Syphilis eye and its appendages is a lesion of the organ of vision caused by infection with pale treponema. The clinical picture is determined by the localization of pathological foci. When the anterior part of the eyes is affected, hard chancres, gummas are detected, which leads to increased lacrimation, pain, hyperemia, photophobia. The symptoms of syphilis of the uveal tract and optic nerve are dominated by visual dysfunction. To make a diagnosis, an ophthalmological examination and serodiagnostics are performed. Specific therapy is reduced to the appointment of penicillin-type drugs. Additionally, symptomatic treatment is carried out.
General information
The lesion of the eye and its appendages in syphilis was first described in 1906 by the Italian scientist Bartarelli after the introduction of pale treponema into the anterior chamber of the eyeball. According to epidemiological features, there are early (up to 2 years) and late (more than 2 years) forms of the disease. It is proved that persons with early syphilis are the most contagious. In males, pathology is registered 2-6 times more often than in women. The disease can develop at any age, but the lesion of the cornea is more often observed with a late congenital variant of the course in young people 6-20 years old. Ophthalmopathology is characterized by ubiquity.
Causes of syphilis eye
The development of syphilis is caused by infection with pale treponema (Schaudin-Hoffman spirochete). The causative agent of the disease has various morphological variants. For the early stages of the disease, a spiral shape is characteristic, for the later stages – incised and L-forms of treponema. Under unfavorable conditions, the spirochete forms specific “forms of survival”, which often cause relapses of pathology. The source of infection is a sick person. There are several ways of transmitting syphilis: direct (sexual, household, transfusion, intrauterine infection of the fetus) and indirect (through everyday items infected with pale treponema).
Pathogenesis
In the mechanism of development of syphilis, there are 3 periods that successively replace each other – primary, secondary, tertiary. During the primary period, inflammatory changes develop at the site of the introduction of the pathogen. This entails the formation of a solid chancre. From 6 to 7 weeks, generalization of infection is noted, which indicates the beginning of the secondary period. Due to the spread of infectious agents by lymphohematogenic (less often – neurogenic) pathways, the phenomenon of spirochete sepsis occurs. Intoxication and asthenovegetative syndrome are detected.
The effect of pale treponema and decay products is the basis of allergic reactions. Clinical manifestations of the disease disappear on their own, which indicates a transition to a latent stage. In the absence of timely treatment, the pathology recurs. The symptoms of the tertiary period develop 3-4 years after the appearance of the first signs. Tertiary syphilids are tubercles and gummas. The peculiarity of the infectious process is the constant alternation of phases of active and latent manifestations. Due to a decrease in immunity, cases of re-infection are often observed.
Symptoms of syphilis eye
In the primary period, the lesion of the appendages of the eye is characterized by the formation of a solid chancre or gum. Pathological formations are usually localized in the lateral corners of the eye, along the periphery of the eyelids, less often they pass to the conjunctiva. Initially, patients note the appearance of a hyperemia zone, which eventually takes the form of a papule. Further, an erosive defect of bright red color forms on its surface, on which a scar forms after 25-35 days. The base of the formation is dense, with raised edges, a tire on the surface. When located on the semilunar fold of the conjunctiva, the chancre has a longitudinal shape, dense consistency. The mucous membrane above the formation is covered with fibrinous plaque. In most cases, the number of chancres does not exceed 1-2. Multiple lesions are rarely observed. The severe course is indicated by the development of tarsitis.
The secondary period begins 2-4 weeks after the formation of a scar defect. On the skin of the eyelids and conjunctiva, specific exanthemums appear in the form of roseoles, papules, pustules. The disappearance of secondary rashes leads to the formation of hyperpigmentation zones. Frequent relapses are noted. Localization of pathological elements of the rash on the periphery of the eyelid provokes the loss of eyelashes. Patients complain about the appearance of enlarged painful regional lymph nodes. The tertiary period is indicated by the formation of gum, which have the appearance of painless brown nodules of different sizes with a shiny surface. After their decay, ulcers form. The lymph nodes do not change at the same time.
When the cornea is affected, diffuse parenchymal keratitis develops. At the stage of infiltration, patients note eye pain, photophobia, increased lacrimation. At the same time, grayish infiltrates form in the peripheral parts. The stage of vascularization is characterized by an increase in clinical symptoms, a decrease in visual acuity. The period of reverse development lasts about 6-8 weeks. When a pathological process occurs in the uveal tract, non-granulomatous, papular or gummous iridocyclitis is observed. The fibrinous nature of the disease is most common in congenital syphilis. Early progressive visual dysfunction is noted.
Syphilitic lesion of the visual pathway in the chiasm is manifested by the loss of the temporal halves of the visual field. Visual acuity decreases against the background of complete well-being, which often complicates diagnosis. With optic nerve neuritis, pronounced visual dysfunction is accompanied by the appearance of “fog” or dark spots in front of the eyes. Patients often experience a throbbing headache, dizziness, nausea, vomiting, disorientation in space. The presence of large-sized chancres or gum with intraocular localization causes a persistent increase in intraocular pressure.
Complications
Syphilitic lesion of the eyelids is complicated by ulcerative blepharitis. The formation of scar defects leads to deformation of the eyelids, the development of ectropion. When the orbital conjunctiva is affected, conjunctivitis occurs, clinical symptoms of psedopterygium. A characteristic complication of the secondary and tertiary periods of syphilis is chronic dacryoadenitis. Possible opacification or neovascularization of the cornea, avascular keratitis. Less often there is atrophy of the iris, iridocyclitis, anterior chorioretinitis. An undesirable consequence of damage to the uveal tract is hypopion, hyphema. With severe syphilis eye, blindness develops.
Diagnostics
Patients with suspected syphilis are prescribed a special examination complex. Visual examination reveals such changes as hard chancre, gum, tubercles, pathological rashes. Used for diagnosis:
- Biomicroscopy of the eye. The basic diagnostic method for pathology of the eyelids, orbital conjunctiva and cornea of the eye. Allows you to study the features of the morphological structure of solid chancre or gum, to assess the depth of the lesion, the severity of secondary changes in the surrounding tissues.
- Tonometry. An increase in intraocular pressure is determined with an intraorbital arrangement of secondary elements of syphilis. In case of damage to the trabecular network, the outflow of intraocular fluid is disrupted. Electronic tonography is used to study intraocular hydrodynamics.
- Visometry. Depending on the affected area, the degree of visual acuity reduction varies from minor visual dysfunction to blindness.
- Perimetry. The technique makes it possible to study the nature of the lesion of the visual field (concentric narrowing or loss of the temporal halves from the field of view), to identify central scotomas.
- Ultrasound of the eyes. Ultrasound examination allows you to visualize turbidity or foci of destruction of the vitreous body, to determine the volume indicators of pathological formations, to measure the longitudinal axis of the eyeball.
- Ophthalmoscopy. When examining the fundus, the ophthalmologist detects edema of the optic nerve disc, gray exudate and hemorrhage zones along its peripheral edge. Ophthalmoscopically revealed areas of hyperpigmentation, gum of the vascular membrane in the form of nodules of yellow or greenish color.
- Optical coherence tomography. It is used for the purpose of diagnosing the features of the lesion of the visual apparatus (optic nerve disc, retina) with opacity of optical media.
The most informative way to confirm the diagnosis is to identify treponemas in the lesion. In the secondary period, blood serum or cerebrospinal fluid is used to determine the increase in antibody titer by complement binding reaction (CBR) and immunofluorescence reaction (IF). Serological diagnostics can also be carried out using:
- Wasserman’s reactions. The express technique is used at the initial stage of examination of the patient in the hospital. The intensity of the binding reaction of cardiolipin with antiphospholipid antibodies makes it possible to establish a preliminary diagnosis or exclude the disease.
- Sedimentary tests. They include the Kahn and Sachs-Vitebsk reactions, which require special antigens.
- Treponema pallidum immobilization. (TPI). The technique is based on determining the ability of the patient’s blood serum to stop the movement of treponemas. To prevent distortion of the results before TPI with syphilitic serum antibodies, it is necessary to cancel antibiotic therapy for 3 weeks.
Treatment of syphilis eye
If the presence of the disease is suspected, symptomatic therapy is indicated, which increases the effectiveness of the main treatment. Specific conservative therapy is carried out only with positive results of serological diagnostics. Surgical intervention (keratoplasty) is resorted to in the presence of secondary scarring. In ophthalmology , the algorithm for managing a patient with an established diagnosis of syphilis eye includes the appointment of the following medications:
- Bismuth preparations. They are used during the preparation of the patient for antibacterial therapy. The effectiveness of the use of colloidal bismuth subcitrate, bismuth nitrate has been proven.
- Antibacterial therapy. Pale treponema is most sensitive to penicillin-type drugs. The duration of the course of penicillin therapy is 1.5-2 months. There should be at least 7-8 courses in total. With individual intolerance and hypersensitivity, erythromycin is used.
- Pyrogenic preparations. They have immunomodulatory, anti-inflammatory and desensitizing properties. The ability to increase the general and specific resistance of the body, a positive effect on the thermoregulatory centers of the hypothalamus is noted.
- Hyposensitizing agents. They are shown in the primary and secondary periods of syphilis. Reduce the severity of secondary allergic reactions, affecting H1-receptors to histamine.
- Preparations of the pyrimidine series. Medications (methyluracil, pentoxil) are prescribed cyclically. The duration of one cycle should be at least 18-20 days. The drugs have an immunostimulating and leukopoietic effect.
- Vitamin therapy. Vitamins of group B, C are shown, and vitamins of group A are shown in case of damage to the optic nerve.
In syphilitic lesions of the cornea and uveal tract, instillations, subconjunctival and parabulbar injections of mydriatics, corticosteroids are additionally used. Manifestations of optic neuritis require the appointment of vasodilators, glutamic acid. In case of optic nerve atrophy, nicotinic acid, riboflavin, calcium pangamate are used 3 weeks before the start of anti-syphilitic treatment. After completion of therapy, clinical and serological control is carried out. In case of a positive result, another 1 course of penicillin therapy is prescribed, after which the serodiagnosis is repeated.
Prognosis and prevention
The prognosis for syphilis eye is determined by the features of the clinical course and localization of the affected area. When the anterior part of the eyeball is involved in the pathological process, the outcome is favorable. Neuritis or atrophy of the optic nerve of syphilitic origin often leads to complete loss of vision. Individual prevention is based on the use of contraceptives. The basis of public preventive measures is the serological diagnosis (Wasserman reaction) upon admission of the patient to the hospital, scheduled preventive examinations.
