Differential Diagnosis and Management of Eye Inflammation

Introduction to Eye Inflammation

The American Academy of Ophthalmology distinguishes conjunctivitis from deeper inflammatory processes by the absence of vision loss and presence of discharge 1.

Conjunctivitis can be infectious (bacterial, viral), allergic, or immune-mediated, and is characterized by inflammation of the conjunctiva 1.
Anterior uveitis is inflammation of the iris and ciliary body, characterized by anterior chamber cells and flare, and has diagnostic implications for seronegative spondyloarthritis 2, 3.
Posterior uveitis is inflammation affecting the choroid and retina, assessed by vitreous haze, chorioretinal lesions, and retinal vascular lesions 4, 5.

Masquerade syndromes, including malignancy and retinal degeneration, occur in up to 2.5% of noninfectious uveitis cases in tertiary centers, and require diagnostic vitrectomy, cerebrospinal fluid cytology, and brain MRI 4, 5, 6.
Infection must be excluded through sampling and culturing of intraocular fluids, particularly in immunosuppressed patients with invasive procedures, indwelling catheters, or systemic sepsis 4, 5.

Topical corticosteroids (prednisolone acetate 1%) are first-line for anterior uveitis, but should be limited to ≤3 months due to glaucoma and cataract risk 2, 3, 7, 8, 9.
Systemic immunomodulatory therapy, including methotrexate and adalimumab, is indicated for JIA-associated uveitis and other chronic noninfectious uveitis when topical therapy is insufficient 2, 3, 7.
The American College of Rheumatology recommends methotrexate as the first-line systemic agent for the treatment of JIA-associated uveitis 2, 3, 7.

When initial therapy fails, exclude nonadherence, infection, and masquerade syndromes, then consider dose escalation or transition to alternative or additional agents 4, 5, 6.

Visual acuity and ocular inflammation (by Standardization of Uveitis Nomenclature criteria) are the strongest evidence-based parameters for adjusting therapy 4, 5, 6.
Inactive disease is defined as grade <1+ anterior chamber cells without new complications from active inflammation 2, 3, 7, 8, 9.

Ocular Mucous Membrane Pemphigoid requires systemic immunosuppression to prevent progression, with treatment options including mycophenolate mofetil, dapsone, azathioprine, or methotrexate for mild/slowly progressive cases, and cyclophosphamide for severe/unresponsive cases 1.