Pyramidal Inflammatory Deposits of the Retinal Pigment Epithelium and Outer Retina in Ocular Syphilis

Abstract

Purpose: To evaluate the role of OCT in the diagnosis of uveitis secondary to syphilis.

Design: Consecutive, retrospective case series.

Participants: All patients 18 years of age or older with ocular syphilis from 2 tertiary referral centers.

Methods: All patients who were diagnosed with intermediate uveitis, posterior uveitis, or panuveitis secondary to syphilis were included in the study (40 patients representing a total of 62 eyes) to identify important imaging features to aid in diagnosis. Patients underwent confirmatory serologic testing, OCT imaging, and dilated examination by a uveitis specialist.

Main outcome measure: Hyperreflective retinal lesions on OCT.

Results: The mean age of the study population was 42.9 ± 12.16 years. Forty-five percent of the eyes included in this study harbored hyperreflective pyramidal lesions of the outer retina and retinal pigment epithelium on OCT. Fifty-four percent of eyes with these imaging findings did not show a placoid retinal lesion on examination. Sixty-eighty percent of the described outer retinal lesions on OCT resolved after treatment for syphilis. Visual acuity ranged from normal (20/20) to no light perception, with a mean of 20/43 at diagnosis, and improved significantly to a mean visual acuity of 20/26 after treatment (P < 0.05). Vision-threatening complications were seen in less than 5% of eyes and included both treatable and irreversible causes of vision loss, including retinal detachment, cystoid macular edema, and optic neuropathy.

Conclusions: Patients treated for uveitis secondary to syphilis achieve good visual recoveries. Outer retinal lesions seen on OCT are common and can serve as an additional imaging finding of the disease.

Keywords: Neurosyphilis; Ocular syphilis; Outer retina; Syphilis; Uveitis.

Figure 1.

A, B, OCT scans showing pyramidal lesions of the retinal pigment epithelium and outer retina that then resolved after treatment of syphilis (B-scans from same retinal location). The location of the lesions is depicted by black arrows in(A) and their approximate location after treatment in (B). The white asterisk indicates vitreous inflammatory cells before treatment.

Figure 2.

Images showing pyramidal lesions and their association with acute syphilitic posterior placoid chorioretinitis (ASPPC). A, fundus photograph showing an eye with large yellowish placoid lesions of the fundus (yellow arrow). B, Fundus autofluorescence image showing that these lesions (yellow arrow) were hyperautofluorescent, consistent with ASPPC. C, OCT image showing pyramidal lesions of the retinal pigment epithelium (RPE) and outer retina (red arrows). D, Fundus photograph of an eye without a yellowish placoid lesion. E, Fundus autofluorescence image showing the eye that lacked corresponding hyperautofluorescence. F, OCT image showing these hyperreflective pyramidal lesions of the RPE and outer retina (red arrows).

Figure 3.

OCT images showing resolution of pyramidal lesions after a second intravenous (IV) penicillin G (PCN) treatment. The hyperreflective pyramidal lesions of the retinal pigment epithelium and outerretina on OCT at 8, 8.5, 9.5, and 12 months after a 2-week course of IV PCN that then resolved within 2 weeks after a second syphilis treatment (8.5-month time point). The location of the lesions is depicted by black arrows throughout time. Dotted line indicates the time of the second treatment.

Figure 4.

Visual outcomes and ocular complications. A, Box-and-whisker plot showing visual acuities as measured on a Snellen eye chart before and after treatment for ocular syphilis, with the mean visual acuity depicted by the solid black line. B, Bar graph showing the percentage of eyes in which visual acuity improved, declined by 1 line or more, or remained unchanged after treatment. C, Bar graph showing the percentage of eyes with complications resulting in both permanent and irreversible vision loss then recorded. *P < 0.05.