The word ‘diagnosis’ comes from the Greek word meaning to distinguish and discern. Diagnosis encompasses both data collection and analysis of the compiled clinical information. The facts used in diagnosis come from a detailed medical history and a thorough physical examination. In the case of patients with uveitis, one must look beyond the eye for important diagnostic clues because the rheumatologic, infectious, and oncologic diseases that cause uveitis are often easier to diagnose after a careful medical history has been taken and a detailed physical examination has been performed. The ophthalmologist who does not examine the skin or joints of the patient with uveitis will miss the opportunity to correctly diagnose many cases. Observing the course of the disease as well as the response to therapy can also provide additional insights into identifying the correct causes of the disease.

A careful and detailed medical history is one of the keys to correct diagnosis in the patient with uveitis. It has been estimated that more than 90% of diagnoses can be made on the basis of the medical history alone. It is important not only to obtain a series of medical facts but also to form an impression about the overall course of the disease and its impact on the patient’s quality of life. Are there defined disease episodes, or is the condition truly chronic? Is inflammation accompanied by pain and redness, or by floaters and visual loss? In chronic disease, the level of visual disability and discomfort that is tolerable for one patient is intolerable for another, and it is important to understand the patient’s perspective before recommending therapy. In addition, some aspects of the disease can be modified by therapy but others cannot. By determining what is really bothering the patient, the physician can attempt to focus therapy on the most troublesome aspect of the disease. For example, some patients are troubled by mild conjunctival erythema and request treatment. Other patients do not like to use medications and tolerate mild redness. Importantly, the perception of visual loss differs greatly among patients. Even mild distortion in vision related to inflammation may interfere with the activities of some patients and warrant aggressive anti-inflammatory therapy. Only by fully understanding the patient and his/her relationship with the disease can the physician best counsel them and put the disorder into proper perspective.

Floaters and reduced vision are the two most common complaints of patients with inflammation of the vitreous, retina, and choroid. Most patients describe floaters as multiple small- or medium-sized spots that move as their eye moves. Other patients complain of blurred or reduced vision. In fact, when visual acuity is severely diminished, patients may be unable to visualize the floaters and may only complain of floaters as their vision starts to improve after therapy. A change in the pattern of floaters or visual impairment often signals a change in the underlying ocular disease, such as an increase in inflammation, the development of vitreous hemorrhage, or the condensation of the vitreous into a more organized opaque tissue. A careful history can also differentiate causes of brief visual impairment, such as vascular emboli, shifting subretinal fluid, or neurologic diseases such as migraine, from visual disability caused by ocular inflammatory disease.

A medical history should include a description of the patient, including age, gender, race, and occupation. The chief complaint should be succinctly stated, including the reason for the visit and the duration of the problem. The history of the present illness should then be documented, with the major symptoms in chronologic order and a definition of what makes those symptoms better or worse. A detailed past medical history, including family history, social history, and sexual history, is frequently omitted from the ophthalmic evaluation but is critical to the evaluation of the patient with uveitis. We find it extremely useful to have patients complete a uveitis medical history questionnaire before the examination; our questionnaire was developed in conjunction with Dr C. Steven Foster at the Massachusetts Eye and Ear Infirmary (see Appendix ). The questionnaire is then reviewed with the patient during the medical history, when additional questions can be asked. The survey helps to guarantee that a core of medical information is gathered for all patients and that important medical questions are not neglected. However, the clinician should realize that completed questionnaires may contain errors. It is important to clarify patient responses and to ask verbally about important aspects of the history, even if the patient denied a symptom on the questionnaire. A study by Seltzer and McDermott showed that 66% of patients who completed the same medical history questionnaire twice made at least one significant omission in their history.

Recently, electronic medical records (EMRs), also known as electronic health records (EHRs), have been incorporated into many clinical practices. The EMR can help address issues of missing records, missing critical information in the medical records, and poor legibility, and promote a more structured collection of data. Some systems use speech recognition to assist in documenting the history. Finally, computerized algorithms may help clinicians improve both diagnosis and subsequent therapy. Unfortunately, despite the potential of EMRs, adoption rates have been slow. Nevertheless, the use of this technology is increasing and should help both research and clinical care going forward.

Although uveitis rarely occurs within families, many forms of the disease, such as iritis associated with ankylosing spondylitis and birdshot retinochoroidopathy, have strong HLA associations that suggest an important inherited component. Thus it is important to recognize that autoimmune diseases may run in a family, and to document the occurrence of these diseases in other family members. Patients with uveitis may have relatives with diseases such as rheumatoid arthritis or systemic lupus erythematosus. Obtaining a social history is also important in the evaluation of the patient with uveitis. A patient’s social situation can influence not only the type and severity of the diseases he/she acquires, but also the physician’s ability to effectively treat the condition. Social problems can impede a patient’s compliance with medical or surgical therapy. Furthermore, patients who are not able to take medication reliably or to comply with frequent laboratory monitoring of hematologic and renal status are not good candidates for immunosuppressive therapy that can impair the immune system.