Recurrent Anterior Uveitis With Systemic Symptoms

Diagnosis: acute nongranulomatous anterior uveitis (iritis), likely HLA-B27-associated given the recurrent unilateral course, low back pain, and episode of painful urination suggestive of reactive arthritis. The posterior synechia indicates prior or current inflammation with iris adherence to the lens.

Immediate treatment:

• Topical corticosteroid: prednisolone acetate 1% every hour while awake is appropriate for 3+ cells. The acetate formulation penetrates the cornea better than phosphate preparations. The frequency is chosen to suppress intense anterior chamber inflammation rapidly and prevent further synechiae and macular edema. Do not start a weaker steroid for severe inflammation.
• Cycloplegic/mydriatic: cyclopentolate 1% twice daily, or atropine 1% if severe, to relieve ciliary spasm, reduce pain, and prevent or break posterior synechiae by keeping the pupil mobile. Use with caution in patients with narrow angles.
• No topical antibiotic: this is not infectious conjunctivitis, and antibiotics would not treat the uveitis.

Check IOP at each visit because steroids can raise pressure and inflammation can cause hypotony or angle closure. If the hypopyon or inflammation is severe, consider a subconjunctival steroid injection and urgent ophthalmology follow-up. Do not use topical steroids without a plan for taper and monitoring.

Reasoning: a first episode of unilateral nongranulomatous anterior uveitis in a healthy young adult may not require an extensive workup. However, this patient has recurrent disease and systemic symptoms-low back pain and dysuria-that raise the probability of an HLA-B27-associated spondyloarthropathy or reactive arthritis. The workup should be targeted, not a shotgun panel.

Reasonable tests:

• HLA-B27 to support the diagnosis of an HLA-B27-associated uveitis; a positive result does not prove causality but helps classify the disease and guide rheumatology referral.
• CBC, ESR, and CRP to assess systemic inflammation.
• Syphilis serology because syphilis can cause recurrent uveitis and must not be missed.
• Chest radiograph and ACE if sarcoidosis is suspected; this patient has no respiratory symptoms, so keep threshold moderate.
• Urinalysis and nucleic acid amplification testing for chlamydia given dysuria; refer to urology or primary care for evaluation of urethritis.
• Rheumatology referral for the low back pain and possible spondyloarthropathy.

If the uveitis is granulomatous, bilateral, or associated with retinal findings, broaden the workup. Document that testing is guided by history and examination, and arrange follow-up of results.

Taper: after 3–7 days of hourly prednisolone acetate 1%, reduce to every 2 hours while awake if cells are improving, then to four times daily, and then taper slowly over 4–6 weeks. Never stop abruptly after prolonged use. The taper should be guided by anterior chamber cell count, not by redness alone. If inflammation recurs as the dose drops, slow the taper or return to the last effective frequency.

Monitoring: check visual acuity, IOP, cell and flare, and posterior synechiae at each visit. Steroid response can raise IOP, so measure pressure at every visit; if IOP rises significantly, add aqueous suppression and consider switching to a weaker steroid. Perform a dilated fundus examination to rule out cystoid macular edema, especially if vision decreases. Monitor for cataract and for posterior synechiae formation. Continue cycloplegia until the anterior chamber is quiet to prevent adhesions.

Referral criteria: refer to a uveitis specialist if inflammation does not improve within 2 weeks, if it recurs during taper or requires long-term steroids, if there is significant IOP elevation or hypotony, if cystoid macular edema develops, if the uveitis becomes granulomatous or bilateral, or if an underlying systemic disease is diagnosed and co-management is needed. Also refer if the patient cannot adhere to follow-up. The overarching judgment is to treat aggressively but taper with monitoring to avoid steroid complications.