This document provides an overview of the approach to diagnosing and treating posterior uveitis. It discusses the importance of a thorough clinical assessment to narrow the differential diagnosis and guide diagnostic testing. Common causes of posterior uveitis include infectious diseases like tuberculosis, toxoplasmosis, and viral infections, as well as non-infectious conditions like Behcet's disease, sarcoidosis, and VKH syndrome. Standard diagnostic tests include bloodwork, chest x-ray, fluorescein angiography, and OCT. Targeted testing depends on clinical features and may include vitreous biopsy and serologic testing. Characterization of the uveitis based on features like laterality, site of inflammation, and morphology

1. Approach to Posterior
Uveitis
Supervised by: Dr. Ahmed Khatatbeh
Presented by: Dr. Fayez Alsharief

2. Introduction
• Inflammation of Retina or Choroid
• Isolated Posterior Uveitis (PU) (20-30%)
• PU associated with Anterior Uveitis (Panuveitis 10-20%)
• Serious Sight Threatening Condition !
• It is considered to be the fourth most common cause
of blindness in individuals 20 to 60 years of age in
developed countries
• (64% of cases of Posterior Uveitis associated with
visiual impairment)
• Reference : O M Durrani, N N Tehrani and P I Murray
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1772296/#

3. Introduction
• Proper Clinical Assessment ; essential in:
• Narrowing the differential diagnosis and providing clues for the
final diagnosis (infectious vs non-infectious vs masqueraders)
• Guiding the diagnostic work-up (imaging, extraocular evaluation
and laboratory testing)
• Evaluating disease activity and severity

4. Etiology of Posterior Uveitis
• We can establish a diagnosis in 80% of cases of Posterior Uveitis.
• Primary Ocular Uveitis
1. White Dot Syndromes
2. Sympathetic Ophthalmia
• Systemic Disease
1. Behcet Disease
2. Sarcoid
3. VKH
• Infectious Disease
1. Tuberculosis
2. Syphilis
3. Toxoplasmosis
4. HSV, CMV

5. Important Questions that should be answered in PU
1. Is it Posterior Uveitis only or is it part of a Panuveitis?
2. Is it Choroiditis, Retinitis, or Retinochoroiditis?
3. Is there associated involvement of the Optic Nerve Head and/or Retinal vessels?
4. Does the clinical feature fit into any known infective or non-infective entity?
5. Is it associated with other systemic features?
6. Is it recurrent? If so, how has it responded to previous therapy?
7. Is it associated with immunocompromised status?
8. Is it a masquerade syndrome?

6. History Taking
• Present Illness: laterality, onset, course, ocular symptoms, treatment
• Demographic data: age, sex, ethnicity
• Geographic history: birthplace, residency location, travel
• Past ocular history: previous episodes, past therapy and response,
previous ocular trauma and surgery
• Medical history: Systemic illness, Immune status , medications
• Social history: dietary habits, sexual history, intravenous drug abuse,
social habits(Alcohol & Smoking)
• Family history: medical illnesses, contagious disease
(Tuberculosis),maternal infections, history of Uveitis

7. Review of Medical Systems
• General: Fever, weight loss, malaise, night sweats
• Rheumatologic: arthralgia, joint stiffness
• Dermatologic: rashes, sores, alopecia, vitiligo, poliosis, tick/insect
bites
• Neurologic: tinnitus, meningism , Cranial neuropathies
paresthesia, weakness/paralysis
• Respiratory: Shortness of breath, cough, sputum production
• Gastrointestinal: Diarrhea, bloody stool, oral aphthous ulcer
• Genitourinary: dysuria, discharge, genital ulcer, balanitis

8. Ocular Examination
1. Visual acuity measurement
2. Evaluation of associated anterior segment inflammatory signs: non-
granulomatous vs granulomatous, hypopyon, ocular hypertension)
3. Measurement of Intraocular pressure (IOP); Rise in IOP is associated with
Toxoplasmosis, HSV
4. Qualitative and Quantitative assessment of posterior segment inflammatory
signs:
-Vitreous cells and haze
-Fundus changes: Retinal and Choroidal lesions
Retinal Vasculitis
Macular Edema, other macular changes
Optic disc changes

9. Investigations
1. Rationale;
• Do we need to do investigations in every case of
Posterior Uveitis?
2. Investigations for diagnosis
3. Investigations for monitoring
a-Activity
b-Damage
C-side effects of medications

10. Diagnostic Investigations
• Hierarchy
• None Some Diseases with clear diagnosis like toxoplasmosis may
require no diagnostic investigations, also known history of
systemic diseases that may cause uveitis like behcet and sarcoid.
• Standard Some non-invasive investigations may be appropriate
in almost all posterior segment Uveitis
• Targeted Some posterior segment Uveitis may warrant additional
tests in a targeted manner

11. “Standard” Ix in Posterior Segment Uveitis
• Bloods:
1. CBC, LFT,KFT
2. CRP,ESR
3. Glucose
4. Syphilis serology
5. ACE Sarcoidosis
6. LFT Sarcoidosis
7. ESR Giant cell arteritis
8. Quantiferon (vs) P.P.D.  Tuberculosis
9. Toxoplasma serum titer
• CXR
• FFA/ICG
• OCT

12. Targeted Investigations
• In the presence of Retinitis :
• AC tap +/- Vitreous Biopsy
1. HSV
2. VZV
3. CMV
4. TOXOPLASMA

13. Targeted Investigations
• In presence of Neuroretinitis consider:
• Serology/ELISA for Infectious agents
1. Syphilis
2. Borrelia Burgdorferi
3. Bartonella
4. Histoplasmosis
5. Brucellosis
6. Chlamydia
7. Viruses HIV, HSV, Mumps
• Non-infectious
• Anti-dsDNA, C3

14. Characterization of Posterior Uveitis (PU)
• Onset/Course
• Signs & symptoms
• Laterality
• Degree of Vitritis
• Primary site of inflammation
• Morphologic Characteristics
Important clues for the differential diagnosis

15. Onset and Course
• Sudden  Think of Infectious causes
• Insidious  Think of non infectious causes

16. Duration of Uveitis
• Acute Uveitis: episodes of sudden onset and limited duration that
usually resolves within 3 months or less
• Chronic Uveitis: persistent, with relapse occurring in less than 3
months after discontinuing treatment
• Recurrent Uveitis: repeated episodes separated by periods of
inactivity without treatment that lasts 3 months or longer

17. Symptoms and Signs of Posterior Uveitis
• 6 Symptoms include:
1. Painless decreased visual acuity
2. Floaters
3. Photopsia
4. Metamorphopsia
5. Scotoma
6. Nyctalopia
• 6 Signs include:
1. Retinal or Choroidal
inflammatory infiltrates
2. Inflammatory sheathing of
arteries or veins
3. Exudative retinal detachment
4. RPE atrophy or hypertrophy
5. Atrophy or swelling of the Optic
nerve head, retina or choroid
6. Choroidal or retinal
neovascularization
7. Macular edema

18. Characterization Of PU
(Laterality)
Unilateral  More often Infectious cause
Bilateral  Infectious or Non-infectious

19. Characterization Of PU
(Degree of Vitritis)

20. Characterization Of PU
(Primary site of inflammation)
Retina in
Retinitis/Retinochoroiditis
Choroid in
Choroiditis/Chorioretinitis

21. Characterization Of PU
(Primary site of inflammation)
Retinal vessel in Retinal
Vasculitis
Optic Nerve in Neuroretinitis

22. Uveitis with Retinal Vasculitis
(AAO classification)
Arteritis Phlebitis Both
Systemic Lupus
Erythematosus
Sarcoidosis Toxoplasmosis
Polyarteritis
Nodosa
Multiple Sclerosis Granulomatosis
with polyangiitis
Syphilis Behcet disease
(Occlusive)
Wegners
HSV (ARN) Birdshot Uveitis Behcet disease?
VZV (P.O.R.N)

23. Characterization Of PU
(Morphologic Characteristics 
Optic nerve involvement)
Optic disc edema NeuroRetinitisOptic disc granuloma

24. Morphologic Characteristics
Unifocal Multifocal Diffuse

25. DDx of Focal chorioretinal lesions
A. With vitreal cells: toxoplasmosis, sarcoid, TB, Toxocariasis.
B. Without vitreal cells: tumours, serpiginous choroidopathy.

26. Differential Diagnosis of Peripheral Multifocal
chorioretinal lesions
A. With vitreal cells: sarcoid, BSCR, MCP, SO, VKH, MEWDS,
Masquerade.
B. Without vitreal cells: POHS, PIC, APMPPE

27. Peripheral multifocal Choroiditis
• Bilateral peripheral multifocal
Choroiditis + Vitritis +
Snowballs +/- Granulomatous
Anterior Uveitis
Sarcoidosis

28. Can differentiate MFC vs PIC vs POH
Ocular Histoplasmosis
SyndromePunctate Inner
Choroidopathy
Caucasian; 20 to 50 years of age
Classic Triad:
1.Multiple choroidal spots
(“histo” spots)
2.Peripapillary changes
3.CNV or disciform scar
4.NO VITRITIS !
Women, 20-50 years of
age
Bilateral , yellowish-white
choroidal infiltrates
+
With Vitritis !
Women, Myopia
Uni or Bilateral small
yellow-whit deep lesions
in the posterior pole
+
No Vitritis
Multifocal Choroiditis
with Panuveitis

29. Differential Diagnosis for Diffuse Choroiditis
• Vogt-Koyanagi-Harada Disease
• Sympathetic Ophthalmia

30. Can You Differentiate ?
VKH VS SO

31. Diffuse Choroiditis
• Bilateral posterior or
Panuveitis with multifocal
serous retinal detachment in
a young darkly pigmented
patient
Acute Vogt-Koyanagi-Harada
Disease

32. Diffuse Choroiditis
• Recurrent Granulomatous
Anterior Uveitis +
• Sunset Glow fundus +
• With/Without Skin
manifestations: poliosis,
vitiligo, alopecia
Chronic/Recurrent VKH

33. Diffuse Choroiditis
• Panuveitis +
• History of penetrating
ocular injury or ocular
surgery
Sympathetic Ophthalmia

34. (Morphologic Characteristics 
Associated Macular Edema)
• May occur in any form of
Uveitis in the following order
from most common ( % ) :
1. Panuveitis 53%
2. Intermediate Uveitis 41%
3. Posterior Uveitis 28%
4. Anterior Uveitis 9%
• Diagnosis is based on:
1. Clinical examination +
2. Fluorescein angiography ++
3. OCT +++

35. Macular Edema

36. (Morphologic Characteristics 
Associated Exudative Retinal Detachment)
• May occur in any form of PU
• Typical features for specific entities

37. Associated Exudative Retinal Detachment
VKH Sympathetic Ophthalmia Posterior Scleritis

38. Necrotizing Retinitis
(In immunocompetent patient)
• Peripheral necrotizing
Retinitis +
• Periarteritis +
• Optic disc edema +
• Severe Vitritis +
• Anterior Uveitis
(granulomatous)
Acute Retinal Necrosis Syndrome
(DDx Atypical Toxoplasmosis Or Syphilis)

39. Necrotizing Retinitis
(Associated with immunosuppression)
• AIDS
• After Renal
transplantation
• After intravitreal
corticosteroid therapy
CMV RETINITIS

40. Can you differentiate?
ARN VS Behcet disease

41. Posterior Uveitis associated Anterior Uveitis
Anterior
Uveitis
Non-
granulomatous
Behcet
Disease
Granulomatous
Sarcoidosis Tuberculosis ARN Syndrome Toxoplasmosis

42. Neuroretinitis
• Etiologies:
• Cat scratch disease
• Tuberculosis
• Rickettsiosis

43. General Guidelines
• 1.Infectious cause : treat the infection
• Antibiotic therapy
• Steroids is prescribed after 48 hours of starting antibiotics
• 2. Non infectious cause:
. Give systemic steroid

44. In CAU and Post NIU
Oral
steroids
MTX VS Cellcept VS
Azathioprine
Cyclosporin
Infliximab
(Remicade)
Humira
(adalimumab)

45. Posterior non infectious uveitis
• Local treatment with steroids (PSK, Ozurdex,Retisert)
is preferred in:
Poor compliance with treatment
unilateral cases
Poor tolerance to systemic medications

46. Recommendations
• Never give periocular steroid injection before excluding
Infectious causes of Posterior Uveitis first.
• Start with Empirical therapy for Posterior Uveitis till the results
of the investigation are obtained.
• If there is worsening in the patient condition after giving steroid,
review the diagnosis and think of Infectious causes
• If there is no response after 2 weeks of steroid use, think of
Masquerade diseases (Lymphoma) Vs infectious cause

47. CONCLUSIONS
• Appropriate approach to the diagnosis of Posterior Uveitis:
1. Meticulous history taking and systemic examination
2. Proper analysis of ocular clinical and imaging findings
3. Tailored laboratory evaluation (limited number of tests)
• Leads to the correct diagnosis in the majority of patients
• Diagnosis may be challenging in atypical clinical presentations:
need for extensive diagnostic work-up

48. Thank you for your Attention !