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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.