Traumatic Iritis ?

[LauraP]

I am 50 years old and just recovered from my first bout of iritis. Eight weeks prior to the onset, my thyroid med (synthroid) was decreased to 50 MCG. At the onset of iritis, synthroid was then adjusted back to 100 MCG. I only mention this in case hypothyroid could have contributed to the iritis. I vaguely remember some eye pain, especially when moving my eye a few weeks prior to the onset, but I assumed this was sinus pain. Twenty years ago I was ANA positive on a blood test initiated by a dermatologist due to rashes. I had not had further blood work and over the years had not had any significant symptoms indicative of autoimmune disorders except a few rashes. I am generally in good health. I had suffered from dry eye the last 10 years or so, but it has been manageable most of the time to the point where I am able to tolerate contact lenses most days. I do supplement with flaxseed oil and use lubricant (preservative free) eye drops. On a Sunday, I took a shower and forgot to take out my contact lenses (they were so comfortable, I forgot about them). I rubbed my eyes in the shower and then remembered they were in my eyes. When I got out of of the shower, I couldn't see the lens in my right eye and didn't know if it had fallen out or was stuck in my eye. Then...I did a very stupid thing. I probed my eye with my finger looking for the lens. I ran my finger across my cornea and iris searching for the lens. I finally discovered it up in the corner and had to manipulate to push it down and remove it. I pushed on my eye for at least 5 minutes. There was no severe discomfort or extreme redness, and an hour later I put my contact back in. Two days later, I woke up on Tuesday to a very red eye. There was not any real discomfort so I just didn't wear my contacts that day or the next. On Thursday, I was still very red so I went in to my opthalmologist. He immediately diagnosed iritis and put me on pred fort. Over the course of that day, the pain and photosensitivity increased and the next morning I woke up to impaired vision in the form of a white cloudy film. I called my doctor, and he had me come in. The cloudiness resolved somewhat as the day progressed. The opthalmologist stated that my iritis had worsened significantly and had me increase the pred fort to every two hours and also insert the drops during the night if I woke up. There was no evidence of iritis in the left eye. By Monday, when I returned the condition had improved. For some reason, he never prescribed dilating drops. Every time he checked my pressure, it was fine, in the teens. I stayed on the drops (with a later tapering schedule) for about 6 weeks. Towards the last 2-3 weeks, I had a difficult time with dry eye and foreign body sensation in the eye but I believe this was due to the preservative in the pred forte and this has now completely resolved.

Now my questions.
I asked my doctor if my iritis could be due to trauma from my probing of my eye and he initially said no because "the iritis would have developed immediately." I did develop within two days. Later, he said it was a possibility. I would LOVE to believe in the possibility of it being a one time Trauma-induced occurrence. Is this type of problem (running and pushing my finger over the iris) consistent with traumatic iritis. From what I have read it seems like it is more usually from a single blow to the eye.

I have been off the steroids for two weeks and my eye has returned to normal except for one thing. The right (effected) eye has a slightly larger pupil when in a darkened room. The pupil contracts fine in brighter light, however. I read that pupil dilation can be a side effect of pred forte, if this is true how long before it resolves? Could this pupil dilation be a complication of the iritis? I thought iritis meant the pupil had difficulty dilating? I guess it is possible this pupil asymmetry predated the iritis and I just never noticed it.

These questions answered and any other feedback would be greatly appreciated. Again, thank you for this site, I was a daily visitor during my 6 weeks of hell and the information here was invaluable.

[Mike Bartolatz]

if I were you I would contact my Primary care Physician and look into ANA again, at your age, hormones are changing and many autoimmune or autoinflammatory disease processes are linked to this. Severe dry eyes is lined to many conditions. if dryness issues are multiple, eyes, mouth and otehr 'female dryness' issues, then you should be checked for Sjogrens' syndrome and Systemic Lupus Erythematosus which are kissing cousins. Sarcoidosis is also an ANA positive condition with severe dry eyes and dry mouth associated with it. with these conditions if dry mouth is present, a Salivary gland can be biopsied to differentiate between sarcoidosis and other causes.
dry eyes can be from RF positive conditions too and symptoms govern what tests are needed to try to figure out a 'cause' this can be problematic because underyling disease antibodies may take a decade in some individuals to show up. usually a rheumatologist with experience in differentiating these things is required to treat the underlying symptoms.
whatever the cause, if this returns or becomes recurrent, you will need to treat this systemically IF pathogens can be ruled out.

severe dry eyes can also be related to the seronegative spondyloarthroptheis and enteropathic arthropahies, Anklosing spondylitis, psoriasis/psoriatic arthritis, reactive arthritis, ulcerative colitis and Crohn's disease.
autoimmune thyroid disease an also be linked through genetics to many of the above conditons through the IL23R and ERAP1 genes.
the HLA B27 gene could also be checked for linked to many of these things.
I do not think that trauma has played a role in this but I am not a doctor so take that for what it is worth

wishing you the very best,
mike

[LauraP]

Thank you Mike for your response. Unfortunately, you were correct and my iritis was not trauma related as it returned in the same eye approx 8 weeks after discontinuing pred forte. I caught it early, and it was rated as +1. Within one day, I began durezol, and my eye cleared quickly and I had minimal pain and photosensitivity after just a day of treatment. For these two flares, my opthalmologist has not prescribed any dilating drops. Due to the reoccurrence, I have had blood work done. CBC was normal, thyroid (TSH) normal (with thyroid meds currently), RA negative, but ANA again moderately positive. I am confused as HLA B27 test was inclusive, stating "The HLA B27 screening assay by Flow Cytometry has yielded and inclusive result. If clinically indicated, you may wish to order and HLA-A and B Phenotype test." Does this mean that HLA B27 is more likely to be negative or is it just a lab error? Is there any solid reason for further HLA testing?

I am seeing my opthalmologist Thursday morning and I am sure he would order more tests if it would help. Do you have any suggestions Mike? I ask because I have made an appointment at the end of the month with Dr. Narsing Rao at the Doheny Eye Center and I am thinking the more lab work I have completed, the more productive the consult will be.

By the way, I am THRILLED with the results from durezol. I had a real difficult time with the pred forte most likely due to sensitivity to the BAK perservative, which severely dried and irritated by eyes. Also, to clarify my earlier post, I do not not believe my mouth is overly dry, and my dentist confirms this. However, I have had a history of intermittent mouth ulcers which have curiously stopped since developing iritis. I would rather have the mouth ulcers, lol I don't think the mouth ulcers are herpes because they were more like canker sores on the tongue and soft tissue inside the mouth, not ever on the lips, not cold sores.

Thank you for all your assistance, this is a wonderful site!

Laura

[Mike Bartolatz]

identifying the mouth sores may prove very helpful in diagnosing your cause. reactive arthritis has mouth sores as does behcet's disease and sarcoidosis,Systemic Lupus erythematosus and sjogren's syndrome and viruses and yeasts etc.
they may wish to do both an HLA A and B panel to look for markers associated with underying cause. DR Rau is an expert in this and will order appropriate tests. I heard him speak in Boston at a medical confrerence a few years ago at An American Academy of Ophthalmology Conference at MEEI. I have suggested that members seek his care in the past and they have been very pleased with his abilities.
Durezol does work well but it can raise pressure inside your eye very quickly so make sure you get in for frequent testing for IOP. that's why it is usually only used for a short period of time such as two weeks.

please bring up the mouth sore situation with Dr Rao as it may help to exclude various other causes for your difficult to control uveitis.
do you have sores elsewhere on your body? any rashes on your lower legs, face etc?

wishing you the very best,
mike