Rhegmatogenous Retinal Detachment in Syphilitic Uveitis: A Case Series and Comprehensive Review of the Literature

PURPOSE

Uveitis is the most common ocular manifestation of syphilis. However, an association between syphilitic uveitis and rhegmatogenous retinal detachment (RRD) is not widely recognized. We report a consecutive series of six new cases of syphilitic uveitis complicated by RRD and describe the typical characteristics, clinical course, and surgical management of such cases.

METHODS

Consecutive case series and comprehensive review of the literature.

RESULTS

We identified a total of 19 cases (23 eyes) with syphilitic uveitis subsequently complicated by RRD, including six new cases (seven eyes) reported here and 13 cases (16 eyes) previously reported in the literature. Fifteen patients (79%) were positive for human immunodeficiency virus (HIV) and not on combination antiretroviral therapy. Most retinal detachments developed within two months of uveitis presentation; retinal breaks were often found in areas of previous retinitis. Sixteen eyes (70%) were complicated by early proliferative vitreoretinopathy. Twenty-one eyes underwent surgical repair, of which six (26%) suffered re-detachment. Surgical management commonly involved pars-plana vitrectomy and silicone oil tamponade, with or without scleral buckling. Visual outcomes were generally poor: only six eyes (26%) attained visual acuity of 20/40 or better and 11 eyes (48%) remained 20/200 or worse.

CONCLUSIONS

Patients with syphilitic uveitis, as with viral retinitis, should be monitored closely for the development of retinal tears and RRD. A combination of pars plana vitrectomy with silicone oil tamponade and/or scleral buckle placement is a prudent surgical approach to most cases of syphilitic RRD, although visual prognosis remains guarded.

Fulminant proliferative vitreoretinopathy in syphilitic uveitis

BACKGROUND

Syphilis 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.

FINDINGS

We 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.

CONCLUSIONS

Syphilitic 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.

Rhegmatogenous Retinal Detachment in Patients with Acute Syphilitic Panuveitis

PURPOSE

To describe the clinical characteristics and surgical management of rhegmatogenous retinal detachment (RD) in patients with acute syphilitic panuveitis.

METHODS

Retrospective case series and comprehensive literature review.

RESULTS

Including present and previously reported cases, we identified 11 eyes in 8 patients with acute syphilitic panuveitis that developed a rhegmatogenous RD. Seven of 11 eyes (63.6%) were repaired with a combined scleral buckling, vitrectomy, and endolaser photocoagulation surgery; 1 eye (9.1%) was repaired with scleral buckling only; and 2 eyes (18.2%) with vitrectomy only. Cryotherapy was used to treat a giant retinal tear in 1 eye (9.1%). Four eyes (36.4%) redetached and 3 underwent a second vitrectomy surgery.

CONCLUSIONS

Although uncommon, rhegmatogenous RD can occur in patients with moderate to severe acute syphilitic panuveitis. We believe scleral buckling, vitrectomy, endolaser photocoagulation, and silicone oil tamponade give the best chance for successful retinal reattachment.

[Bilateral panuveitis with papillary swelling]

Lues (syphilis) is a chronic cyclic infectious disease which can continue for decades if untreated. A simultaneous HIV infection can result in false negative results in serological tests for lues. The occurrence of neurolues has frequently been described in HIV positive patients. In the differential diagnosis an early ocular manifestion of lues should be considered. A 40-year-old homosexual patient presented in our hospital with bilateral pain-free increasing loss of vision. The ophthalmological examination revealed an intermediately expressed panuveitis with streaky opacity of the vitreous body and pronounced bilateral papillary swelling. Following systemic anti-inflammatory therapy with cortisone the situation worsened after initial improvement. The serological investigations revealed both HIV and lues infections. Intravenous therapy with mega units of penicillin led to a slow improvement of clinical symptoms and also vision. In cases of uveitis of unclear origin together with a HIV infection and suspected lues, regular serological testing should be carried out because the occurrence of late complications of lues can be avoided by the diagnosis of lues and adequate treatment.

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.

Rhegmatogenous retinal detachment and uveitis

PURPOSE

To evaluate the frequency, high-risk factors, and visual prognosis of rhegmatogenous retinal detachment (RRD) in patients with uveitis.

DESIGN

Retrospective case-control study.

PARTICIPANTS

We included 1387 consecutive patients with uveitis who consulted our uveitis clinic from January 1990 through December 1997 of whom 43 patients (46 eyes) with RRD were identified. The retinal detachment (RD) controls were 212 consecutive patients with RRD (221 eyes, first occurrence of RD, not associated with uveitis) who were admitted for surgery in the period from April 1999 to April 2000. The uveitis control group consisted of 150 age-matched patients (210 eyes) selected from the entire uveitis series.

INTERVENTION

Retrospective analysis of clinical data.

MAIN OUTCOME MEASURES

The presence of RRD and eventual risk factors for RRD, such as myopia, retinal lattice degeneration, prior intraocular surgery, anatomic location of uveitis, its specific diagnosis, and clinical manifestations. Furthermore, the surgical and nonsurgical outcomes of RRD, as well as the results of various treatment regimens, were analyzed.

RESULTS

RRD was identified in 3.1% of the patients with uveitis. RRD was most frequently associated with panuveitis (6.6%). RRD was associated more frequently with infectious (7.6%) than noninfectious uveitis (2.1%). At the onset of RRD, uveitis was active in most (46%) affected eyes. Proliferative vitreoretinopathy was present in 30% of the uveitic RRD eyes at presentation in contrast to 12% of the RRD control eyes. In uveitic RRD, the retina was reattached in 59% of eyes with a single operation; the final anatomic reattachment rate was 88%. Finally, a visual acuity of less than 20/200 was present in 71% of the uveitic RRD eyes, 10% of which had no light perception.

CONCLUSIONS

We discovered a high prevalence of RRD in patients with active panuveitis and infectious uveitis and document that uveitis in itself is a risk factor for the development of RRD. The visual prognosis of RRD in uveitis was poor because of the uveitis itself and the frequent development of proliferative vitreoretinopathy.