Known as the great imitator, Syphilis has been all but eradicated in the US, but is still a prevalent problem in third world and developing countries. It is caused by the spirochete Treponema palidum. It still remains a global problem and can easily be transmitted to the US via any individual that has exposure to individuals from other lands. 12 million new cases were diagnosed in 1999 alone! Two thirds of the acquired cases occurred in male homosexual relationships; which was also related to HIV infections in the same people.

Syphilis is a systemic disease that affects the eyes. It can be acquired transplacentally in utero or via sexual encounters after birth. Congenital syphilis can present in childhood with Hutchinson’s Teeth, saddle nose deformity, and deafness. Ocular complications are often interstitial keratitis, and a displaced natural lens ( ectopia lentis).

Acquired syphilis is broken down into 4 stages. The first is the development of a painless chancre which appears 2-6 weeks after exposure to the spirochetes usually at the site of introduction. Secondary syphilis occurs 4-10 weeks after exposure and presents as fever, malaise and a generalized rash on the palms or soles. The third stage called latent, is undetectable may last for many years. The final stage, called tertiary, is characterized by neurologic and cardiovascular changes and occurs many years after exposure. Morbidity and death are complications at this stage.

The ocular manifestations involve most structures. Conjunctivitis, episcleritis, scleritis, interstitial keratitis, conjunctival injection, and terrier chamber inflammation, natural lens dislocation, uveitis, glaucomatous precipitates, iris nodules and dilated iris blood vessels known as roseola are very common in tertiary syphilis. In addition, elevated intraocular pressure is very common and is called Inflammatory Ocular Hypertension Syndrome. In addition, the back of the eye can become involved in the form of chorioretinitis, retinitis, vasculitis, vitritis, and panuveitis.

Diagnosis of ocular syphilis relies largely on serologic testing. There are two types of antibody based serum tests called non-treponemal and treponemal.

The treatment of choice is penicillin for all stages of the disease. IV penicillin G 18-24 million units daily for 2 weeks followed by intramuscular procaine penicillin 2.4 million units for 3 weeks. If the patient is allergic to penicillin then alternative antibiotics must be used such as tetracycline, doxycycline, chloramphenicol, ceftriaxone and the macrolide family of medications. The long term complications of untreated syphilis include glaucoma, uveitis, cataracts, epiretinal membranes and macular edema.

The best way to avoid all these extremely unpleasant complications is to seek immediate medical care at the first sign of any disease. In this case the chancre is an unmistakable sign and should never be ignored. The fact that is goes away should not be construed as a green light to good health.