Great imitator — ocular syphilis

We examined a 44-year-old woman without any known systemic disease with a decreased vision of a month duration in her left eye. She had undergone left uneventful cataract surgery with intraocular lens implantation elsewhere 14 years ago. On examination, her Snellen visual acuity was 1.0 (with the correction of –0.50–0.25 × 120) in the right eye and 0.4 (with the correction of +0.75–2.25 × 115) in the left. There was left hypochromic heterochromia. While the right anterior segment was unremarkable, there were small to medium-sized keratic precipitates, 3+ anterior chamber cells, a posterior chamber intraocular lens with an intact posterior capsule, and a few vitreous cells in the left eye. Fundus autofluorescence imaging revealed peripapillary hyperautofluorescence in the left eye, and fluorescein angiography revealed a marked optic nerve head and perivascular leakage at the posterior pole. The findings were not compatible with Fuchs uveitis, so the full infectious panel was worked out. Serologic investigations yielded the presence of syphilis, and the patient was treated successfully with systemic antibiotics. Our case demonstrates the mimic-king nature of ocular syphilis and the importance of high clinical suspicion when reaching the correct diagnosis.