Ocular Syphilis: Diagnostic Challenges and Current Management Strategies
DOI:
https://doi.org/10.55606/termometer.v4i4.7015Keywords:
Diagnosis of Ocular Syphilis, HIV Co-Infection, Management of Ocular Syphilis, Neurosyphilis, Ocular SyphilisAbstract
Ocular syphilis is an important and potentially sight-threatening manifestation of T. pallidum infection, capable of occurring at any stage of the disease. Known as “The Great Imitator,” it presents with highly variable and non-specific clinical features that frequently resemble autoimmune or other infectious ocular conditions, leading to delayed diagnosis and potential mismanagement. The pathophysiology involves early hematogenous dissemination, endothelial injury, and immune-mediated inflammation, often overlapping with mechanisms seen in neurosyphilis. Ocular involvement may affect virtually all eye structures, with uveitis being the most common presentation, alongside manifestations such as retinitis, vasculitis, optic neuritis, and interstitial keratitis. Diagnosis is made through an increased index of clinical suspicion, based on the results of treponemal and nontreponemal tests. Imaging studies like optical coherence tomography and fluorescein angiography help assess the condition but are not definitive. Management follows neurosyphilis treatment protocols, with intravenous penicillin as the cornerstone of therapy and adjunctive corticosteroids or immunosuppressive agents in selected cases. Given the global resurgence of syphilis and increasing reports of ocular involvement, early recognition and prompt treatment are essential to prevent irreversible visual impairment.
Downloads
References
Bettuzzi, T., Jourdes, A., Robineau, O., et al. (2021). Ceftriaxone compared with benzylpenicillin in the treatment of neurosyphilis. Lancet Infectious Diseases, 21(10), 1441–1447. https://doi.org/10.1016/S1473-3099(21)00307-5
Centers for Disease Control and Prevention. (2024). Sexually transmitted disease surveillance 2023. U.S. Department of Health and Human Services.
Chen, J. L., Tessema, R., Emami-Naeini, P., & Lim, M. C. (2023). A vascular syphilitic iris lesion and posterior placoid chorioretinopathy. American Journal of Ophthalmology Case Reports, 31, 101858. https://doi.org/10.1016/j.ajoc.2023.101858
Eandi, C. M., Neri, P., Adelman, R. A., et al. (2022). Multimodal imaging in infectious posterior uveitis. Progress in Retinal and Eye Research, 90, 101042. https://doi.org/10.1016/j.preteyeres.2022.101042
Furtado, J. M., Arantes, T. E., Nascimento, H., Vasconcelos-Santos, D. V., Nogueira, N., Queiroz, R. P., Brandão, L. P., Bastos, T., Martinelli, R., Santana, R. C., Muccioli, C., Belfort, R., Jr., & Smith, J. R. (2018). Clinical manifestations and ophthalmic outcomes of ocular syphilis at a time of re-emergence of the systemic infection. Scientific Reports, 8(1), 12071. https://doi.org/10.1038/s41598-018-30559-7
Furtado, J. M., Simões, M., Vasconcelos-Santos, D. V., et al. (2022). Ocular syphilis. Survey of Ophthalmology, 67(2), 440–462. https://doi.org/10.1016/j.survophthal.2021.06.003
Gonzalez, H., Koralnik, I. J., & Marra, C. M. (2019). Neurosyphilis. Seminars in Neurology, 39(4), 448–455. https://doi.org/10.1055/s-0039-1688942
Hook, E. W., III, & Marra, C. M. (2020). Acquired syphilis in adults. New England Journal of Medicine, 382(9), 845–854. https://doi.org/10.1056/NEJMra1901593
Lapere, S., Mustak, H., & Steffen, J. (2019). Clinical manifestations and cerebrospinal fluid status in ocular syphilis. Ocular Immunology and Inflammation, 27(1), 126–130. https://doi.org/10.1080/09273948.2018.1521436
Marra, C. M. (2022). Neurosyphilis. Continuum: Lifelong Learning in Neurology, 28(5), 1368–1391. https://doi.org/10.1212/CON.0000000000001188
Mathew, R. G., Goh, B. T., & Westcott, M. C. (2022). Ocular syphilis: Update on clinical spectrum and management. Eye, 36(3), 494–503. https://doi.org/10.1038/s41433-021-01633-8
Oliver, S. E., Aubin, M., Atwell, L., et al. (2016). Ocular syphilis—Eight jurisdictions, United States, 2014–2015. MMWR Morbidity and Mortality Weekly Report, 65, 1185–1188. https://doi.org/10.15585/mmwr.mm6543a2
Park, I. U., Tran, A., Pereira, L., & Fakile, Y. (2020). Performance of treponemal tests for the diagnosis of syphilis. Clinical Infectious Diseases, 71(Suppl. 1), S13–S20. https://doi.org/10.1093/cid/ciaa345
Pichi, F., Ciardella, A. P., Cunningham, E. T., Jr., et al. (2021). Multimodal imaging findings in acute syphilitic posterior placoid chorioretinitis. Retina, 41(3), 501–512. https://doi.org/10.1097/IAE.0000000000002893
Queiroz, R. F., Severo, E. G., Vasconcelos, T. R., Lira, R. P., & Vasconcelos-Santos, D. V. (2020). Double infection: Ocular syphilis and HIV. International Journal of Retina and Vitreous, 6, 28. https://doi.org/10.1186/s40942-020-00225-6
Reid, G. A., Halmagyi, G. M., Whyte, C., & McCluskey, P. J. (2024). Ocular vs neurosyphilis: Are they the same? A guide to investigation and management. Eye, 38(12), 2337–2349. https://doi.org/10.1038/s41433-024-03150-w
Shields, M. K., Arantes, T. E., Lake, S. R., Belfort, R., Jr., Muccioli, C., Nascimento, H., Queiroz, R. P., Vasconcelos-Santos, D. V., Furtado, J. M., & Smith, J. R. (2024). Influence of gender on clinical presentation, management practices and outcomes of ocular syphilis. Scientific Reports, 14(1), 16390. https://doi.org/10.1038/s41598-024-66412-3
Tuddenham, S., & Zenilman, J. M. (2022). Syphilis and ocular disease: Current concepts in diagnosis and management. Clinical Infectious Diseases, 74(Suppl. 2), S131–S137. https://doi.org/10.1093/cid/ciac060
Workowski, K. A., Bachmann, L. H., Chan, P. A., et al. (2021). Sexually transmitted infections treatment guidelines, 2021. MMWR Recommendations and Reports, 70(4), 1–187. https://doi.org/10.15585/mmwr.rr7004a1
Ye, Z., Chen, Y., Li, J., et al. (2023). Clinical characteristics and visual outcomes of ocular syphilis: A retrospective study. Pathogens, 12(9), 1123. https://doi.org/10.3390/pathogens12091123
Zamli, A. K. G., Ngah, N. S. I., Tan, C. E., Muhammed, J., Wan Hitam, W.-H., Hussein, A., & Zunaina, E. (2019). Clinical profile and visual outcomes of ocular syphilis: A five-year review in Hospital Universiti Sains Malaysia. Cureus, 11(2), e4015. https://doi.org/10.7759/cureus.4015
Downloads
Published
How to Cite
Issue
Section
License
Copyright (c) 2026 Luh Putu Indah Wahyuningtyas, I Dewa Agung Gede Agastya Janardhana
This work is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License.
