The Clinical Spectrum and Outcomes of Ocular Syphilis in Saudi Arabia: The Emergence of a Uveitic Masquerader.

Abstract

This retrospective multicenter cohort study aimed to describe the clinical features and report the outcomes of the management of ocular syphilis in Saudi Arabia. Thirty-three eyes of 19 patients with ocular syphilis were reviewed, including data on visual acuity, signs of anterior and posterior uveitis, systemic work-up, and treatment outcomes. A total of 38 eyes from 19 patients were examined, with 33 eyes showing manifestations of ocular syphilis. The majority of patients (89.5%; n = 17) were males, with an average age of 40.6 ± 12 years. About one half of the patients (52.6%; n = 10) reported previous unprotected sexual encounters, and 26.3% had positive human immunodeficiency virus (HIV) testing. Systemic manifestations of syphilis were observed in 68.4% of the patients. Fourteen patients (73.7%) had bilateral disease. At presentation, the average Log MAR visual acuity was 0.81 ± 0.80 (Snellen equivalent = 20/120). Anterior chamber inflammation was seen in 72.7% of eyes (n = 28 eyes), while posterior segment examination revealed vitritis in 48.5% (n = 18 eyes), hyperemic optic discs in 62.5% (n = 24 eyes), and vascular sheathing in 46.9% (n = 17 eyes). Placoid lesions were observed in 51.5% of eyes (n = 20 eyes). The most common ocular syphilitic phenotypes were acute syphilitic posterior placoid chorioretinitis (ASPPC) in 54.5% of eyes (n = 21 eyes) and necrotizing retinochoroiditis in 15.2% (n = 6 eyes). Treatment included intravenous penicillin G for 14 days in 12 patients, intramuscular penicillin G in 2 patients, and systemic ceftriaxone in 2 patients. All treated patients showed clinical improvement, with a mean follow-up duration of 6.5 ± 4.5 weeks and a significant improvement in mean Log MAR visual acuity to 0.23 ± 0.46 (Snellen equivalent = 20/30; P < 0.001). These findings highlight the emergence of ocular syphilis in Saudi Arabia and the need for ophthalmologists to recognize its diverse clinical and multimodal retinal imaging features to ensure timely diagnosis and treatment.