For this manuscript, the MUV task force selected members from the MUV steering committee and additional imaging experts in uveitis and medical retina who were not formally part of any subcommittee studying uveitic conditions. The experts were chosen keeping in mind global representation to account for disease phenotype variability. The team was tasked to review the recommendations of the five subcommittees and develop guidelines for outcome measures using formal consensus methods. Before participating in this study, subcommittee experts conducted a thorough literature review. We followed the principles of Standards for Reporting Qualitative Research: A Synthesis of Recommendations (SRQR) for reporting the results of our study.

The subcommittee extracted “imaging statements” from the MUV manuscripts related to SC, MFCPU/PIC, APMPPE, BSCR, and MEWDS, ^,,,, focusing on findings from the following MMI modalities: FFA, ICGA, OCT, FAF, and OCTA. When necessary, the experts reviewed the cases analyzed by the individual subcommittees for the various diseases. For each imaging modality, the subcommittee compiled statements to serve as outcome measures, categorizing them into features suggestive of active disease (SAD) and features suggestive of inactive disease (SID). The subcommittee also identified features on imaging modalities that do not necessarily imply complete inactivity, but an advanced stage of healing. Such imaging features may need additional analysis and detailed evaluation (equivocal).

We chose the nominal group technique (NGT) with a rigid, structured process to prepare imaging outcome measures by the subcommittee. The NGT technique provides a structured and transparent framework for building consensus agreements in scientific studies, ensuring balanced participation of individual experts. The advantages of NGT include independent idea generation with iterative ranking, which enhances the quality of recommendations compared with other techniques such as Delphi-based methods. NGT was chosen to improve the methodological rigor and strengthen the credibility of consensus-based analysis. The NGT subcommittee was led by two imaging experts in uveitis (A.A. and P.R.). Among the members of the subcommittee, one acted as a neutral facilitator (A.A.). The members were provided an introduction and orientation to the goals of this manuscript. In the next step, the subcommittee was provided with the imaging statements compiled from the five MUV manuscripts. Each participant was allowed to present their ideas without interruption, discussion, or criticism in a round robin format. After equal representation by all members, the facilitator ensured a discussion to clarify and elaborate on the key imaging features for each entity. The facilitator allowed anonymous voting to achieve a supermajority consensus. The subcommittees also performed NGT discussions for identifying the most effective modalities for assessing disease activity and complications, including CNVs.

The subcommittee members drafted statements defining SAD and SID based on the findings of the MUV reports for individual diseases. These preliminary recommendations were discussed and debated by the members of the subcommittee and revised as needed based on this discussion. Based on the consensus obtained, the recommendations were subsequently voted upon by the entire MUV task force (Supplement A) from diverse geographical regions and subspecialty training in uveitis. Using an anonymous online survey system, the task force members assessed the recommendations, and any requested modifications were discussed collaboratively among the team members. Finally, a consensus was achieved by all the members of the MUV taskforce defined as follows:

Unanimous consensus: 100% participants agree

Strong consensus: > 95% vote

Consensus: 75% to 95% vote

Majority agreement: > 50% to 75% vote

No consensus: < 50% vote (lack of agreement or divided votes)

The percentage thresholds for consensus derived by voting were reported as per the guidelines of various international associations, including Guidelines International Network (GIN), European League Against Rheumatism (EULAR), and Association of Scientific Medical Associations of Germany (AWMF). In case there was no consensus achieved (<50% vote), the guidelines were rejected.

Study data were collected and managed using REDCap electronic data capture tools hosted at Vanderbilt University Medical Center. ^, REDCap (Research Electronic Data Capture) is a secure, web-based software platform designed to support data capture for research studies, providing (1) an intuitive interface for validated data capture; (2) audit trails for tracking data manipulation and export procedures; (3) automated export procedures for seamless data downloads to common statistical packages; and (4) procedures for data integration and interoperability with external sources.

For SC, the subcommittee members agreed that the clinical appearance of the lesions can help determine if the lesion is active. Since the lesions of SC are either paucifocal or multifocal, each lesion should be examined for activity, including those in the periphery. Depending on the stage of the disease, only certain lesions may be active, and careful attention must be paid to the edges since the lesions tend to enlarge in a serpentine pattern. Yellow raised lesions with fuzzy margins are indicative of activity, whereas atrophic edges with variable pigmentation indicate inactive lesions. OCT and FAF are useful imaging modalities for determining the activity of SC. On OCT, focal thickening of the choriocapillaris (usually associated with outer retinal/RPE disruption) colocalizes to the clinically active-appearing areas, indicating that the disease is active. Clumping and atrophy, along with thinning of choriocapillaris, indicate healed disease. Photoreceptor ellipsoid and myoid zone hyperreflectivity, and focal disruption of the outer retina and RPE, are ambiguous indicators of activity. Therefore, these are unreliable as standalone imaging outcome measures. On FAF, if an area of fuzzy hyperautofluorescence surrounds the edges, they indicate active lesions, whereas completely hypoautofluorescent edges clearly indicate healed disease. Stippled hyper- and hypoautofluorescence within the lesion may not necessarily indicate activity and must be carefully evaluated. Ultrawide field FAF can be valuable for evaluating peripheral retinal lesions, as some cases may exhibit active pathology exclusively in the far periphery ( Figure 1 ).

Features of active disease in serpiginous choroiditis on multimodal imaging. A. On color fundus photography, the active lesion appears as a yellow, elevated area with fuzzy margins ( white arrowhead ) developing at the edge of an atrophic, hypopigmented lesion. B. In early-phase fluorescein angiography, the active lesion demonstrates diffuse hypofluorescence ( white arrowhead ). C. In late-phase fluorescein angiography, the active lesion exhibits uniform hyperfluorescence ( white arrowhead ). D. In early phase indocyanine green angiography, the active lesion shows dark hypofluorescence ( white arrowhead ). E. In late phase indocyanine green angiography, the active lesion remains hypofluorescent ( white arrowhead ). F. On fundus autofluorescence imaging, the active lesion presents as fuzzy hyperautofluorescence ( white arrowhead ). G. On optical coherence tomography, the active lesion corresponds to focal thickening of the choriocapillaris, accompanied by disruption of the outer retina and retinal pigment epithelium ( white arrowhead ).

On FFA and ICGA, the edges of the lesions must be examined carefully. On FFA, active lesions typically appear diffusely hypofluorescent in the early phase, followed by uniform diffuse hyperfluorescence in the late phase. Healed, inactive lesions appear variably hyperfluorescent with RPE “window defects.” ICGA shows “dark” hypofluorescence at the active edge, which remains completely hypofluorescent in the late phase. This is a feature of active disease, and ICGA may show more extensive involvement compared to what is visible clinically. Variable ill-defined hypofluorescence with visible underlying choroidal vessels is also signs of inactivity ( Figure 1 ). The “dark” hyporeflectivity on OCTA at the clinically visible active edges indicates regions of choriocapillaris flow deficit. Variable hypo- and hyperreflectivity at the edge or within the lesion can indicate healing or atrophic stages of the disease, but segmentation has to be critically evaluated by the operator as it often fails due to the disrupted outer retinal anatomy. It is important to note that OCTA can present with several artefacts that need careful evaluation, as they may be misinterpreted as signs of activity or CNVs. Table 1 summarizes the consensus statements with the strength of consensus.

The subcommittee members agreed that chorioretinal lesions of MFCPU/PIC are creamy and ill-defined when active, but atrophic, variably pigmented, and punched out when inactive. The activity of the lesions is preferably assessed using OCT imaging. Similar to SC, it is important to analyze all individual lesions for activity. On OCT, active lesions present with a fluffy, ill-defined subretinal hyperreflective material (SHRM) along with ellipsoid zone (EZ) disruption, which may extend beyond the borders of the lesion. There may be focal thickening of the choroid accompanying active choroiditis lesions. When the lesions are healed, the SHRM may resolve, and the lesion may appear thinned with a punched-out appearance on OCT. Disruption of the EZ/RPE can be present in active or inactive lesions. Serial OCT imaging helps identify the longitudinal course of the disease in cases with MFCPU/PIC ( Figure 2 ).

Features of active disease in multifocal choroiditis and panuveitis/ punctate inner choroidopathy on multimodal imaging. A. On color fundus photography, the active lesion appears as a creamy, ill-defined area ( white arrowhead ). B. In early-phase indocyanine green angiography, the active lesion demonstrates diffuse hypofluorescence ( white arrowhead ). C. On fundus autofluorescence imaging, the active lesion appears uniformly hypoautofluorescent ( white arrowhead ). D. On optical coherence tomography, the active lesion corresponds to fluffy, ill-defined subretinal hyperreflective material, accompanied by ellipsoid zone disruption and focal choroidal thickening ( white arrowhead ).

New, active lesions of MFCPU/PIC appear uniformly hyper-FAF, whereas completely healed lesions appear uniformly hypoautofluorescent. Occasionally, inactive but not yet completely healed lesions may have a hyperautofluorescent cuff. FFA and ICGA are less helpful in determining the activity of lesions of MFCPU and PIC, since the lesions may have variable hyperfluorescence. However, ICGA is particularly useful in detecting diffusely hypofluorescent new lesions that are not visible on clinical examination, especially those outside of the macula. Similar to FFA, OCTA does not offer utility in the determination of activity in MFCPU/PIC, but is essential to differentiate inflammatory lesions from active CNVs. Table 2 summarizes the consensus statements with the strength of consensus.

The active lesions of APMPPE are multifocal, deep, yellow, creamy, and ill-defined. They tend to become confluent over time. The subcommittee agreed that OCT imaging is useful for determining the activity of APMPPE. Active lesions are characterized by hyperreflectivity of the EZ, external limiting membrane (ELM), and notably, the outer nuclear layer (ONL). The hyperreflectivity in the ONL may align with the angular contours of the Henle fiber layer (HFL) neurons, forming the ASHH sign (“angular Sign of HFL hyper-reflectivity”). There may be underlying choriocapillaris ischemia with thickening and loss of the normal “dotted pattern” on OCT. Occasionally, active disease can present with EZ elevation and bacillary layer detachment (BALAD). Thinning of the outer retina with hyporeflectivity of the retinal layers and RPE atrophy are signs of an inactive disease. Unlike SC, assessment of activity on FAF in eyes with APMPPE may be more challenging. Early active lesions can be hypoautofluorescent on FAF with progressive hyperautofluorescence as the disease advances. Healing is characterized by a decrease in the hyperautofluorescent signal ( Figure 3 ).

Features of active disease in acute posterior multifocal placoid pigment epitheliopathy on multimodal imaging. A. On color fundus photography, the active lesion appears as a yellow, creamy, ill-defined, and deep lesion ( white arrowhead ). B. In early-phase fluorescein angiography, the active lesion demonstrates diffuse hypofluorescence ( white arrowhead ). C. In late-phase fluorescein angiography, the active lesion exhibits uniform hyperfluorescence ( white arrowhead ). D. In early phase indocyanine green angiography, the active lesion shows dark hypofluorescence ( white arrowhead ). E. In late phase indocyanine green angiography, the active lesion remains hypofluorescent ( white arrowhead ). F. On optical coherence tomography angiography, the active lesion appears as a hyporeflective flow-void area ( white arrowhead ). G. On optical coherence tomography, the active lesion colocalizes with hyperreflectivity of the ellipsoid zone and external limiting membrane, accompanied by underlying choriocapillaris thickening and hyporeflectivity ( white arrowhead ). The angular sign of Henle fiber layer hyperreflectivity (ASHH, red arrowhead ) also serves as an indicator of disease activity.

Similar to SC, on FFA and ICGA, active APMPPE is characterized by early uniform hypofluorescence. In the late phase, the active lesions are diffusely hyperfluorescent on FFA. On ICGA, active lesions have persistent hypofluorescence. Since healing is accompanied by variable hypo- and hyperfluorescent signals, both FFA and ICGA have limited utility as outcome measures for determining inactive disease ( Figure 3 ). However, OCTA assessment is useful for determining activity in APMPPE. Active lesions are characterized by hyporeflective flow deficit regions, whereas resolution of flow deficit areas on the choriocapillaris slab is indicative of healed disease. Table 3 summarizes the consensus statements for APMPPE with the strength of consensus after voting by the task force.

TABLE 3

Imaging Measures for Active and Healed Disease on Multimodal Imaging for Acute Posterior Multifocal Placoid Pigment Epitheliopathy (APMPPE)

	SAD	Consensus for SAD	SID	Consensus for SID	Equivocal Features	Consensus for Equivocal
OCT	Hyperreflectivity of EZ, ELM, ONL or ASHH and CC thickening with loss of “dotted pattern” a EZ elevation/BALAD	95.9% (strong consensus) 97.9% (strong consensus)	Thinning of OR; hyporeflectivity/ atrophy of RPE	95.9% (strong consensus)	Disruption and variable reflectivity of OR/RPE	97.9% (strong consensus)
FAF	–	–	–	–	Variable hypo- and hyper-FAF depending on disease stage	100% (unanimous consensus)
FFA	Early hypofluorescence with late diffuse hyperfluorescence b	97.9% (strong consensus)	–	–	Variable hypo- or hyperfluorescence	100% (unanimous consensus)
ICGA	Hypofluorescent lesions that persist in late phase b	83.7% (consensus)	–	–	Variable hypofluorescence	100% (unanimous consensus)
OCTA	“Dark” hyporeflective flow void areas	83.7% (consensus)	Complete resolution of flow deficit areas	100% (unanimous consensus)	–	–

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