UNILATERAL OPTIC NEURITIS AND CENTRAL RETINAL VASCULITIS DUE TO OCULAR SYPHILIS

Prognostic effect of HIV on visual acuity in ocular syphilis: a systematic review

BACKGROUND/OBJECTIVES

Ocular syphilis is a vision-threatening disease that can lead to permanent blindness if left untreated. The global re-emergence of syphilis warrants greater investigations into the visual prognosis of eyes affected by this potentially devastating disease. This systematic review investigates the impact of HIV on visual acuity (VA) outcomes in ocular syphilis.

METHODS

A literature search of Medline, PubMed, Embase, Clinicaltrials.gov and Cochrane Reviews was conducted for studies published between 01 January 2011 and 19 March 2022, reporting non-aggregate initial and post-treatment VA data of eyes with ocular syphilis and corresponding HIV status in patients ≥ 18 years.

RESULTS

A total of 95 studies, including 364 patients and 568 eyes, were evaluated. Among people living with HIV with a diagnosis of ocular syphilis, affected eyes were more likely to have optic nerve involvement and panuveitis. However, HIV status, CD4 cell count, and HIV viral load were not predictive of VA outcomes of treated ocular syphilis. Prognostic factors of final VA worse than 1.00 logMAR were female sex, the presence of macular edema, and VA ≥ 1.00 at presentation. The strongest predictor of a worse final VA was VA ≥ 1.00 at presentation.

CONCLUSIONS

This systematic review demonstrates that HIV status, CD4 cell count, and HIV viral load are not significant factors impacting VA outcomes of eyes with ocular syphilis. While visual prognosis is generally good, poor visual outcome is most strongly predicted by poor VA at presentation. This underscores the importance of early recognition and treatment prior to permanent vision loss.

Assessment of Visual Acuity Outcomes in Ocular Syphilis Treated With Adjunctive Topical or Oral Steroids

PURPOSE

There is no consensus surrounding adjunctive steroid use in the treatment of ocular syphilis. We evaluated clinical outcomes of patients with ocular syphilis who were treated with penicillin plus either topical or oral steroids.

METHODS

Nine male patients aged 26 to 72 years with a diagnosis of ocular syphilis were retrospectively identified (18 eyes). All patients were treated with penicillin and adjunctive topical or oral steroids. Visual acuity reported as the logarithm of the minimum angle of resolution (logMAR) and slit lamp findings were documented at presentation, short-term follow-up (<7 days after initiating therapy), and long-term follow-up (day 7+). Visual acuity outcomes were compared between eyes treated with topical versus oral steroids as well as eyes treated simultaneously with adjunctive steroids and penicillin versus patients treated with steroids after penicillin.

RESULTS

At short-term follow-up, the mean logMAR (SD, Snellen fraction) visual acuity for eyes treated with topical steroids 0.93 (0.53, 20/170) was significantly lower than that for the oral steroid group 0.23 (0.09, 20/110; p=0.0075). Similarly, at long-term follow-up, the topical steroid group had a significantly lower visual acuity of 0.75 (20/112) compared to a visual acuity of 0.07 (20/25) for the oral steroid group (p=0.0022). Moreover, the oral steroid group displayed significant improvement in visual acuity at long-term follow-up compared to baseline while the topical steroid group did not demonstrate the same effect (p=0.0406 and p=0.5945, respectively). Initiation of steroid treatment simultaneously with penicillin did not result in better visual acuity than delayed steroid treatment (p>0.05).

CONCLUSIONS

Steroids are an effective adjunctive treatment for patients with ocular syphilis. Oral steroids may be superior to topical steroids for improving visual function, especially in patients with a severe inflammatory component. Patients treated with oral or topical steroids and penicillin simultaneously did not demonstrate better visual acuity outcomes than patients treated with oral or topical steroids after penicillin was initiated.

Bilateral exudative retinal detachment in undiagnosed ocular syphilis after treatment with corticosteroids

A case of a young Caucasian male who presented bilateral papilledema is described. He was misdiagnosed with bilateral anterior optic neuritis, developing panuveitis and exudative bilateral retinal detachment after being treated with megadoses of corticosteroids. He was finally diagnosed with ocular syphilis and treated with intravenous aqueous crystalline penicillin for 14 days, with complete resolution of his symptoms.

Effect of intravitreal triamcinolone acetonide injection at the end of vitrectomy for vitreous haemorrhage related to proliferative diabetic retinopathy

Background/Aims

To investigate whether intravitreal injection of triamcinolone acetonide (IVTA) combined with vitrectomy prevents postoperative inflammation in patients with vitreous haemorrhage (VH) due to proliferative diabetic retinopathy (PDR).

Methods

This prospective, multicentre, randomised study conducted at seven sites in Japan enrolled patients diagnosed as having VH following PDR. Patients underwent vitrectomy with (IVTA+VIT group) or without (VIT group) IVTA at the end of the surgery. Anterior flare intensity (AFI), central retinal thickness (CRT), best-corrected visual acuity (BCVA) and intraocular pressure (IOP) were measured before and at 3 days, 1 week, 1, 3 and 6 months after surgery and compared.

Results

Number of patients who completed 6 months of follow-up was 40 and 41 in VIT group and IVTA+VIT group, respectively. AFI was significantly higher in the VIT group than in the IVTA+VIT group at 3 days (P=0.033), 1 week (P=0.019) and 1 month (P=0.037). There were no significant differences in CRT, BCVA and IOP between the groups through the observational periods. In the cases with macular oedema >350 µm of CRT at 3 days, CRT was significantly lower in the IVTA+VIT group than in the VIT group at 1 month (P=0.041).

Conclusions

IVTA combined with vitrectomy and cataract surgery contributed to inhibit the postoperative inflammation in patients with VH due to PDR. The effect of IVTA in the reduction of diabetic macular oedema may be limited to the early stage after surgery.

Trial registration number

UMIN000020376, Post-results.