Fulminant proliferative vitreoretinopathy in syphilitic uveitis

Abstract

BackgroundSyphilis is a reemerging sexually transmitted disease that can lead to any type of intraocular inflammation. Prognosis of syphilitic uveitis after appropriate therapy is classically regarded as favorable. However, visual threatening complications may develop, rarely including rhegmatogenous/tractional retinal detachment (R/T RD) and proliferative vitreoretinopathy.FindingsWe report 4 patients presenting with complex R/T RD and fulminant proliferative vitreoretinopathy despite treatment among 19 patients with syphilitic posterior uveitis consecutively seen at our uveitis service. Most of these complications occurred during or shortly after antibiotic therapy. All patients presented with significant intraocular inflammation, including vitritis, occlusive retinal vasculitis, and retinal infiltrates (necrotizing retinochoroiditis in six eyes of four patients). Two patients (50 %) tested HIV positive, and the same proportion had inadvertently received high dose oral ± intravenous corticosteroids prior to diagnosis of syphilis. Two patients (three eyes) underwent RD surgical repair. Histopathology of an excised epiretinal membrane disclosed fibroglial tissue, with immature glial cells and metaplastic retinal pigment epithelium, admixed with lymphoplasmacytic infiltrate.ConclusionsSyphilitic uveitis may be complicated by complex RD/fulminant fibroglial proliferation, occurring during/after treatment. Predisposing factors are currently unknown but may include prior use of corticosteroid, necrotizing retinitis and/or high spirochaetal load. A significant inflammatory component may underlie this fulminant fibroglial proliferation, being possibly amenable to modulation by aggressive anti-inflammatory therapy delivered concurrently with parenteral antibiotics.

A Case of Syphilitic Uveitis in Which Vitreous Surgery Was Useful for the Diagnosis and Treatment

“…Among them can be seen cases like this one in which vitreous surgery was effective for proliferative changes from the obstructive retinal vasculitis. Queiroz et al [ 10 ] reported 4 cases in which proliferative retinopathy developed in the early stages following syphilis treatment and for which vitreous surgery was performed, and they identified a high rate of retinal necrotic change. Haug et al [ 11 ] report 11 cases of rhegmatogenous retinal detachment complicated with syphilitic uveitis, theorizing that retinal necrosis caused by the syphilis was the origin of the tear formation.…”

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

“…Visual prognosis in syphilitic uveitis is classically considered as favourable, with good response to adequate antibiotic therapy, 46,74,83,84 even though complications are not uncommon and poor outcome may be seen in a significant number of cases. 37,44,85 HIV coinfection is not associated with a worse visual outcome. 42,75,76,84,86 However, posterior segment complications and incidence rates of visual acuity loss, but not rates of vision loss and changes in visual acuity, are slightly more common among those with HIV infection.…”

The ghost of the great imitator: prognostic factors for poor outcome in syphilitic uveitis

“…The authors could find that baseline BCVA and initial improvement at 1 week were associated with recovery at 1 month and periocular dexamethasone injections and methylprednisolone pulses negatively affected the outcomes. However, complications might still arise after 1 month of treatment onset, as previously reported [26].…”