yet active inflammation causing structural damage. What does this teach you about the importance of systematic screening over symptom-driven care in high-risk patient groups? As you consider the treatment ladder, reflect on the tension between controlling inflammation (which requires steroids) and preventing steroid toxicity (which requires minimising steroids). How would you frame this balance in a conversation with the patient and her parents? Now consider India's disease context: if you encounter a young adult with granulomatous uveitis and a strongly positive Mantoux test, would you start ATT before waiting for a microbiological diagnosis? What are the risks and benefits of empirical treatment in this setting?