Recent reports from different world regions suggest ocular syphilis is re-emerging, in parallel with an increasing incidence of the systemic infection globally. We conducted a large observational study of 127 persons consecutively treated for ocular syphilis at public medical centers in Brazil over a 2.5-year period ending July 2015. Of 104 individuals serologically tested for human immunodeficiency virus (HIV), 34.6% were positive. Ophthalmological evaluations included measurement of Snellen visual acuity and intraocular pressure, and assessment of inflammation by slit lamp examination and dilated posterior eye examination. Involvements in 214 eyes were anterior (6.1%), intermediate (8.4%), posterior (76.2%) and pan- (8.4%) uveitis, and scleritis (0.9%). Multiple anterior and posterior eye complications were observed, including cataract in the anterior eye (incidence rate, 0.18/eye-year) and epiretinal membrane in the posterior eye (incidence rate, 0.09/eye-year); incidence rates of reduction in best-corrected visual acuity to ≤20/50 and ≤20/200 were 0.10 and 0.06/eye-year, respectively. Rates of complications and visual acuity loss did not differ significantly between HIV- positive and negative individuals. In an era of re-emergence, syphilis has ocular complications that may compromise vision, despite treatment with appropriate anti-microbial drugs.

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Syphilis and HIV infection may coexist in the same individual. Ocular syphilis and/or neurosyphilis may develop at any stage of coinfection, with a stronger association between ocular and neurosyphilis in individuals living with HIV, than in HIV-uninfected individuals.The diagnosis of ocular syphilis in HIV-infected and -uninfected patients remains with some controversy due to unspecific clinical manifestations and limited diagnostic tests. Penicillin is the mainstay of treatment of ocular syphilis, but alternative options are warranted. This review describes the epidemiology, pathophysiology and clinical manifestations, as well as the diagnostic and therapeutic challenges posed by ocular syphilis against the background of HIV coinfection.

BackgroundSyphilitic uveitis is reemerging globally, may lead to any type of intraocular inflammation, and is potentially sight-threatening. We aim to characterize clinical features and prognostic factors in patients with syphilitic posterior uveitis.MethodsRetrospective chart review at two tertiary university-based referral centers in Brazil. Clinical data, laboratory results, and treatment outcomes were analyzed. Statistical analysis was performed using Fisher’s exact test for categorical variables and Mann-Whitney U test for continuous variables.ResultsForty-four patients (81 eyes) were consecutively diagnosed with syphilitic posterior uveitis between March 2011 and April 2013.Thirty-one were male (70.5%) and the mean age was 43.8 years (range 15–81). HIV confection was disclosed in 12 patients (29.3%). The most prevalent finding was vitritis (85.2%), followed by retinal involvement (76.4%) and optic disc abnormalities (63.5%). After treatment, mean visual acuity improved from 1.2 (20/320) to 0.6 (20/80; median 20/30), but 19 eyes (23.5%) persisted with ≤ 1.0 (20/200). Factors associated with final visual acuity ≤ 1.0 despite therapy were prior use of systemic corticosteroids (p = 0.001), higher Venereal Disease Research Laboratory titers (p = 0.004), longer duration of symptoms (p = 0.024), and worse initial VA (p < 0.001).ConclusionsSyphilitic uveitis is reemerging. Delayed diagnosis and inadvertent use of systemic corticosteroids are potentially modifiable prognostic factors to be considered for possibly improving outcomes.

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.

This Article contains an error in the Methods section. "(2) an abnormal CSF (i.e. reactive VDRL and/or greater than 4 leukocytes/mm 3 and protein concentration less than 40 mg/dl);" should read: "(2) an abnormal CSF (i.e reactive VDRL and/or greater than 4 leukocytes/mm 3 and protein concentration greater than 40 mg/dl);"

IV ceftriaxone may be an effective alternative for treatment of syphilitic uveitis, in the setting of unavailability of penicillin G.

The investigation of uveitis epidemiology is important because its occurrence, aetiology, severity and outcome are affected by genetic, racial, geographical, social and environmental factors. 1,2 After obtaining institutional review board approval, we examined the clinical and epidemiological profiles of uveitis between January 2004 and October 2013 at the Uveitis Service of Hospital São Geraldo/Hospital das Clínicas da UFMG, a public university-based referral centre in Southeastern Brazil.We analysed patient age at presentation, sex, bestcorrected visual acuity (BCVA), laterality, anatomic classification, etiologic diagnosis, associated systemic diseases, human immunodeficiency virus (HIV) infection, hospitalisation and follow-up time. Anatomic classification was performed according to the standardisation of uveitis nomenclature. 3 Among 3683 new patients with uveitis (Figure S1), the mean age was 33.8 ± 15.7 years, 50.3% were female and 6.7% were HIV-positive (Table S1). Posterior uveitis was the most common anatomical type, followed by anterior, intermediate and panuveitis (Table 1). Bilateral involvement (15.2%) occurred more frequently in patients with intermediate/panuveitis. At presentation, 39.1% showed BCVA ≤20/200 in at least one eye and 5.5% were legally blind (BCVA<20/200 in the better-seeing eye).Specific diagnosis/aetiology was presumed in 72.3% of uveitis cases; the remaining cases were classified as