Anterior uveitis (iritis): GP recognition and same-day referral

Anterior uveitis — also called acute iritis — is inflammation of the iris and anterior ciliary body. It is the most common form of uveitis seen in general practice, accounting for about 50–60% of all uveitis presentations. Australian annual incidence is approximately 12 per 100,000 people. It is not a self-limiting condition: untreated, it causes posterior synechiae (iris-to-lens adhesions), cataract, secondary glaucoma, and chronic vision impairment.

The GP’s role is recognition and same-day referral. Treatment initiation belongs with an ophthalmologist who can confirm the diagnosis by slit-lamp examination, grade the severity, exclude infectious causes, and monitor intraocular pressure throughout treatment.

A. Core clinical — the AU general-practice framework

Recognising anterior uveitis

The classic presentation is a unilateral red eye with:

• Photophobia — significant sensitivity to light, often with brow ache and watering
• Deep aching pain — worse with accommodation (reading, near tasks); distinct from the superficial irritation of conjunctivitis
• Blurred vision — due to aqueous flare (protein in the anterior chamber)
• Ciliary flush — a ring of deep redness around the cornea, rather than peripheral conjunctival redness
• Small or irregular pupil — sphincter spasm and early posterior synechiae pull the pupil into an irregular shape

The pupil is the key discriminator: a small, irregular, or sluggish pupil in a painful photophobic red eye means anterior uveitis until proven otherwise. Acute angle-closure glaucoma causes a mid-dilated fixed pupil — a different emergency, different management.

Differentiating from other red-eye causes

The RACGP red-eye approach provides a practical framework. Key discriminators:

Condition	Redness pattern	Pain	Discharge	Pupil
Anterior uveitis	Ciliary flush (perilimbal)	Deep, photophobic	None	Small / irregular
Conjunctivitis	Peripheral, diffuse	Mild / none	Mucopurulent or watery	Normal
Keratitis	Ciliary flush	Foreign-body, surface	Variable	Normal
Acute angle-closure glaucoma	Diffuse	Severe, with nausea	None	Mid-dilated, fixed
Episcleritis / scleritis	Sectoral or diffuse	Variable	None	Normal

History to take

• Symptom timeline — onset, laterality, prior episodes.
• Systemic review — back stiffness (ankylosing spondylitis), bowel symptoms or blood in stool (inflammatory bowel disease), skin or nail changes and joint pain (psoriatic arthritis), mouth or genital ulcers (Behçet’s disease), cough and breathlessness (sarcoidosis).
• Infectious risk — travel history, STI risk (syphilis, HIV), TB exposure.
• Medications — bisphosphonates, rifabutin, sulfonamides, and immune-checkpoint inhibitors (pembrolizumab, nivolumab) can all trigger uveitis.
• Prior episodes — laterality and pattern of recurrence strongly guide the systemic workup.
• Children — juvenile idiopathic arthritis (JIA) causes a chronic anterior uveitis that is often completely asymptomatic (“white eye” iritis). JIA-associated uveitis must be screened for regularly in at-risk children, not waited for.

What investigations to order

For a first unilateral episode in an otherwise well adult with no systemic features, the diagnostic yield from extensive investigations is low (D’Alessandro, Br J Ophthalmol 2017). A baseline syphilis screen (RPR/TPHA) is recommended at every episode regardless — syphilis is the great mimic and is treatable.

For recurrent, bilateral, granulomatous, or atypical presentations, the workup expands:

• FBC, CRP, ESR
• HLA-B27 — positive in ~50% of acute anterior uveitis; guides prognosis and counselling about systemic disease risk
• Serum ACE and calcium — sarcoidosis
• Chest X-ray — sarcoid hilar adenopathy, TB
• QuantiFERON-TB Gold — before any biologic if chronic uveitis is being considered
• ANA, RF, ANCA — connective-tissue and vasculitis screen
• HIV serology if clinically indicated

Always test for syphilis in any uveitis — a treatable infectious cause should never be missed.

B. Management — the GP role and specialist treatment

Same-day ophthalmology referral is mandatory

The GP should not start topical steroids without an ophthalmology assessment. The diagnosis requires a slit-lamp examination to grade anterior chamber cells and flare (using the Standardization of Uveitis Nomenclature [SUN] framework, Jabs, Am J Ophthalmol 2005), identify keratic precipitates (fine in non-granulomatous disease; “mutton-fat” deposits in granulomatous sarcoid, TB, syphilis, or herpetic disease), check intraocular pressure, and examine the fundus to exclude posterior involvement.

If same-day specialist access is genuinely unavailable and the presentation is clearly non-infectious with an intact cornea (no herpes dendrite on fluorescein), eTG permits a GP to initiate topical prednisolone and cycloplegic with simultaneous ophthalmology contact. This is the exception, not the rule.

Specialist-led treatment

Topical corticosteroid — prednisolone acetate 1% (Pred Forte) one drop every 1–2 hours initially, tapering over 4–6 weeks based on slit-lamp response. Frequency is determined by severity grade. Intraocular pressure is monitored weekly during high-frequency dosing — steroid-responders (30–40% of the population) develop IOP elevation of ≥10 mmHg.

Cycloplegic — cyclopentolate 1% three times daily or atropine 1% twice daily. Purposes: pain relief from ciliary spasm, prevention of posterior synechiae, and dilation for fundus examination. AMH summarises the pharmacology and dosing.

Oral prednisolone (0.5–1 mg/kg/day with taper) is added for bilateral severe disease or significant systemic disease.

When recurrence or chronicity requires more

For recurrent or chronic non-infectious anterior uveitis, steroid-sparing immunomodulators (methotrexate, azathioprine, mycophenolate) are initiated by the specialist. For refractory non-infectious uveitis, adalimumab (Humira) has PBS Authority Required (Section 100) for severe cases — supported by the VISUAL I trial (Jaffe, NEJM 2016) and VISUAL II (Nguyen, Lancet 2016). For JIA-associated uveitis, adalimumab combined with methotrexate is the current gold standard based on the SYCAMORE trial.

Herpetic anterior uveitis (HSV or VZV) requires oral antiviral therapy (valaciclovir 1 g three times daily for 7–10 days) alongside topical prednisolone — not steroids alone. Syphilitic uveitis requires IV penicillin plus sexual health and ophthalmology comanagement.

C. Understanding HLA-B27 and systemic associations

Why HLA-B27 matters

About 50% of acute anterior uveitis in Australian patients of European background is HLA-B27 positive (Linder, Ophthalmology 2004). HLA-B27 is present in approximately 8% of the general Australian population but rises to 50% among those with anterior uveitis — a dramatic enrichment reflecting a shared inflammatory pathway. HLA-B27 triggers IL-23/Th17-driven inflammation in both the spine and the eye.

HLA-B27 testing in the context of anterior uveitis risk-stratifies the patient for future systemic disease and recurrence, even if it does not change the acute management. The main systemic associations are:

• Ankylosing spondylitis — approximately 50% of HLA-B27-positive uveitis patients have or will develop axial spondyloarthropathy. Ask specifically about morning back stiffness lasting more than 30 minutes.
• Psoriatic arthritis — about 10% of psoriatic arthritis cases develop uveitis; ask about skin and nail changes and joint pain.
• Inflammatory bowel disease — up to 10% of people with Crohn’s disease or ulcerative colitis develop uveitis, often bilateral or with posterior involvement.
• Reactive arthritis — classically follows enteric or urethral infection.

Identifying the systemic driver matters because treating the underlying disease (biologic therapy for ankylosing spondylitis or IBD) substantially reduces uveitis recurrence frequency.

D. Australian operations

MBS billing for GP workup and monitoring

Standard GP consultations under items 23, 36, and 44 apply for assessment, initial referral, and follow-up review. Pathology for the systemic workup is billed via routine pathology episode-of-care (FBC/CRP/ESR, RPR/TPHA, QuantiFERON-TB Gold [item 69478], HLA-B27 [item 73529 — specialist-anchored], serum ACE, ANA/RF/ANCA). Chest X-ray under item 58503. Ophthalmology referral under items 104 (initial) and 105 (subsequent). The GPCCMP (items 965/967) applies for chronic recurrent uveitis with comorbid spondyloarthropathy or IBD.

PBS medications

Prednisolone acetate 1% (Pred Forte), dexamethasone 0.1% (Maxidex), and cyclopentolate 1% and atropine 1% are all on the PBS general schedule. Loteprednol etabonate 0.5% (lower IOP-rise risk) is Authority Required. Methotrexate is Authority Required for severe uveitis. Adalimumab is PBS Section 100 Authority Required for severe refractory non-infectious uveitis. For HSV/VZV uveitis, oral valaciclovir and aciclovir are Authority Required (PBS).

Telehealth considerations

Acute anterior uveitis requires in-person slit-lamp assessment — telehealth cannot substitute. After specialist review and treatment stabilisation, telehealth follow-up (video, item 91790) under the 12-month existing-relationship rule may support compliance reviews and systemic disease monitoring between in-person visits.

E. Special populations

ATSI communities. Higher rates of TB and syphilis-associated uveitis occur in Aboriginal and Torres Strait Islander populations. TB and syphilis should be screened for at any episode, not deferred to recurrence. ATSI health assessment (item 715) can incorporate eye health alongside general preventive care.

Children with JIA. JIA-associated anterior uveitis is often completely asymptomatic — children do not complain of pain or redness. Regular slit-lamp screening is mandated for at-risk groups (ANA-positive oligoarticular JIA females under 7 at diagnosis: 3-monthly slit lamp). A “white quiet eye” in a child with JIA must not be taken as visual health. Paediatric ophthalmology manages this closely.

Pregnant women. Systemic and some topical medications require careful review in pregnancy. Ophthalmology and obstetric comanagement is needed for severe or recurrent disease. Most topical treatments can be used with caution; systemic immunosuppressants require specialist guidance.

Immunocompromised patients. CMV-associated anterior uveitis (Posner-Schlossman syndrome or post-cataract surgery) requires specialist antiviral therapy (valganciclovir or ganciclovir gel), not standard steroid-cycloplegic treatment.

When to escalate

Refer urgently or to emergency when:

• Suspected acute angle-closure glaucoma (mid-dilated fixed pupil, halos, nausea, rocky globe) — this is a different ocular emergency.
• Hypopyon (visible pus in the anterior chamber) — suggests Behçet’s disease, severe HLA-B27 uveitis, or infectious endophthalmitis.
• Sudden significant vision loss — endophthalmitis until proven otherwise.
• Suspected scleritis (deep boring pain, non-blanching scleral redness).
• Any child with a white pupil or leukocoria — retinoblastoma until proven otherwise; same-day paediatric ophthalmology.

Refer within days for: recurrent uveitis without a systemic diagnosis, bilateral simultaneous disease, granulomatous keratic precipitates, any uveitis in a child.

What this article is and is not

This is general health information based on current Australian ophthalmology and general practice guidelines — RANZCO uveitis guidelines, Therapeutic Guidelines, Australian Medicines Handbook, and RACGP red-eye approach. It is not personal medical advice and does not create a doctor–patient relationship. Eye conditions with visual symptoms require in-person specialist assessment — this article cannot substitute for that.

For Australian consumer resources: HealthDirect — Uveitis, Vision Australia, Arthritis Australia.

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Sources cited

1. RACGP — Acute red eye approach
2. Therapeutic Guidelines (eTG) — Eye: Anterior uveitis
3. Australian Medicines Handbook
4. RANZCO — Uveitis clinical guidelines
5. HealthDirect — Uveitis
6. Better Health Channel
7. Vision Australia
8. Arthritis Australia
9. PBS
10. Jabs DA et al. — SUN Working Group nomenclature. Am J Ophthalmol 2005
11. Linder R et al. — HLA-B27 AAU epidemiology. Ophthalmology 2004
12. D’Alessandro LP et al. — Diagnostic yield, first-episode AAU. Br J Ophthalmol 2017
13. Jaffe GJ et al. — VISUAL I adalimumab. NEJM 2016