Ocular Manifestations of Syphilis

By Stage of Infection

Primary Syphilis

• Eyelid/conjunctival chancre — painless ulcerated lesion
• Madarosis — loss of eyelashes or eyebrows
• Regional lymphadenopathy near periorbital area

Secondary Syphilis (Most common stage for ocular involvement)

• Uveitis — most frequent manifestation; posterior and panuveitis more common than anterior; anterior uveitis occurs in 5–10% of secondary syphilis cases
  • Patchy iris hyperemia with fleshy pink nodules near the iris sphincter is a classic presentation
• Optic neuritis / papillitis
• Chorioretinitis and retinitis
  • Acute posterior placoid chorioretinitis (APPC) — multifocal white placoid lesions in the posterior pole; strongly suggestive of syphilis
  • Punctate inner retinitis — superficial punctate creamy-white lesions; strongly suggestive of syphilis
• Serous retinal detachment
• Retinal vasculitis
• Interstitial keratitis
• Conjunctivitis, episcleritis, scleritis, dacryoadenitis, dacryocystitis
• Pupillary abnormalities

"The diagnosis of ocular syphilis is often considered only after patients fail to respond to topical steroid therapy" — Harrison's, 22nd Ed.

Tertiary / Late Syphilis (Neurosyphilis)

• Argyll Robertson pupil — the classic finding; small, irregular pupil that accommodates but does not react to light ("prostitute's pupil"); seen in ~90% of tabes dorsalis
• Optic atrophy — seen in ~20% of tabes dorsalis
• Cranial nerve palsies — III, IV, VI (due to syphilitic basilar meningitis)
• Chronic anterior uveitis
• Old chorioretinitis scar
• Bitemporal hemianopia — from chiasmal syndrome due to gummas or basilar meningitis
• Retinal detachment, cataracts, glaucoma (advanced)
• Stroke syndromes involving optic/oculomotor nerves

Fundus Photographs — Ocular Syphilis

Placoid Retinopathy in Secondary Syphilis

Syphilitic Posterior Uveitis with Disc Edema and Retinitis (HIV co-infected patient)

Congenital Syphilis — Ocular Findings

Hutchinson's Triad (Late Congenital Syphilis)

1. Interstitial keratitis
2. Hutchinson teeth — peg-shaped, widely spaced, notched incisors
3. Eighth-nerve (sensorineural) deafness

Summary Table: Ocular Structures Affected

Key Clinical Points

• "The great imitator" — ocular syphilis can mimic almost any uveitic or retinal condition
• All patients with confirmed syphilitic uveitis should have lumbar puncture (VDRL, FTA, protein, cell count) as the condition is managed as neurosyphilis
• In 70% of ocular syphilis cases, concomitant CSF abnormalities are found
• HIV co-infection increases risk of ocular and neurologic complications; HIV testing is mandatory in all syphilis patients
• Men who have sex with men (MSM) are at highest risk

Diagnosis

• Reverse algorithm: Treponemal test first (FTA-ABS, EIA, MHA-TP) → if reactive, confirm with nontreponemal test (RPR/VDRL) for disease activity and treatment response
• CSF VDRL: highly specific for neurosyphilis (insensitive but diagnostic when positive)

Treatment

• Aqueous penicillin G IV — treated as neurosyphilis regardless of CSF findings
• RPR/VDRL titers should decrease fourfold within 6–12 months post-treatment
• For congenital syphilis: IV penicillin G managed by pediatrician/ID specialist