A 50-Year-Old Man With Optic Disc Edema

Rod Foroozan, MD

Disclosures

June 25, 2019

Case Diagnosis

Funduscopy showed optic disc edema with chorioretinal scarring. There was evidence of vitritis. These findings were suggestive of an inflammatory or infiltrative cause of optic neuropathy and retinopathy. Syphilitic optic neuropathy is the condition that would most likely cause these findings.

This patient was obese and had bilateral optic disc edema; however, the clinical findings were not consistent with idiopathic intracranial hypertension, as there was an abnormal cerebrospinal fluid consistency and vitritis in each eye.

The presence of vitritis would also help exclude nonarteritc anterior ischemic optic neuropathy.

Although this patient had central visual loss in the left eye, a hallmark of visual loss from Leber hereditary optic neuropathy, there were also cells in the vitreous, which would not be expected. The areas of chorioretinal scarring around the optic disc would also be unexpected.

Clinical Course

Blood test results for rapid plasma reagin (1:1024) and fluorescent treponemal antibody absorption were positive. The cerebrospinal fluid Venereal Disease Research Laboratory test result was negative.

The patient was sent to an infectious disease specialist and treated with intravenous penicillin for 14 days.

Two months later, his visual acuity was 20/20 in the right eye and 20/40 in the left eye, and the optic disc edema and vitritis had resolved. The chorioretinal scars were unchanged in each eye.

Discussion

Ocular involvement in syphilis has been estimated to occur in around 10% of patients[1] with systemic infection, most commonly from secondary or tertiary stages of the infection.

Ocular involvement from syphilis is on the rise, with an increase in incidence reported in the United States and worldwide. In one series from Israel, 23 of 93 patients (25%) with syphilis had ocular involvement; of these, 18 had optic nerve involvement.[1] Men are more commonly affected than women.[1]

Syphilis may cause optic neuropathy characterized by optic disc edema; however, the optic neuropathy may be retrobulbar so that disc edema may not be present. The optic neuropathy may be unilateral or bilateral.[2] Concurrent uveitis has been noted in 40% of patients with optic nerve involvement.[3] Optic neuropathy may be the initial finding of systemic infection.[4] However, despite optic nerve involvement, many patients may have no visual symptoms.

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