Ocular Manifestations and Treatment of Syphilis

Syphilis is a sexually transmitted, chronic, systemic infection caused by the spirochete Treponema pallidum. If left untreated, the disease progresses through four stages, with the potential to cause significant morbidity to any major organ of the body. Frequent syphilitic ocular manifestations, which can occur at any stage of the disease, include interstitial keratitis, anterior, intermediate, and posterior uveitis, chorioretinitis, retinitis, retinal vasculitis and cranial nerve and optic neuropathies. Diagnosis is centered around a high level of clinical suspicion and includes treponemal specific and non-treponemal serologic tests. All patients with newly diagnosed syphilis should be tested for co-infection with human immunodeficiency virus, as the risk factors are similar for both diseases. Additionally, all patients with ocular syphilis should be tested for neurosyphilis. The preferred treatment for all stages of syphilis remains parenteral penicillin G. With proper diagnosis and prompt antibiotic treatment, the majority of cases of syphilis can result in a cure.     

Melanin-Laden Macrophages in the CSF to Diagnose Vogt-Koyanagi-Harada Simulating Ocular Syphilis

Purpose: To describe a case of Vogt-Koyanagi-Harada (VKH) disease initially presenting as ocular syphilis. Methods: A 51-year-old woman presented with counting fingers vision in both eyes. She underwent a complete ophthalmic examination, serological testing, fluorescein angiography, and CSF analysis. Results: Serological testing revealed positive titers for syphilis. Fluorescein angiography demonstrated findings suggesting VKH. CSF cytology showed macrophages containing melanin granules consistent with VKH. Subsequent treatment with corticosteroids and cyclosporine resulted in significant improvement of vision. Conclusion: The presence of melanin-laden macrophages within the CSF allows for the differentiation of VKH from ocular syphilis.     

Use of Lumbar Punctures in the Management of Ocular Syphilis

Purpose: Ocular syphilis has become rare in the developed world, but is a common presentation to ophthalmology departments in South Africa. We investigated the proportion of patients diagnosed with ocular syphilis who went on to receive lumbar punctures, and determined the fraction of these who had cerebrospinal fluid findings suggestive of neurosyphilis. We aimed to determine whether the use of lumbar punctures in ocular syphilis patients was beneficial in picking up cases of neurosyphilis. Methods: Retrospective study of case notes of patients admitted to two district hospitals in Durban, South Africa, with ocular syphilis over a 20-month period. Results: A total of 31 of 68 ocular syphilis patients underwent lumbar puncture, and of these, eight (25.8%) had findings suggestive of neurosyphilis. Conclusions: Lumbar puncture in ocular syphilis patients should continue to be a routine part of the investigation of these patients; a large proportion of ocular syphilis patients show cerebrospinal fluid findings suggestive of neurosyphilis, are at risk of the complications of neurosyphilis, and should be managed accordingly.     

Double Trouble: Challenges in the Diagnosis and Management of Ocular Syphilis in HIV-infected Individuals

ABSTRACT

Syphilis and HIV infection may coexist in the same individual. Ocular syphilis and/or neurosyphilis may develop at any stage of coinfection, with a stronger association between ocular and neurosyphilis in individuals living with HIV, than in HIV-uninfected individuals. The diagnosis of ocular syphilis in HIV-infected and -uninfected patients remains with some controversy due to unspecific clinical manifestations and limited diagnostic tests. Penicillin is the mainstay of treatment of ocular syphilis, but alternative options are warranted. This review describes the epidemiology, pathophysiology, and clinical manifestations, as well as the diagnostic and therapeutic challenges posed by ocular syphilis against the background of HIV coinfection.     

Immunoblot and Polymerase Chain Reaction to Diagnose Ocular Syphilis and Neurosyphilis in HIV-positive and HIV-negative Patients

ABSTRACT

Purpose: To evaluate immunoblot (IB) and polymerase chain reaction (PCR) to diagnose ocular- and neurosyphilis.

Methods: Prospective cross-sectional study. Aqueous humor (AH) and cerebrospinal fluid (CSF) samples were tested for treponemal DNA or antibodies to treponemal antigens.

Results: Thirteen of 106 cases had positive syphilis serology of which 69.2% were HIV+ (median CD4+ = 181 cells/µL). Four cases met CDC criteria for neurosyphilis (3 confirmed, 1 probable) and 2 additional cases required neurosyphilis treatment according to UpToDate algorithms. All AH and CSF samples tested PCR negative. Five cases were CSF IB+ and 3 cases AH IB+. Using our classification, eight patients had confirmed neurosyphilis, one had probable neurosyphilis, three had confirmed ocular syphilis and nine had probable ocular syphilis.

Conclusion: Our findings suggest that IB of AH and CSF provides additional evidence to diagnose ocular and neurosyphilis and allows us to classify them as probable or confirmed.     

Cytokine Profiles in Aqueous Humor and Plasma of HIV-infected Individuals with Ocular Syphilis or Cytomegalovirus Retinitis

Purpose: To characterize the immunologic profile in aqueous humor (AqH) of HIV-infected individuals with cytomegalovirus retinitis (CMVr) or ocular syphilis and to assess if AqH and plasma represent independent cytokine compartments.

Methods: Concentrations of 27 cytokines in AqH and plasma of HIV-infected individuals with CMVr (n = 23) or ocular syphilis (n = 16) were measured by multiplex assay. Cytokine profiles of both groups were compared.

Results: Individuals with CMVr had higher plasma concentrations of interleukin (IL)-7, IL-8, IL-10, interferon (IFN)-γ, IFN-α2, G-CSF, IP-10 and IL-1α; as well as higher AqH concentrations of IL-1α, IP-10 and GM-CSF than those with ocular syphilis. AqH and plasma levels correlated only for IP-10 in both ocular infections.

Conclusions: Individuals with CMVr had higher plasma cytokine levels than those with ocular syphilis. The immunologic profiles in AqH and plasma are independent. Therefore, AqH cytokine concentrations cannot be inferred from plasma cytokine concentrations in the population studied.     

Ocular Syphilis: An Update

This review aims to provide an update on the clinical presentation, diagnosis, and treatment of ocular syphilis. While ocular syphilis is not a new phenomenon, recent resurgence in the incidence of overall syphilis, particularly among HIV-positive individuals, has sparked a new interest in an old disease. The challenge of ocular syphilis is manifold: firstly, it manifests in a spectrum of ways that can occur at any stage of the disease, with the most common finding being panuveitis. It may occur as early as 6 weeks after transmission and may be the only presenting feature of systemic syphilis; secondly, the relationship between HIV and syphilis has been established, as primary syphilis facilitates HIV transmission and HIV may modify the natural course of syphilis, increasing the propensity of the disease to progress to neurosyphilis. The authors present the latest updates to the changing landscape of ocular syphilis.     

多发性硬化的眼部表现及长期观察

在１２８例具有眼部青现的多发性硬化中，长期随访了６４例，对视力、眼底、视野、ＶＥＰ、球眼运动及复视、眼球震颤、上睑下垂进行了长期观察，平均随访８、８年。ＭＳ的眼部病变多数预后良好，少数视功能丧失久性致盲。提出关于本病的误诊应引起眼科医师和神经医师的双向注意。     

梅毒性眼病的临床分析

目的：探讨以眼后节表现为主的梅毒性眼病的临床特点。

方法：回顾性病例研究。回顾性分析2007-01/2012-01本院收治的首诊于眼科的梅毒性眼病13例23眼,分析其临床表现、治疗方法、预后等。13例患者按神经梅毒除1例因青霉素过敏予静滴头孢曲松治疗,其余全部予静滴青霉素治疗。

结果：患者13例中,9例17眼患者表现为脉络膜视网膜炎,2例3眼患者表现为视神经视网膜炎,1例1眼患者表现为视神经炎,1例2眼患者表现为渗出性视网膜脱离。抗梅毒治疗后,所有炎症消退,12例22眼患者视力提高,平均视力0.56±0.23。患者RPR滴度下降4倍,平均1：16.6。

结论：梅毒性眼病表现多样,容易漏诊、误诊,临床上应提高警惕,及早发现,及早治疗。     

Ocular syphilis resurgence in an urban underserved community in the United States

AIM: To evaluate the clinical characteristics, demographics, and visual outcomes of patients with ocular syphilis at an urban hospital to increase awareness and assist in earlier diagnosis and treatment of the resurgent disease.METHODS: A retrospective chart review was performed on patients with ICD-9 and ICD-10 diagnosis codes correlating with syphilis or syphilis-related ocular diseases between 2010 and 2019. Variables evaluated included age, gender, race, vision, ocular findings, human immunodeficiency virus (HIV) status and men who have sex with men status, recreational drug and alcohol use.RESULTS: Ocular syphilis was diagnosed in 40 patients (53 eyes) of a total of 229 patients who tested positive for syphilis via serum and/or cerebrospinal fluid treponemal testing from 2010-2019. Among patients with ocular syphilis, most patients were males, aged 45 or above and Black, and had no diagnosed HIV infection. Approximately 50% patients had 20/40 vision or better. Nearly 50% had non-granulomatous anterior uveitis as their initial presentation, and 49% of patients had involvement of the posterior segment. Neovascular glaucoma (5.7%), papillitis (7.5%), vasculitis (5.7%), and retinal detachment (5.7%) were rarer presentations of the disease and were associated with a poorer visual prognosis.CONCLUSION: Given the increased prevalence and protean manifestations of syphilis, early diagnosis and treatment are paramount. More studies on ocular syphilis are warranted to understand this resurging disease.     

Wegener's Granulomatosis: Clinical Manifestations, Differential Diagnosis, and Management of Ocular and Systemic Disease

Wegener's granulomatosis (WG) is a systemic inflammatory disease whose histopathologic features often include necrosis, granuloma formation, and vasculitis of small-to-medium-sized vessels. WG involves many interrelated pathogenic pathways that are genetic, cell-mediated, neutrophil-mediated, humoral, and environmental. WG most commonly involves the upper respiratory tract, lungs, and kidneys, but has been reported to affect almost any organ. Ophthalmologic involvement is an important cause of morbidity in WG patients, occurring in approximately one-half of patients. The presence of unexplained orbital inflammatory disease, scleritis, peripheral ulcerative keratitis, cicatricial conjunctivitis, nasolacrimal duct stenosis, retinal vascular occlusion, or infrequently uveitis should raise the question of possible WG. A thorough clinical examination, laboratory testing, radiologic imaging, and histologic examination are essential to diagnosing WG and excluding potential mimics. Previously a uniformly fatal disease, treatment with cytotoxic and immunosuppressive agents has greatly improved survival. Treatment-related morbidity is a serious limitation of conventional therapies, leading to numerous ongoing studies of alternative agents.     

Clinical Manifestations and Outcomes of Syphilis-associated Uveitis in Northern Spain

Purpose: To describe the clinical characteristics and to assess visual prognosis of patients with syphilis-associated uveitis in northern Spain.

Methods: Retrospective review of clinical records in eight general uveitis referral centers.

Results: Since the year 2000, 50 patients have been diagnosed: 31 men and 19 women; median age was 41 (19–76) years. A total of 34% were co-infected with HIV and 24% presented systemic manifestations of syphilis. Median initial visual acuity and vision at last visit in 93 affected eyes was 20/50 (20/20–20/2000) and 20/22 (20/20–20/2000), respectively (p?p?=?0.009).

Conclusions: In our series, patients with syphilitic uveitis were more usually middle-aged men and were frequently co-infected with HIV. Although most patients showed posterior segment involvement, visual prognosis was good.     

Ocular Manifestations of Sickle Cell Disease: Signs,Symptoms and Complications

ABSTRACT

Background

Sickle cell disease is an inherited hematological disorder that can affect any organ in the body including the eyes (1–6). Previous studies on ocular manifestations of sickle cell disease generally included samples of less than 100 patients. In this study, we aim to assess the frequency of different ocular signs, symptoms and complications among sickle cell disease patients.     

Quantification of Ocular Biomechanics In Ocular Manifestations of Systemic Autoimmune Diseases

Purpose: To quantify biomechanical change associated with autoimmune diseases using Corvis ST deformation data.

Methods: Cross-sectional, observational, case control study of 76 patients with systemic autoimmune disease and 21 control subjects. All patients underwent detailed ophthalmic examination with Corvis-ST (Oculus Optikgerate Gmbh, Germany) measurements for biomechanical properties of the eye.

Corneal deformation and also deformation caused by the extracorneal tissue were recorded. Using a mathematical formula, the three parameters, namely, corneal stiffness (kc), extracorneal tissue stiffness (kg), and extracorneal tissue viscosity (μg), were defined.

Results: The biomechanical analysis showed that kc and μg were significantly lower in patients with systemic autoimmune disease with eye manifestations than control group. However statistically, it was significant in rheumatoid arthritis (RA) patients only.

Conclusion: The new parameters, namely, kc, kg, and μg, can provide a sensitive marker of the ocular activity of the collagen vascular diseases.     

Clinical Features and Prognosis in Ocular Toxoplasmosis

Purpose To evaluate retrospectively the clinical characteristics, complications, and prognosis in patients with ocular toxoplasmosis.Patients and Methods We reviewed the records of 189 patients (243 eyes) with ocular toxoplasmosis who were examined between 1972 and 1999. Color fundus photography and, in some patients, fluorescein angiography and indocyanine green angiography were performed. There were 98 male (52%) and 91 female (48%) patients with a mean age of 22.8 ± 8.9 years.Results Of the patients, 140 (74%) had congenital and 49 (26%) had acquired toxoplasmosis. At the initial examination, there were active lesions in 65 eyes and inactive lesions in 178 eyes. Active lesions included retinochoroiditis in 59 (91%), papillitis in 2 (3%), and neuroretinitis in 4 (6%) eyes. There was also an inactive scar in 17 eyes with active retinochoroiditis. Localisation of the active retinochoroiditis was the macula in 44 (74%), the macula and peripheral retina in 3 (5%), the peripheral retina in 9 (15%) and the peripapillary retina in 3 (5%) eyes. Optic atrophy, pigment epithelial detachment, choroidal neovascularization, lamellar macular hole, and retinal neovascularization were seen during the follow-up period.Conclusions Ocular toxoplasmosis commonly affects the macula and seriously impairs visual acuity. The prevention of acquired and congenital infections is very important in controlling ocular toxoplasmosis. Patients should be followed to avoid late complications. Jpn J Ophthalmol 2004;48:386–391 © Japanese Ophthalmological Society 2004This study was an oral presentation at the International Symposium on Ocular Inflammation VI, June 18–23, 2000, Istanbul, Turkey.     

Simultaneous Bilateral Exudative Retinal Detachment and Peripheral Necrotizing Retinitis as Presenting Manifestations of Concurrent HIV and Syphilis Infection

Purpose: To describe an unusual case of simultaneous bilateral exudative retinal detachment and peripheral necrotizing retinitis as presenting manifestations of concurrent HIV and syphilis infection. Case report: A previously healthy 35-year-old Caucasian male was first seen for bilateral sudden visual loss. Ophthalmoscopy showed bilateral exudative retinal detachment involving the posterior pole and a placoid-like area of peripheral necrotizing retinitis in his left eye. Physical examination revealed anal condylomata and aphthous oral lesions. Laboratory investigations confirmed the diagnosis of concurrent HIV and syphilis infection. Ocular lesions resolved in response to anti-syphilitic medication administered for three weeks. Discussion: This case demonstrates the importance of considering syphilis as a cause of atypical retinitis in the HIV-positive population.