Non-human Immunodeficiency Virus-related Ocular Syphilis in a Korean Population: Clinical Manifestations and Treatment Outcomes

Abstract

Purpose: To describe the clinical manifestations and treatment outcomes of ocular syphilis in patients without human immunodeficiency virus (HIV) infection.

Methods: A total of 45 eyes from 39 patients with ocular syphilis confirmed by serologic tests were reviewed retrospectively. The included cases were all non-HIV-infected patients presenting with intraocular inflammation from 2002 to 2014 at Kyung Hee University Hospital. Medical records of 45 eyes were analyzed and included best-corrected visual acuity and ophthalmologic examination findings of the anterior and posterior segments to determine the focus of inflammation. Optical coherence tomography and fluorescein angiography findings as well as both medical and surgical management were also analyzed.

Results: The mean patient age was 61.0 years (range, 37 to 89 years). Bilateral ocular involvement occurred in 6 patients (15.4%), and diagnoses at presentation were most frequently related to posterior uveitis (38%), followed by panuveitis (29%) and optic neuritis (11%). Isolated interstitial keratitis and intermediate uveitis were uncommon (4%, both). Twenty-eight eyes (62.2%) were treated with penicillin, and 11 eyes (24.4%) underwent surgical treatment. The mean baseline best corrected visual acuity was 0.79 ± 0.59 (mean ± standard deviation, logarithm of the minimum angle of resolution) and significantly improved to 0.60 ± 0.63 at the final follow-up after treatment (p = 0.019). Mean visual improvement was significantly greater in the penicillin-treated group (p = 0.001). Visual impairment at the final visit occurred in 11 eyes (24.4%). Among the visual impairment group, 10 eyes (90.1%) had posterior segment-involving uveitis.

Conclusions: Visual outcomes of treated, non-HIV-related ocular syphilis were favorable regardless of time to presentation. Posterior segment-involving uveitis at presentation was associated with poor visual outcome.

Keywords: Human immunodeficiency virus; Penicillins; Syphilis; Uveitis.

Fig. 1. The annual distribution of ocular syphilis cases. The peak incidence was found in 2004, after which the number of cases decreased.

Fig. 2. Fundus photograph (A) and fluorescein angiography (B) of a syphilitic posterior uveitis case at presentation. (A) Uniform distribution of outer retinal and inner choroidal inflammation with opacification in a discrete oval or circular area of the posterior pole presenting as acute syphilitic posterior placoid chorioretinitis. (B) Mid-phase fluorescein angiography showing diffuse vascular leakage in the same area of opacification.

Fig. 3. The frequencies of diagnoses at presentation in patients with ocular syphilis.

Fig. 4. Changes in mean best-corrected visual acuity (BCVA) according to penicillin treatment (Tx). Mean BCVA was significantly increased from baseline acuity 1 month after treatment in both penicillin-treated and total eyes. Eyes without penicillin treatment showed no significant improvement in BCVA throughout the follow up visits. logMAR = logarithm of the minimum angle of resolution. ^*Significantly different from baseline, p < 0.05.

Fig. 5. Changes in mean best-corrected visual acuity (BCVA) according to treatment other than administration of penicillin. Mean BCVA in both vitrectomy and intravitreal injection groups was significantly worse than the BCVA of the eyes after treatment. Mean BCVA of the intravitreal injection group showed a significant decrease 6 months after treatment. logMAR = logarithm of the minimum angle of resolution. ^*Significantly worse than the BCVA of all eyes; ^†Significantly worse than baseline BCVA, p < 0.05.