Pyramidal Inflammatory Deposits of the Retinal Pigment Epithelium and Outer Retina in Ocular Syphilis


      To evaluate the role of OCT in the diagnosis of uveitis secondary to syphilis.


      Consecutive, retrospective case series.


      All patients 18 years of age or older with ocular syphilis from 2 tertiary referral centers.


      All patients who were diagnosed with intermediate uveitis, posterior uveitis, or panuveitis secondary to syphilis were included in the study (40 patients representing a total of 62 eyes) to identify important imaging features to aid in diagnosis. Patients underwent confirmatory serologic testing, OCT imaging, and dilated examination by a uveitis specialist.

      Main Outcome Measure

      Hyperreflective retinal lesions on OCT.


      The mean age of the study population was 42.9 ± 12.16 years. Forty-five percent of the eyes included in this study harbored hyperreflective pyramidal lesions of the outer retina and retinal pigment epithelium on OCT. Fifty-four percent of eyes with these imaging findings did not show a placoid retinal lesion on examination. Sixty-eighty percent of the described outer retinal lesions on OCT resolved after treatment for syphilis. Visual acuity ranged from normal (20/20) to no light perception, with a mean of 20/43 at diagnosis, and improved significantly to a mean visual acuity of 20/26 after treatment (P < 0.05). Vision-threatening complications were seen in less than 5% of eyes and included both treatable and irreversible causes of vision loss, including retinal detachment, cystoid macular edema, and optic neuropathy.


      Patients treated for uveitis secondary to syphilis achieve good visual recoveries. Outer retinal lesions seen on OCT are common and can serve as an additional imaging finding of the disease.


      Abbreviations and Acronyms:

      ASPPC (acute syphilitic posterior placoid chorioretinitis), CSF (cerebrospinal fluid), HIV (human immunodeficiency virus), IS/OS (inner segment and outer segment), IV (intravenous), RPE (retinal pigment epithelium), RPR (rapid plasma reagin)
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        • Conrady C.D.
        • Anesi S.C.
        • Foster C.S.
        • Vitale A.T.
        Pediatric uveitis.
        in: Hartnett M.E. Pediatric Retina. 3rd ed. Wolters Kluwer, Philadelphia, PA2020
        • Majumder P.D.
        • Chen E.J.
        • Shah J.
        • et al.
        Ocular syphilis: an update.
        Ocul Immunol Inflamm. 2019; 27: 117-125
        • Mathew R.G.
        • Goh B.T.
        • Westcott M.C.
        British Ocular Syphilis Study (BOSS): 2-year national surveillance study of intraocular inflammation secondary to ocular syphilis.
        Invest Ophthalmol Vis Sci. 2014; 55: 5394-5400
        • United States Centers for Disease Control and Prevention
        Clinical advisory: ocular syphilis in the United States. Published July 20, 2020.
        (Available at:)
        • Pratas A.C.
        • Goldschmidt P.
        • Lebeaux D.
        • et al.
        Increase in ocular syphilis cases at ophthalmologic reference center, France, 2012–2015.
        Emerg Infect Dis. 2018; 24: 193-200
        • Jabs D.A.
        • Belfort Jr., R.
        • Bodaghi B.
        • et al.
        Classification criteria for syphilitic uveitis.
        Am J Ophthalmol. 2021; 228: 182-191
        • Matsumoto Y.
        • Spaide R.F.
        Autofluorescence imaging of acute syphilitic posterior placoid chorioretinitis.
        Retin Cases Brief Rep. 2007; 1: 123-127
        • Eandi C.M.
        • Neri P.
        • Adelman R.A.
        • et al.
        Acute syphilitic posterior placoid chorioretinitis: report of a case series and comprehensive review of the literature.
        Retina. 2012; 32: 1915-1941
        • Zett C.
        • Lima L.H.
        • Vianello S.
        • et al.
        En-face optical coherence tomography of acute syphilitic posterior placoid chorioretinopathy.
        Ocul Immunol Inflamm. 2018; 26: 1264-1270
        • Fu E.X.
        • Geraets R.L.
        • Dodds E.M.
        • et al.
        Superficial retinal precipitates in patients with syphilitic retinitis.
        Retina. 2010; 30: 1135-1143
        • Harris P.A.
        • Taylor R.
        • Thielke R.
        • et al.
        Research Electronic Data Capture (REDCap)—a metadata-driven methodology and workflow process for providing translational research informatics support.
        J Biomed Inform. 2009; 42: 377-381
        • Lima L.H.
        • de Andrade G.C.
        • Vianello S.
        • et al.
        Multimodal imaging analyses of hyperreflective dot-like lesions in acute syphilitic posterior placoid chorioretinopathy.
        J Ophthalmic Inflamm Infect. 2017; 7 (1–1)
        • Burkholder B.M.
        • Leung T.G.
        • Ostheimer T.A.
        • et al.
        Spectral domain optical coherence tomography findings in acute syphilitic posterior placoid chorioretinitis.
        J Ophthalmic Inflamm Infect. 2014; 4 (2–2)
        • Vaze A.
        • De Angelis R.E.
        • Simões M.
        • et al.
        Optical coherence tomography findings in ocular syphilis involving the posterior segment of the eye.
        Ocul Immunol Inflamm. 2021; 15: 1-7
        • Brito P.
        • Penas S.
        • Carneiro Â.
        • et al.
        Spectral-domain optical coherence tomography features of acute syphilitic posterior placoid chorioretinitis: the role of autoimmune response in pathogenesis.
        Case Rep Ophthalmol. 2011; 2: 39-44
        • Pichi F.
        • Ciardella A.P.
        • Cunningham E.T.J.
        • et al.
        Spectral domain optical coherence tomography findings in patients with acute syphilitic posterior placoid chorioretinopathy.
        Retina. 2014; 34: 373-384
        • Moll-Udina A.
        • Figueroa-Vercellino J.P.
        • Llorenç V.
        • et al.
        Angiography and en face optical coherence tomography findings in acute syphilitic posterior placoid chorioretinopathy.
        Case Rep Ophthalmol. 2019; 10: 165-171
        • Mathew D.
        • Smit D.
        Clinical and laboratory characteristics of ocular syphilis and neurosyphilis among individuals with and without HIV infection.
        Br J Ophthalmol. 2021; 105: 70-74
        • Dai W.
        • Luo Z.
        • Xu R.
        • et al.
        Prevalence of HIV and syphilis co-infection and associated factors among non-commercial men who have sex with men attending a sexually transmitted disease clinic in Shenzhen, China.
        BMC Infectious Diseases. 2017; 17: 86
        • Segura M.
        • Bautista C.T.
        • Marone R.
        • et al.
        HIV/STI co-infections, syphilis incidence, and hepatitis B vaccination: the Buenos Aires cohort of men who have sex with men.
        AIDS Care. 2010; 22: 1459-1465
        • Lee S.Y.
        • Cheng V.
        • Rodger D.
        • Rao N.
        Clinical and laboratory characteristics of ocular syphilis: a new face in the era of HIV co-infection.
        J Ophthalmic Inflamm Infect. 2015; 5 (56–56)
        • Rasoldier V.
        • Gueudry J.
        • Chapuzet C.
        • et al.
        Early symptomatic neurosyphilis and ocular syphilis: a comparative study between HIV-positive and HIV-negative patients.
        Med Mal Infect. 2021; 51: 351-356
        • Moradi A.
        • Salek S.
        • Daniel E.
        • et al.
        Clinical features and incidence rates of ocular complications in patients with ocular syphilis.
        Am J Ophthalmol. 2015; 159: 334-343.e1
        • Furtado J.M.
        • Arantes T.E.
        • Nascimento H.
        • et al.
        Clinical manifestations and ophthalmic outcomes of ocular syphilis at a time of re-emergence of the systemic infection.
        Sci Rep. 2018; 8: 12071
        • Zweifel S.
        • Imamura Y.
        • Spaide T.
        • et al.
        Prevalence and significance of subretinal drusenoid deposits (reticular pseudodrusen) in age-related macular degeneration.
        Ophthalmology. 2010; 119: 1775-1781