White Dot Syndromes: MEWDS, APMPPE, Serpiginous, Birdshot and MCP
Last updated: November 2026
The white dot syndromes are inflammatory disorders of the outer retina, RPE, choriocapillaris and choroid that show as pale spots. Some are self-limiting; others destroy the macula or cause choroidal neovascularisation. Imaging (FAF, OCT, FFA and ICG) is the key to telling them apart.
The main syndromes
| Syndrome | Typical patient | Key features | Course and treatment |
|---|---|---|---|
| MEWDS (multiple evanescent white dot) | Young myopic woman, unilateral | Small grey-white dots, granular fovea, enlarged blind spot; wreath-like FFA hyperfluorescence | Resolves in weeks; no treatment |
| APMPPE | Young adults after a viral illness, bilateral | Large flat cream placoid lesions; early hypo-, late hyperfluorescence on FFA | Usually good recovery; exclude cerebral vasculitis if headache |
| Serpiginous choroiditis | Middle-aged, bilateral | Grey-yellow lesions spreading from the disc in a snake-like (geographic) pattern | Recurrent and sight-threatening; immunosuppression; in India exclude TB (serpiginous-like choroiditis) |
| Birdshot chorioretinopathy | Middle-aged Caucasian, HLA-A29 in over 95% | Cream ovoid spots radiating from the disc, vitritis, vasculitis, CMO | Chronic; systemic immunosuppression |
| Punctate inner choroidopathy (PIC) | Young myopic women | Small punched-out spots at the posterior pole, no vitritis | CNV is common: anti-VEGF |
| Multifocal choroiditis with panuveitis | Young myopic women | Like PIC but with vitritis and peripheral lesions | Steroids and immunosuppression; CNV risk |
Approach
- Rule out infections first: syphilis, TB, toxoplasma, and in older patients, lymphoma.
- Use multimodal imaging: FAF and OCT show outer retinal damage; ICG shows choroidal lesions often more numerous than seen clinically.
- Watch for choroidal neovascularisation (sudden distortion): treat with anti-VEGF.
Where residents slip
- Treating serpiginous-like choroiditis with steroids alone in a TB-endemic country.
- Missing CNV in PIC.
- Forgetting HLA-A29 testing in suspected birdshot.
Test yourself: flip cards
Related: TB, Sarcoid and Syphilis Uveitis, FFA and ICG Angiography Patterns: Quick Reference Card, Uveitis Made Easy: SUN Terms, Patterns and Work-up.
Key sources
- Crawford CM, Igboeli O. A review of the inflammatory chorioretinopathies: the white dot syndromes. ISRN Inflamm. 2013;2013:783190
- SUN Working Group. Classification criteria for the white dot syndromes. Am J Ophthalmol. 2021
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