Uveitis is often the presenting sign of syphilis but can occur at any stage of the infection. Syphilitic uveitis is confirmed through serologic testing with both the specific and sensitive fluorescent treponemal antibody absorption (FTA-ABS) test and the nonspecific VDRL or rapid plasma reagin (RPR) tests, which are complementary to each other. Additional confirmatory tests include the Treponema pallidum particle agglutination assay (TP-PA) and the microhemagglutination assay for T pallidum antibodies (MHA-TP). Patients with uveitis who test positive for syphilis on serologic tests should also have their cerebrospinal fluid anti–treponemal antibody titers measured before and, when present, after completion of therapy to document a complete response to treatment.
Many patients with syphilitic uveitis present with a nondescript panuveitis, which supports the need for routine syphilis testing in all sexually active adults with uveitis. Specifically suggestive clinical findings include inflammatory ocular hypertensive syndrome, iris roseola, and retinochoroiditis. The retinochoroiditis is often diaphanous—appearing less opaque than either herpetic or toxoplasmic necrotizing retinitis—and is accompanied by overlying inflammatory accumulations termed retinal precipitates. A distinctive form of syphilitic outer retinitis termed acute syphilitic posterior placoid chorioretinitis (ASPPC) is characterized by the presence of a placoid, round or oval, yellow-white lesion that involves or is near the macula (Fig 11-20). Because coinfection is common, all patients with syphilis should be tested for HIV. Patients with syphilitic uveitis should be treated for neurosyphilis.
Figure 11-20 Syphilitic retinochoroiditis. A, Color fundus photograph montage shows a right eye with vitritis. B, Fundus photograph shows placoid yellow lesions in the macula and inferior periphery representing acute syphilitic posterior placoid chorioretinitis (ASPPC). C, OCT image demonstrates location of ASPPC in the outer retina.
(Courtesy of Stephen J. Kim, MD.)
Excerpted from BCSC 2020-2021 series: Section 10 - Glaucoma. For more information and to purchase the entire series, please visit https://www.aao.org/bcsc.