Download Rumbach, M

The case of an 83-year-old man with bilateral exudative retinal detachments secondary
to chronic posterior uveitis shows the importance of early intervention of Syphilis, a
sexually-transmitted infection with potentially sight-threatening consequences.
I. Case History
a. Patient demographics: 83 year-old white male
b. Chief complaint: This patient presents on July 31st as an inpatient consult
for bilateral vision loss. He reported that he suddenly lost vision in the
right eye sometime in May and then lost vision in the left eye several
days later. The patient denied any ocular pain, flashes of light, floaters.
He reported a slight “soreness” only when pressing on the right globe. He
did not present with eye redness, irritation, or photophobia
c. Ocular History
1. Patient reports seeing a private retina specialist for an
unknown infection/inflammation prior to his vision loss,
referred to a second retinal specialist who did not pursue
treatment. He was then referred to OSU Ophthalmology
2. Last comprehensive eye examination—unknown per
patient
3. Bilateral cataract extraction
d. Medical History: Neurosyphilis, Chronic obstructive bronchitis
e. Medications:
i. Systemic: albuterol, aspirin, atenolol, cholecaliferol, clotrimazole,
finasteride, flunisolide, furosemide, ipratropium bromide,
polyethylene glycol, simvastatin, terazosin
ii. Ocular: None
f. Other salient information: currently admitted for inpatient IV Penicillin G
for neruosyphilis.
II. Pertinent Findings
a. Clinical
i. visual acuity: NLP OD, LP at 2 inches OS
ii. pupils: fixed dilated OU
iii. confrontation visual field : unable to perform due to severely
decreased vision OU
iv. anterior segment:
1. lids/lashes: mild debris OU, mild telangiectasia OU
2. iris: inferior bowing posteriorly and atrophy nasally OD –
with suspected rubeosis iridis 360. WNL normal OS
v. dilated fundus examination:
1. OD: no views of posterior chamber due to dense fibrosis
with vasculature visible in the anterior vitreous cavity.
Fibrotic material undulated with eye movement. Minimal
red reflex was visible in far superior position.
2. OS
a. ONH: superior half visualized only, pallorous,
distinct superior margins
b. Posterior Pole: Macula-off retinal detachment (RD);
only two clock hours of posterior pole visible
superiorly which appeared to have a goldencolored hue. No hemorrhages were visible
c. Periphery: Macula-off retinal detachment
extending from 1-10:00
d. Vitreous: anterior vitreous cells present with
snowballs and snowbanking, most dense inferiorly
b. Imaging Studies
i. B-Scan: Posterior ultrasound revealed choroidal effusion with
associated total retinal detachment OD. In the left eye,
ultrasound confirmed subtotal retinal detachment. Dense
hyperechoic floating vitreal opacities were noted bilaterally.
ii. External photography OD: dense white fibrotic tissue with
associated vasculature just posterior to the PCIOL OD.
III. Differential Diagnosis
a. Primary/leading: Exudative retinal detachment secondary to chronic
syphilitic chorioretinitis OU
b. Others: Tractional retinal detachment, rhegmatogenous retinal
detachment, syphilitic neuroretinitis
IV. Diagnosis and Discussion
a. The presumptive diagnosis after examining the patient was an exudative
retinal detachment secondary to chronic syphilitic chorioretinitis OU.
Due to the previously established serology testing for syphilis, other
infectious etiologies could be ruled out prior to examination.
i. Exudative retinal detachments are characterized by the
separation of the retina due the accumulation of subretinal fluid
in the absence of a break or hole in the retinal tissue. The
longstanding posterior inflammation secondary to the syphilis
infection, led to an insurmountable amount of subretinal fluid
that the retinal pigment epithelial could not absorb.
b. Differential Diagnosis
ii. Rhegmatogenous retinal detachments are the result of a break in
the retinal tissue and the subsequent separation from the choroid
secondary to the influx of subretinal fluid.
iii. Tractional retinal detachments are primarily caused by the
contraction of fibrotic tissues in the areas of attachment between
the vitreous and the retina. The most common causes of these
types of detachments are proliferative retinopathies (e.g.
proliferative diabetic retinopathy). This type of retinal
detachment can be ruled based on his systemic history, and that
he denied any previous ocular trauma
iv. Syphilitic neuroretinitis presents with papillitis with associated
papillary edema. The minimal view available of the optic nerve
revealed distinct margins and normal optic nerve perfusion. The
patient was diagnosed with neurosyphilis based on serology
testing but the optic nerve section visible during examination was
did not show signs of the active neuroretinitis in conjunction with
the neurospyhilis.
V. Treatment and Management
a. A local retinal specialist provided a phone consultation. Due to this
patient’s neurospyhilis diagnosis and the extent of the posterior
inflammation, the provider felt the patient would best be served by a
uveitis specialist.
b. The uveitis specialist treated the patient with a scleral buckle (SB), pars
plana vitrectomy (PPV), membrane peel (MP), and silicone oil. The
patient also received intravitreal injections of vancomycin and triesence.
c. The patient’s first procedure failed due to significant systemic
inflammations from the syphilis. He was retreated with corrective
endolaser, repeat vitrectomy, and silicone oil injection.
i. The retinal detachment repair failed due to persistent ocular and
systemic inflammation. Oral steroids were prescribed once the
patient finished his course of IV penicillin in order to facilitate the
repeat procedure.
ii. The repair also likely failed because of the extent of the patient’s
exudative retinal detachment: the buckle alone did not facilitate
the proper reattachment due to the amount of subretinal fluid so
endolaser was utilized during the repeat procedure.
iii. Other causes of failed RD repair include missed retinal breaks or
the opening of a preexisting break, scleral buckle failure, or
proliferative vitroretinopathy.
VI. Conclusion
a. Patients with untreated / dormant syphilis can present with
chorioretinitis that can be detrimental to vision if it continues to
progress.
b. A careful examination of the fundus must be done in any suspected case
of syphilis to rule out any chorioretinal inflammation. Untreated
chorioretinal inflammation can be a precipitating factor in the
development of an exudative retinal detachment.
VII. Bibliography
a. Arruga J, J Valentines, F Mauri, G Roca, R Salom, G Rufi. “Neuroretinitis
in acquired syphilis. Ophthalmology. 90(2): 262-270. 1985.
b. De Smet M . “Exudative retinal detachment”. Acta Ophthalmologica. 91
(252): 2013
c. Jumper M, R Machemer, R Gallemore, G Jaffe. “Exudative retinal
detachment and retinitis associated with acquired syphilitic uveitis”. The
Journal of Retina and Vitreous Diseases. 20(2): 190-194. 2000.
d. Kanski JJ. “Retinal Detachment”. 705-726. Clinical Ophthalmology: 7th
Edition. Butterworth-Heinemann. 2011.
e. Kanski JJ. “Syphilis”. 451-452 Clinical Ophthalmology: 7th Edition.
Butterworth-Heinemann. 2011.
f. Kim CS, KN Kim, WJ Kim, JY Kim. “Intraoperative endolaser retinopexy
around the sclerotomy site for prevention of retinal detachment after
pars plana vitrectomy.” The Journal of Retina and Vitreous Diseases.
31(9):1772-1776. 2011.