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b) AC reaction: qualify and quantify

1) Look for cell and flare before using any drops

2) Use brightest parallelepiped about the size of the pupil to find cell and flare. Back-scattered light from the iris will wash out view if the beam is too large

3) Look in front of black pupil, but search the entire chamber

4) Grade cell (looks like small white spheres), flare (looks like smoke or white lint), and pigment individually with a 1 mm2 spot beam directed from as far to side as possible

5) Iritis grading system: cell is diagnostic for follow up as the iritis resolves

a) Rare: 1 or less cell in 1 mm2 beam

b) Occasional: 3 cells in 1 mm2 beam

c) ½+: 5 cells in a 1 mm2 beam

d) I+: 10 cells in a 1 mm2 beam

e) II+: 20 cells in a 1 mm2 beam

f ) III+: 30 cells in a 1 mm2 beam

g) IV+: 40 cells in a 1 mm2 beam (driving through blizzard with headlights on)

6) Grade pigment and flare with the same scale

7) Is the aqueous plasmoid? Do the cells circulate or are they fixed? If plasmoid, the increased fibrin levels indicate a more severe iritis and cause an increased risk of synechiae. A plasmoid aqueous may also indicate ciliary body shut-down

8) Is there a hypopyon or individual red blood cells? Indicates human leukocyte antigens (HLA)-B27 or possibly Behcet’s or an endogenous endophthalmitis

9) Is the chamber deep, no peripheral anterior synechiae?

c) Iris

1) Look for posterior synechiae, but can’t tell for sure until dilate

2) Look for iris nodules (granulomatous)

3) Look for iris atrophy or color change (Fuch’s heterochromic iridocyclitis). Sector atrophy and transillumination defects are probably herpes simplex

d) Lens

1) Not diagnostic unless hypermature cataract causing inflammation, trauma, or posterior synechiae

2) If pseudophakic, R/O UGH (uveitis, glaucoma, hyphema)

5) IOP

1) Usually low: OK

2) If high: treat, avoid prostaglandins. Do not use optipranolol or pilocarpine. Do not do argon laser trabeculoplasty (ALT)

3) If dangerously high, consider Fuch’s or glaucomatocyclitic crisis (Posner-Schlossman)

a) IOP may be 40 – 60

b) Mild AC reaction

c) Mild, fine KPs on cornea or in trabecular meshwork

d) Start glaucoma meds and topical steroid

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