Christine Clavell, MD and Marco Zarbin, MD, PhD
Institute of Ophthalmology & Visual Science
Rutgers-New Jersey Medical School
The role of early vitrectomy in ocular syphilis
Purpose: Ocular syphilis has experienced a resurgence in recent years. Syphilitic panuveitis is one of the several manifestations of this disease. Surgical intervention is reserved for cases with complications such as cataract, retinal detachment or persistent vitreous opacification. In cases of syphilitic uveitis affecting the posterior segment, pars plana vitrectomy has not been reported as an early primary treatment. We describe the clinical course of an HIV positive patient with bilateral syphilitic panuveitis who was treated with penicillin and had a pars plana vitrectomy in both eyes within a week of presentation. We will review the short and long-term anatomic and functional outcomes.
Retrospective case review
The right eye suffered a macula-sparing rhegmatogenous retinal detachment shortly after the initial vitrectomy. Following surgical repair with silicone oil tamponade, this eye improved from the presenting vision of counting fingers to a best corrected visual acuity of 20/30 which was maintained for one year. The right eye eventually developed cystoid macular edema, epiretinal membrane, cataract, and reverse pseudohypopyon. Therefore, a pars plana vitrectomy with lensectomy, membrane peel, and silicone oil removal was performed. The final visual acuity was 20/100.
The left eye developed chronic hypotony and an epiretinal membrane after the initial vitrectomy. Six months later, a vitrectomy was undertaken to drain the suprachoroidal effusions and peel the epiretinal membrane. After this surgery a cataract and reverse pseudohypopyon formed. A third vitrectomy was done to remove the cataract and silicone oil. The hypotony never resolved. The patient remained with a final vision of 20/300. The final visual acuities were taken without aphakic correction.
This case illustrates the potential benefits and complications which can arise when performing vitrectomy in cases of infectious posterior uveitis. Surgery performed early in the disease course results in faster recovery and improved short-term vision compared to systemic therapy alone. Vitrectomy removes the inflammatory mediators which are typically trapped against the retina due to an intact posterior hyaloid. We propose that the development of severe uveitic complications is mitigated when these inflammatory mediators are removed early in the disease course. However long-term visual outcome may be limited due to adverse effects from uveitis and surgery.