Intraocular corticosteroids are used in ophthalmologic conditions such as macular edema secondary to vascular occlusions, diabetes, and uveitis.1–3 Triamcinolone acetonide was used primarily.4 Clinicians now have the alternative of continuous-release corticosteroid implants. Primarily, infectious ocular diseases must be ruled out before intravitreal corticosteroid implantation. Ocular syphilis has varied manifestations in the eye. We report a diabetic case with vitreous hemorrhage due to the injection of bilateral intravitreal dexamethasone for the treatment of bilateral macular edema with an unnoticed presence of syphilis.
A 53-year-old diabetic woman visited Bursa Retina Eye Hospital with the complaint of deterioration of vision in the right eye for the past 7 days after the injection of intravitreal Ozurdex implant (dexamethasone intravitreal implant 0.7 mg; Allergan, Dublin, Ireland) because of macular edema. In her medical history, we learned that she underwent intravitreal Ozurdex injections in her left eye 2 months earlier and in her right eye 10 days ago due to macular edema associated with diabetes.
Visual acuities (VAs) were hand motion in the right eye and 20/80 in the left eye. On slit-lamp examination, we saw cell reaction in the anterior chamber of both eyes and dense vitreous hemorrhage in the right. In the left eye, we detected the Ozurdex implant in the vitreous and diffuse changes in the color-like paleness and thickness of the retina, as well as intraretinal white-colored deposits (Figure 1).
In the left eye, we detected Ozurdex implant and sectional retinal invasion including inferior retina, observed as diffuse changes in the color-like paleness and thickness of the retina as well as intraretinal white-colored deposits.
Pars plana vitrectomy was performed in the right eye (Figure 2). After concluding core vitrectomy, we saw the same type of intraretinal deposits that were seen previously in the left eye (Figure 3). This led us to suspect a case of infectious bilateral retinitis. Vitreous culture was performed in order to detect bacterial and fungal infections; however, the result was negative.
In the right eye, Ozurdex implant and vitreous hemorrhage were observed during pars plana vitrectomy.
(A) After concluding core vitrectomy, we identified the same type of intraretinal deposits that were seen in the left eye previously. (B) Ozurdex implant was removed with vitrectomy cutter.
Syphilis serology showed a venereal disease research laboratory (VDRL) test of 1:32 and treponema pallidum hemagglutination assay (TPHA) test of 1:160. Human immunodeficiency virus (HIV) serology was negative. Lumbar puncture was performed, and cerebrospinal fluid evaluation resulted in neurosyphilis. For syphilis treatment, 24 million units of intravenous penicillin G was infused per day for 14 days. The retinal lesions resolved during the next 4 weeks, but retinal hemorrhage was detected in the macula of the left eye (Figure 4). VAs were 20/50 in the right eye and 20/80 in the left eye.
Intravenous penicillin G 24 million units per day for 14 days was infused. (A) The retinal lesions resolved. (B) Retinal hemorrhage was detected in the macular of the left eye.
As steroids may be used for noninfectious uveitis treatment, infectious causes such as syphilis, herpes family viruses, toxoplasmosis, and tuberculosis must be ruled out before the initiation of the treatment.5
Syphilis is primarily a sexually transmitted disease, and the number of patients has decreased relatively in recent years. Ocular syphilis can be identified at any stage but is most frequently seen in secondary syphilis; 4.6% of secondary syphilis patients are reported to have ocular symptoms.6,7 Ocular involvement may be unilateral or bilateral.
It is essential to be aware that anterior uveitis in syphilis can present itself as non-granulomatous or granulomatous, imitating ocular sarcoidosis and tuberculosis.8 Posterior uveitis usually presents as chorioretinitis, but it is also possible to occur solely as retinitis. Necrotizing retinitis and retinal vasculitis are other types of ocular involvement of syphilis. Once retinal vasculitis occurs solely, it might be unlikely to differentiate it with vein occlusions. Argyll Robertson pupil, extraocular palsies, or loss of VA may be the indicators of ocular nerve involvement.6 Less than 1% of intraocular inflammation is caused by syphilis.9 Syphilis is able to produce countless signs and symptoms that may imitate numerous diseases.10 Therefore, syphilis should be included in the differential diagnosis of ocular inflammation. Unfortunately, the appropriate diagnosis and treatment of syphilis may be delayed when the signs and symptoms of eye disease become prominent, which may result in permanent visual loss and major systemic morbidity.6,11
Nontreponemal tests of VDRL are the standard screening tests to detect syphilis; however, these tests may display false-positive results due to cross-reactivity. TPHA, FTA-Abs and dark field microscopy of the tissue are the gold standard tests to distinguish syphilis.11 Furthermore, syphilis proliferates HIV transmission risk. Hence, every syphilis patient should be tested for HIV.12
Because ocular syphilis is considered as an alternate of neurosyphilis, every patient with syphilitic uveitis should proceed with lumbar puncture and cerebrospinal fluid analysis to recognize neurological involvement.13 On the other hand, some authors claim that this is only crucial in the event of neurological symptoms or higher RPR titer values.14 Once cerebrospinal fluid analysis was performed, neurological involvement was detected in our case.
Intravenous penicillin G 18 million to 24 million units per day for 10 to 14 days is recommended in syphilis treatment. Ceftriaxone, oral doxycycline, and azithromycin are the alternative treatments in the case of penicillin allergy.
There are formerly reported cases with oral corticosteroid and intravitreal triamcinolone.15–17
Based on the literature review, there were no cases in which vitreous hemorrhage occurred after dexamethasone injection for posterior uveitis associated with syphilis. Therefore, we would like to report our case. We believe that our case report would contribute to the literature.
In conclusion, we would like to emphasize that infectious ocular diseases must be ruled out before intravitreal corticosteroid implantation, and that potential permanent complications could be averted via early diagnosis and prompt treatment of syphilitic uveitis.
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- de Smet MD. Corticosteroid intravitreal implants. Dev Ophthalmol. 2012;51:122–133. doi:10.1159/000336330 [CrossRef]
- Glacet-Bernard A, Coscas G, Zourdani A, Soubrane G, Souied EH. Steroids and macular edema from retinal vein occlusion. Eur J Ophthalmol. 2011;21Suppl 6:S37–44. doi:10.5301/EJO.2010.6053 [CrossRef]
- Kok H, Lau C, Maycock N, McCluskey P, Lightman S. Outcome of intravitreal triamcinolone in uveitis. Ophthalmology. 2005;112(11):1916.e1–7. doi:10.1016/j.ophtha.2005.06.009 [CrossRef]
- Kuo A, Ziaee SM, Hosseini H, et al. The great imitator: Ocular syphilis presenting as posterior uveitis. Am J Case Rep. 2015;16:434–437. doi:10.12659/AJCR.893907 [CrossRef]
- Kiss S, Damico FM, Young LH. Ocular manifestations and treatment of syphilis. Semin Ophthalmol. 2005;20(3):161–167. doi:10.1080/08820530500232092 [CrossRef]
- Parc CE, Chahed S, Patel SV, Salmon-Ceron D. Manifestations and treatment of ocular syphilis during an epidemic in France. Sex Transm Dis. 2007;34(8):553–556. doi:10.1097/01.olq.0000253385.49373.1a [CrossRef]
- Doris JP, Saha K, Jones NP, Sukthankar A. Ocular syphilis: The new epidemic. Eye (Lond). 2006;20(6):703–705. doi:10.1038/sj.eye.6701954 [CrossRef]
- Ishijima K, Namba K, Ohno S, Mochizuki K, Ishida S. Intravitreal Injection of bevacizumab in a case of occlusive retinal vasculitis accompanied by syphilitic intraocular inflammation. Case Rep Ophthalmol. 2012;3(3):434–437. doi:10.1159/000346046 [CrossRef]
- Meehan K, Rodman J. Ocular perineuritis secondary to neurosyphilis. Optom Vis Sci. 2010;87(10):E790–796. doi:10.1097/OPX.0b013e3181f361b0 [CrossRef]
- Aldave AJ, King JA, Cunningham ET Jr, . Ocular syphilis. Curr Opin Ophthalmol. 2001;12(6):433–441. doi:10.1097/00055735-200112000-00008 [CrossRef]
- Amaratunge BC, Camuglia JE, Hall AJ. Syphilitic uveitis: A review of clinical manifestations and treatment outcomes of syphilitic uveitis in human immunodeficiency virus-positive and negative patients. Clin Exp Ophthalmol. 2010;38(1):68–74. doi:10.1111/j.1442-9071.2010.02203.x [CrossRef]
- Browning DJ. Posterior segment manifestations of active ocular syphilis, their response to a neurosyphilis regimen of penicillin therapy, and the influence of human immunodeficiency virus status on response. Ophthalmology. 2000;107(11):2015–2023. doi:10.1016/S0161-6420(00)00457-7 [CrossRef]
- Libois A, De Wit S, Poll B, et al. HIV and syphilis: When to perform a lumbar puncture. Sex Transm Dis. 2007;34(3):141–144. doi:10.1097/01.olq.0000230481.28936.e5 [CrossRef]
- Solebo AL, Westcott M. Corticosteroids in ocular syphilis. Ophthalmology. 2007;114(8):1593. doi:10.1016/j.ophtha.2007.04.017 [CrossRef]
- Erol N, Topbas S. Acute syphilitic posterior placoid chorioretinitis after an intravitreal triamcinolone acetonide injection. Acta Ophthalmol Scand. 2006;84(3):435. doi:10.1111/j.1600-0420.2005.00641.x [CrossRef]
- Mushtaq B, Gupta R, Elsherbiny S, Murray PI. Ocular syphilis unmasked following intravitreal triamcinolone injection. Ocul Immunol Inflamm. 2009;17(3):213–215. doi:10.1080/09273940902745411 [CrossRef]