Ocular Syphilis

What is ocular syphilis?

Ocular syphilis is an eye condition that can happen if you have syphilis that isn’t treated. Syphilis is a sexually transmitted infection (STI), a bacterial infection. The infection can also spread to the fetus through pregnancy.

Untreated syphilis can move into other organs and body systems, including your nervous system and your brain (neurosyphilis). Untreated syphilis can also affect:

• Your eyes (ocular syphilis or eye syphilis).
• Your ears (otosyphilis).

Without treatment, ocular syphilis can lead to vision loss and even blindness.

How common is ocular syphilis?

Globally, there are some 12 million new cases of syphilis per year, with about 55,400 of them in the United States. Ocular syphilis happens in an estimated 1% to 5% of cases of neurosyphilis in the United States.

What are the signs and symptoms of ocular syphilis?

Healthcare providers describe syphilis as “the great imitator” because it can look like so many other diseases.

You can show symptoms of ocular syphilis at any stage of syphilis, though it may be more common in later stages. If you aren’t treated, your disease progresses through stages. Broadly, the stages of syphilis are:

• Primary: This stage can start anywhere from two to 12 weeks after you’ve been exposed to someone with syphilis. You’ll have a painless sore on your genitals that goes away, but you’re still able to pass the infection on.
• Secondary: One to six months after the sore goes away, you’ll develop a rash on your body. You can pass the infection at this stage.
• Latent: If you aren’t treated, you’ll still have syphilis at this stage, but you may not have any signs or symptoms. You’re unlikely to pass the infection on to sexual partners at this stage.
• Tertiary: This stage, also called the late stage, is the one where serious health problems can happen.

General signs and symptoms of syphilis may include:

• Red eyes.
• Eye floaters.
• Eye pain.
• Sensitivity to light (photophobia).
• Abnormal eye movements.
• Argyll Robertson pupil, a term that refers to small pupils that get smaller (constrict) when focusing on a near object, but not when they’re exposed to bright light.
• Blurred vision or vision loss.
• Lesions (bumps or spots) on or in your eyes.
• Chancre (painless sore) on eyelid (rare).

What part of the eyes does ocular syphilis affect?

Syphilis can affect any part of your eyes, but it affects your uvea most often. The uvea is the part of your eye that’s underneath the white of your eye (sclera). The iris, the choroid and the ciliary body make up the uvea.

Uveitis is the name for inflammation and infection in the uvea. Many healthcare providers believe that they should test everyone who has uveitis for syphilis just to be sure.

What causes ocular syphilis?

The bacterium Treponema pallidum is the cause of syphilis and ocular syphilis.

How does ocular syphilis spread?

Syphilis spreads by close skin-to-skin contact with an infected person. Most often, syphilis spreads through unprotected oral, anal and vaginal sex.

A pregnant person can also pass the infection to their fetus. This is why it’s important for providers to test for syphilis in pregnant people. Having syphilis can harm the fetus.

What are the risk factors for ocular syphilis?

You might have a higher risk for ocular syphilis if you:

• Have unprotected sex, especially if you have more than one partner.
• Are a man who has sex with men (MSM).
• Currently have HIV or test positive for another STI.
• Have had sex with someone who’s tested positive for syphilis.

What are the complications of ocular syphilis?

Complications over time of ocular syphilis may include:

• Cataracts.
• Neovascularization of your eye.
• Corneal opacity (the cornea is no longer see-through).
• Glaucoma.
• Macular pucker.
• Macular edema (swelling of the macula).
• Scarring of eye tissue.

How is ocular syphilis diagnosed?

To diagnose ocular syphilis, your health care provider will ask you questions about your symptoms and medical history. An eye care provider will do a complete eye exam and other tests. They’ll check:

• Visual acuity.
• Your pupils.
• Your eye pressure.
• Your blood serum.
• Your cerebrospinal fluid (CSF).

What tests will be done to diagnose ocular syphilis?

Some of the tests for ocular syphilis include:

• Blood tests.
• Tonometry.
• Slit lamp exam.
• Fluorescein angiography.

How is ocular syphilis treated and cured in adults?

Providers treat and cure ocular syphilis with antibiotics, primarily penicillin. The specifics depend on the stage of syphilis. Your provider may also recommend topical or other oral drugs for ocular syphilis.

Treating ocular syphilis with antibiotics and other medications

In general, your provider will suggest:

• Intravenous (IV, through your vein) penicillin G antibiotics for 10 to 14 days.
• Intramuscular (through your muscle) injections of benzathine penicillin G along with oral probenecid for three weeks.
• Ceftriaxone or azithromycin if you’re allergic to penicillin.

IV penicillin is the preferred treatment for ocular syphilis and neurosyphilis. If you’re allergic to penicillin, your provider may try to desensitize you to the drug so you can take it.

Note: There’s an exception to antibiotics for ocular syphilis. If you have syphilitic keratitis, your provider will prescribe steroids instead of antibiotics.

After you start antibiotic treatment, your provider may suggest you take oral steroids or use topical steroids for inflammation. Your provider may also suggest other topical medicines, like:

• Nonsteroidal anti-inflammatories (NSAIDS).
• Lubricants for your eyes.
• Medication to dilate your pupils (mydriatics).

Complications/side effects of the treatment

Syphilis treatments may have some side effects or risks. Some of these include:

• Jarisch-Herxheimer reaction (JHR): This type of reaction can happen with IV medicines. Your provider will look for fever and sweats, headaches, rashes that get worse or increased inflammation in your eyes.
• Permanent vision loss: Taking only steroids, without antibiotics, can result in vision loss you can’t recover. If you have syphilitic uveitis, you need to take antibiotics, too.
• Complications from steroid usage: Steroids are very useful drugs, but they can cause side effects when taken for a long time. Some of these side effects include weight gain, mood changes, difficulty sleeping and higher blood pressure and blood sugar.

How soon after treatment will I feel better?

The treatment for ocular syphilis lasts about two weeks, or sometimes even longer. You may begin to feel better after a few days of treatment, but you’ll need to complete the entire course of prescribed medicine.

Can ocular syphilis be prevented?

The only way to prevent syphilis, which can lead to ocular syphilis, is to avoid sexual activity with someone with syphilis and to avoid touching syphilis sores.

How can I lower my risk?

You can lower your risk by:

• Abstaining from sex.
• Having sex with only one other person who’s tested negative for any type of STI.
• Using latex condoms and dental dams correctly when you have anal, oral or vaginal sex with other people.

What can I expect if I have ocular syphilis?

You’ll have to ask your provider about when to return to work or school. You’ll have to work around your scheduled intravenous or intramuscular antibiotics.

What is the outlook for ocular syphilis?

Syphilis, including ocular syphilis, has a cure. Like nearly all other eye diseases, diagnosing and treating ocular syphilis early gives better outcomes in terms of your vision. Other factors, such as having HIV or poor vision to begin with, also play a role in the prognosis (outlook).

When should I see my healthcare provider about ocular syphilis?

See your healthcare provider if you notice any change in vision or new and worsening symptoms.

When should I go to the emergency room (ER)?

Go to the ER if you have:

• A sudden loss of vision.
• Severe pain in your eye.
• Any reaction to medicine that affects your breathing.

What questions should I ask my healthcare provider about ocular syphilis?

You may want to ask your provider questions like these:

• What should I know about ocular syphilis?
• What treatment do you recommend?
• What should I know about the risks related to treatment?
• What side effects do you want to know about immediately?
• What’s the process for telling sexual partners that they may also have syphilis?

A note from Cleveland Clinic

No one wants to hear that they’ve tested positive for any sexually transmitted infection, such as syphilis. You might think that STIs only affect your reproductive organs, but that’s not the case with syphilis. It can affect your eyes, and ocular syphilis can lead to vision loss and even blindness. However, your provider can cure ocular syphilis with early and complete antibiotic treatment. Make sure you let your provider know if you’ve ever had a sensitivity to penicillin because penicillin treatment is the preferred therapy.