Multiple evanescent white dot syndrome: Typical, atypical, and secondary variants

Multiple Evanescent White Dot Syndrome (MEWDS) is a primary outer retinal inflammatory disorder, classically presenting as an acute, unilateral, self-limiting condition in young to middle-aged adults. It is characterized by multiple small white spots at the posterior pole, foveal granularity, wreath-like hyperfluorescence on fluorescein angiography, and a "dot-over-spot" hypofluorescent pattern on late-phase indocyanine green angiography. This PRISMA-compliant systematic review analyzed 592 eyes from 240 publications, supplemented by an institutional case series. While most cases conformed to the typical phenotype (62 %), nearly one-third were atypical (20 %) or secondary (18 %) to other chorioretinal diseases. Atypical forms included bilateral or recurrent presentations, distinctive angiographic patterns, or absence of spontaneous recovery with permanent structural damage. We also identified a previously unreported phenotype in older adults, featuring confluent hyperautofluorescence extending into the mid-periphery and hyperreflective outer retinal lesions, often with subacute worsening and partial steroid responsiveness. Secondary MEWDS occurred in association with various chorioretinal disorders, most commonly punctate inner choroiditis. Collectively, these findings support viewing MEWDS within the broader spectrum of outer retinal disorders sharing photoreceptor pathology but differing in triggers, imaging signatures, and outcomes. Recognition of atypical and secondary variants is essential for accurate diagnosis, risk stratification, and tailored management.