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Year : 2022  |  Volume : 2  |  Issue : 4  |  Page : 1010-1011

Pro-imaging strategies in syphilitic uveitis: What is really intriguing?

Department of Uvea, Aravind Eye Hospital and Postgraduate Institute of Ophthalmology, Pondicherry, India

Date of Web Publication11-Oct-2022

Correspondence Address:
Dr. Sivaraman Bala Murugan
Uveitis Clinic, Aravind Eye Hospital, Thavalkuppam, Pondicherry – 605 007
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijo.IJO_675_22

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How to cite this article:
Murugan SB. Pro-imaging strategies in syphilitic uveitis: What is really intriguing?. Indian J Ophthalmol Case Rep 2022;2:1010-1

How to cite this URL:
Murugan SB. Pro-imaging strategies in syphilitic uveitis: What is really intriguing?. Indian J Ophthalmol Case Rep [serial online] 2022 [cited 2022 Nov 27];2:1010-1. Available from: https://www.ijoreports.in/text.asp?2022/2/4/1010/358181

The art of converting an obstacle into opportunity requires mastery even in imaging syphilitic uveitis.[1] Fundus lesions with vitritis that prelude detailed ophthalmoscopy can be better delineated by posterior segment imaging tools.[2] The varied angiographic findings should propel the clinician to recap the diverse manifestations of syphilis. Once the clinician fixates the clinical spectra and discerns the pathophysiology, the imaging findings glide the plausible path of probability. The plane of retinitis lesion—preretinal, superficial, and deep retinal—has to be elegantly captured using imaging tools.

The classical leopard spotting pattern[3] in syphilis is characterized in the early phase as hypofluorescence or faint hyperfluorescence with scattered hypofluorescence spots. In the mid and late phases of fundus fluorescein angiogram (FFA), an obvious hyperfluorescence is visible progressively.

The ICG findings in ocular syphilis are characterized by hypofluorescence corresponding to the FFA/clinical lesions that continue to persist in the late phase as hypofluorescence. This ICG finding was considered pathognomic of ocular syphilis when compared with other infectious retinitis by Knecht et al.[4]

What is very clear in the confluent type of syphilitic retinochoroiditis is the increased pretest probability and high diagnostic predictive value[3] of the combination of two findings, namely confluent inner retinitis and multiple preretinal/inner retinal dots. Thus, a focused clinician uses the imaging armematorium using optical coherence tomogram (OCT), FFA, and ICG to correlate the clinical spectra.

When the syphilitic lesion is superficial,[5] it blocks fluorescence in the early phase and neither leaks nor stains in the late phases. Retinal pigment epithelitis is a unique finding that reveals outer retinal and RPE staining without early hypofluorescence.[2] During its resolution, it may transition as an RPE window defect (marked as early well-defined hyper that fades in late phases) or RPE hyperplasia (hypofluorescence) varied pigment disruption. At this juncture, autofluorescence findings should have a higher focus along with FFA.

Syphilitic chorioretinitis needs to be delineated for its sequel of choroidal neovascularization. It has its classical pattern and early hyper and late leakage. Syphilitic vasculitis has to be assessed as large arteriolar involvement (occlusive arteriolitis, periarteritis, Kayraleigh's plaque), small-vessel involvement (cystoid macular edema), and the most common syphilitic vasculitis as phlebitis[6] (central or branch retinal vein occlusions). The vessels on the optic nerve head, if involved with vascular engorgement leaks on fundus fluorescein angiogram and will need neuro ophthalmology correlation as well.

ICG has an added advantage of delineating the iceberg phenomenon[2],[7] as well. The clinician can extend the array of knowledge on ICG findings from the varied hyperfluorescence.[3],[7] Three distinct patterns of hypofluorescence[3] in early/mid/late phases apart from the “leopard spot pattern” have been described in the literature.

OCT can be easily employed to assess the treatment response to monitor the dynamic changes[3],[8] in the findings such as punctate choroidal hyperreflectivity, choroidal thickness index, loss of inner segment/outer segment layer signals as well as external limiting membrane, nodular RPE thickening, and accumulation of subretinal fluid. The reversibility of the abovementioned OCT findings suggests physiological rather than anatomical damage. What is fascinating in syphilis are the intriguing reports of spontaneous improvement of some of these findings without treatment![3] The proposed postulates include prolonged latency[3] and adequate regional response.[3] The clinician needs to be wary of delayed progression[3] to frank posterior uveitis as well.

B-scan also has a definitive role in analyzing the configuration of retinal detachment and potentially reversible ONH gummas[2] with definitive treatment in syphilis. With the dynamic changes in the literature on ocular syphilis, imaging adjuncts require a matching dynamism from the practicing astute clinician.

  References Top

Ramdoss J, Jain A, Biswas J. Multimodal imaging in syphilitic retinitis with vasculitis in an immunocompetent patient: A case report. Indian J Ophthalmol Case Rep 2022;2:708-10.  Back to cited text no. 1
  [Full text]  
Jumper JM, Randhawa S. Imaging syphilis uveitis. Int Ophthalmol Clin 2012;52:121-9.  Back to cited text no. 2
Pichi F, Neri P. Multimodal imaging patterns of posterior syphilitic uveitis: A review of the literature, laboratory evaluation and treatment. Int Ophthalmol 2020;40:1319-29.  Back to cited text no. 3
Knecht PB, Papadia M, Herbort CP. Secondary choriocapillaritis in infectious chorioretinitis. Acta Ophthalmol 2013;91:e550–5.  Back to cited text no. 4
Fu EX, Geraets RL, Dodds EM, Echandi LV, Colombero D, McDonald HR, et al. Superficial retinal precipitates in patients with syphilitic retinitis. Retina. 2010;30:1135–43.  Back to cited text no. 5
Villanueva AV, Sahouri MJ, Ormerod LD, Puklin JE, Reyes MP. Posterior uveitis in patients with positive serology for syphilis. Clin Infect Dis 2000;30:479–85.  Back to cited text no. 6
Mora P, Borruat F, Guex-Crosier Y. Indocyanine green angiography anomalies in ocular syphilis. Retina 2005;25:171–81.  Back to cited text no. 7
Pichi F, Ciardella AP, Cunningham ET Jr, Morara M, Veronese C, Jumper JM, et al. Spectral domain optical coherence tomography findings in patients with acute syphilitic posterior placoid chorioretinopathy. Retina 2014;34:373-84.  Back to cited text no. 8


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