Uveitis Work-up: A Targeted Approach for Residents
Last updated: October 2026
The worst uveitis work-up is a "shotgun" panel of every test for every patient. The best one starts from a careful clinical description and asks: which few diagnoses fit this picture, and which tests will change management? This page gives you that framework.
Step 1: Describe the uveitis (SUN system)
- Anatomical site: anterior (iris and ciliary body), intermediate (vitreous and pars plana), posterior (choroid and retina), or panuveitis.
- Onset: sudden or insidious.
- Duration: limited (3 months or less) or persistent (more than 3 months).
- Course: acute (sudden onset, limited duration), recurrent (episodes separated by inactive periods of at least 3 months off treatment), or chronic (persistent, relapsing within 3 months of stopping treatment).
- Laterality: unilateral, bilateral, or alternating.
- Granulomatous or non-granulomatous: mutton-fat keratic precipitates and iris nodules suggest granulomatous disease (TB, sarcoidosis, syphilis, VKH, sympathetic ophthalmia, herpes).
Grading anterior chamber cells (SUN)
Count cells in a 1 mm × 1 mm slit beam:
| Grade | 0 | 0.5+ | 1+ | 2+ | 3+ | 4+ |
|---|---|---|---|---|---|---|
| Cells in field | <1 | 1–5 | 6–15 | 16–25 | 26–50 | >50 |
Step 2: Tests worth doing in most patients
- Syphilis serology (a treponemal test): syphilis can mimic almost any uveitis and is curable.
- Tuberculosis screening (IGRA or Mantoux) and a chest X-ray: especially important in India and other TB-endemic regions, and essential before starting immunosuppression.
- The chest X-ray also screens for sarcoidosis (hilar lymphadenopathy).
Step 3: Targeted tests based on the picture
| Clinical picture | Think of | Useful tests |
|---|---|---|
| Acute unilateral recurrent anterior uveitis, fibrin, back pain | HLA-B27-associated disease | HLA-B27; spine imaging or rheumatology review if symptoms suggest it |
| Unilateral anterior uveitis with high IOP, sectoral iris atrophy, or corneal scarring | Herpetic (HSV/VZV) or CMV anterior uveitis | Aqueous PCR if the diagnosis is unclear |
| Bilateral granulomatous uveitis, snowballs, periphlebitis | Sarcoidosis, TB | Chest X-ray or CT chest, serum ACE and lysozyme, calcium |
| Intermediate uveitis in a young adult | Pars planitis, multiple sclerosis, sarcoidosis | MRI brain if neurological symptoms (and before anti-TNF therapy) |
| Focal retinochoroiditis next to a pigmented scar | Toxoplasmosis | Usually clinical; serology or PCR in atypical cases |
| Bilateral serous detachments, headache, tinnitus | VKH | OCT, FFA/ICGA, B-scan (choroidal thickening); see VKH |
| Recurrent hypopyon, oral and genital ulcers, occlusive retinal vasculitis | Behçet disease | Clinical criteria; pathergy test; see Behçet |
| Child with chronic, painless anterior uveitis and arthritis | Juvenile idiopathic arthritis | ANA; regular screening schedule with paediatric rheumatology |
| Older patient with vitritis not responding to steroids | Vitreoretinal lymphoma (masquerade) | Vitreous biopsy, MRI brain; see masquerade syndromes |
| Immunocompromised patient with necrotising retinitis | CMV retinitis, acute retinal necrosis, toxoplasmosis | HIV test, CD4 count, vitreous or aqueous PCR |
Step 4: Treatment principles
- Exclude infection first, especially TB, syphilis, herpes and toxoplasmosis, before starting steroids or immunosuppressants.
- Anterior uveitis: topical steroid, tapered according to activity, plus a cycloplegic to relieve pain and prevent posterior synechiae.
- Intermediate, posterior and panuveitis: periocular or intravitreal steroids for unilateral disease; systemic steroids for bilateral or severe disease.
- Steroid-sparing therapy (e.g., methotrexate, mycophenolate, or adalimumab, which was effective in the VISUAL trials) is needed when steroids cannot be reduced to a safe dose.
- Monitor for steroid complications: raised IOP, cataract, and systemic effects.
- Treat complications: cystoid macular oedema, glaucoma, cataract (operate only when the eye has been quiet for at least about 3 months), and band keratopathy.
Related: uveitis notes, all uvea topics, and MUST trial.
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