Ocular Immunology & Inflammation, Early Online, 1–8, 2014 ! Informa Healthcare USA, Inc. ISSN: 0927-3948 print / 1744-5078 online DOI: 10.3109/09273948.2014.925122
Rhegmatogenous Retinal Detachment in Patients with Acute Syphilitic Panuveitis Sara J. Haug, MD, PhD, 1,2, Ako Takakura, MD, 1, J. Michael Jumper, MD, 1,2, David Heiden, MD, 2, H. Richard McDonald, MD, 1,2, Robert N. Johnson, MD, 1,2, Arthur D. Fu, MD, 1,2, Brandon J. Lujan, MD, 1,2,3, and Emmett T. Cunningham, Jr., MD, PhD, MPH, 1,2,4,5 Ocul Immunol Inflamm Downloaded from informahealthcare.com by Nyu Medical Center on 07/21/15 For personal use only.
1
Department of Ophthalmology, California Pacific Medical Center, San Francisco, California, USA, 2West Coast Retina Medical Group, San Francisco, California, USA, 3Department of Vision Science, School of Optometry, University of California, Berkeley, California, USA, 4Department of Ophthalmology, Stanford University School of Medicine, Stanford, California, USA, and 5The Francis I. Proctor Foundation, UCSF School of Medicine, San Francisco, California, USA
ABSTRACT Purpose: To describe the clinical characteristics and surgical management of rhegmatogenous retinal detachment (RD) in patients with acute syphilitic panuveitis. Methods: Retrospective case series and comprehensive literature review. Results: Including present and previously reported cases, we identified 11 eyes in 8 patients with acute syphilitic panuveitis that developed a rhegmatogenous RD. Seven of 11 eyes (63.6%) were repaired with a combined scleral buckling, vitrectomy, and endolaser photocoagulation surgery; 1 eye (9.1%) was repaired with scleral buckling only; and 2 eyes (18.2%) with vitrectomy only. Cryotherapy was used to treat a giant retinal tear in 1 eye (9.1%). Four eyes (36.4%) redetached and 3 underwent a second vitrectomy surgery. Conclusions: Although uncommon, rhegmatogenous RD can occur in patients with moderate to severe acute syphilitic panuveitis. We believe scleral buckling, vitrectomy, endolaser photocoagulation, and silicone oil tamponade give the best chance for successful retinal reattachment. Keywords: Giant retinal tear, lues, proliferative vitreoretinopathy, retina detachment, retinitis, syphilis, uveitis
Acquired syphilis is a serious sexually transmitted disease caused by the spirochete Treponema pallidum.1,2 The World Health Organization has estimated that the total annual incidence of syphilis worldwide exceeds 11 million, with over 90% infections occurring in the developing world and being both undiagnosed and latent.3 In the United States, the annual rate of primary and secondary syphilis reached its lowest recorded level in 2000, but then increased steadily for over a decade.4 A similar resurgence in incidence was observed in Europe during this timeframe.5,6 Much of these increases have been driven by an increase in high-risk sexual behavior, particularly among men who have sex with men (MSM).
Ocular inflammation is an uncommon manifestation of syphilis, but can be the presenting sign of infection.1,2 Common complications of ocular syphilis include anterior uveitis, vitritis, papillitis, chorioretinitis, and retinitis, often with superficial retinal precipitates and retinal vasculitis.1,2,7,8 While exudative retinal detachments (RD) are well known to occur in eyes with syphilitic chorioretinitis,8–12 reports of rhegmatogenous RD in eyes with acute syphilitic uveitis are uncommon.13–15 We present here four new cases of rhegmatogenous RD that occurred in the setting of acute syphilitic panuveitis, followed by a comprehensive review of previously reported cases.
Received 8 August 2013; revised 19 March 2014; accepted 13 May 2014; published online 24 June 2014 Correspondence: Sara J. Haug, MD, PhD, West Coast Retina Medical Group, Inc., 1445 Bush Street, San Francisco, CA 94109, USA. E-mail: [email protected]
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FIGURE 1. Color photomontage of the right eye showing an area of syphilitic retinitis and vasculitis in the temporal mid-periphery of case 1.
CASE REPORTS Case 1 A 45-year old man with a 20-year history of HIV infection and a recent CD4 count of 200 cells/uL presented with pain and blurry vision in the left eye of unknown duration. Best-corrected visual acuity (BCVA) at presentation was 20/40 in the right eye and 10/200 in the left. Anterior segment examination on the left showed severe inflammation with hypopyon and scattered posterior synechiae. Posterior segment examination on the left revealed moderately severe vitritis and a large area of active retinitis in the superotemporal fundus. The right eye was initially unaffected, but over the next weeks developed optic disc swelling and an area of retinal whitening in the temporal mid-periphery (Figure 1). Syphilis serologies were notable for a positive rapid plasma reagin (RPR) test at 1:1024, prompting treatment for neurosyphilis with a 10-day course of intravenous penicillin. Three weeks following completion of penicillin treatment, the patient developed an inferior maculaoff rhegmatogenous RD in the right eye with multiple retinal breaks in the inferotemporal periphery. The rhegmatogenous breaks and detachment were not in an area of prior retinitis; most likely these were the result of vitreous contraction given the previous inflammation and now healed retinitis. At the time of the detachment, there was no active retinitis or vasculitis. The vitreous was dense and the view posteriorly was hazy, but there did not appear to be cells in the vitreous at the time of detachment nor was there a complete posterior vitreous detachment. The patient underwent placement of a scleral buckle with vitrectomy, membranectomy, endolaser photocoagulation, and gas–fluid exchange with C3F8 gas. Following the surgery, the patient was treated with hourly prednisolone acetate drops in the surgical eye for the first week and then slowly tapered. The patient was followed weekly after the initial
FIGURE 2. Color photomontage of the right eye of case 1 following second successful retinal detachment repair.
postoperative visit for the first 3 weeks to monitor the inflammation, then the visit interval was increased to every few weeks. Four months after the initial surgery, the retina redetached due to proliferative vitreoretinopathy and required lensectomy, vitrectomy, membrane peel, and endolaser photocoagulation with gas–fluid exchange. At his most recent follow-up visit approximately 9 years after initial presentation, the right retina was attached (Figure 2) and his BCVA was 20/80 on the right and 20/20 on the left with no evidence of active inflammation in either eye.
Case 2 A 47-year old man with a history of HIV infection and recently diagnosed and treated bilateral syphilitic panuveitis was referred for management of his uveitis. Best-corrected visual acuity was 20/160 on the right and 10/200 on the left. Anterior segment Ocular Immunology & Inflammation
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Retinal Detachment and Acute Syphilitic Panuveitis
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FIGURE 3. Color photomontages of the (A) right and (B) left eyes of case 2 at presentation.
examination showed trace cells in the anterior chamber and anterior vitreous bilaterally. Posterior segment examination on the right showed moderate vitreous inflammation, a sclerotic arteriole off the inferonasal aspect of the optic disc, and resolving superficial retinal precipitates in the mid-periphery (Figure 3A). Posterior segment examination on the left showed severe vitreous inflammation with barely visible large retinal vessels and optic disc (grade 3+; Figure 3B). Approximately 2 weeks later, the patient returned with acutely decreased vision on the left. His BCVA was 20/100 on the right and hand motion (HM) on the left. Anterior segment examination showed no inflammation in either eye, and posterior examination on the right showed marked improvement of the vitreous inflammation. Posterior examination on the left revealed a total rhegmatogenous RD in a funnel configuration with an attached hyaloid (Figure 4). No active posterior inflammation was observed. The patient underwent scleral buckling, vitrectomy, membranectomy, lensectomy, endolaser photocoagulation, and air–fluid exchange with silicone oil tamponade (Figure 5). During the surgery, it was noted there was an area of atrophic retina approximately 5 disc diameters in size with bare retinal pigment epithelium in the superonasal quadrant. A posterior vitreous detachment (PVD) was induced during surgery and the hyaloid peeled to the vitreous base. Proliferative membranes causing retinal folds were peeled with forceps, most notably around the optic disc. For control of postoperative inflammation, the patient was given prednisolone acetate eyedrops to be used 4 times daily the first week after surgery and tapered over the next 3 weeks. In addition, the patient had been started on oral prednisone previously and was continued on his prednisone taper. Three months post-operatively, an intraocular lens was placed at the time of silicone oil removal. Six months after the RD repair, best-corrected visual acuity is 20/32 on the right and 20/40 on the !
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FIGURE 4. B-scan ultrasonography of the left eye of case 2 showing a total rhegmatogenous retinal detachment in a funnel configuration.
left, with no evidence of active inflammation in either eye.
Case 3 A 56-year-old man with no past medical or ocular history presented with 3 months of decreased vision in the right eye. Best-corrected visual acuity was HM on the right and 20/30 on the left. Anterior segment examination on the right showed mild conjunctival injection and trace anterior chamber cell and flare. There was posterior synechiae and a dense posterior subcapsular cataract with significant phacodonesis and vitritis. The anterior segment examination on the left was normal. Posterior segment examination on the right revealed choroidal detachment throughout the periphery, particularly in the inferotemporal and
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FIGURE 5. Color photomontage of the left eye of case 2 following a scleral buckle, vitrectomy, membranectomy, lensectomy, endolaser, and air-fluid exchange with silicone oil placement.
superonasal periphery, but no associated retinal tear or detachment. The posterior segment examination on the left was unremarkable. The patient was found to be RPR and FTA-ABS positive and started on intravenous penicillin therapy for neurosyphilis. Six weeks after initial presentation, the choroidal detachment on the right resolved and there was severe elevation of his intraocular pressure. He also developed serous RD with associated retinitis along the inferotemporal arcade. The patient was then lost to follow-up without adequate treatment of the syphilis. Three months later, patient re-presented and completed IV penicillin therapy. His BCVA was HM OD with proliferative vitreoretinopathy and a maculaoff rhegmatogenous RD in the inferior and temporal quadrants, which corresponds to the location of the previous serous detachment. A star fold with proliferative membranes was observed inferotemporally along the inferior arcade. No PVD was appreciated. The left eye remained unaffected with BCVA of 20/20. The patient was given oral prednisone 70 mg per day for 3 days, followed by a slow taper. Surgical repair was done for the rhegmatogenous RD, which included scleral buckling, lensectomy, vitrectomy, membrane peeling (including subretinal membrane dissection), endolaser photocoagulation, and placement of silicone oil. Four months after the initial repair, the silicone oil was removed and the retina remains attached. Best-corrected visual acuity in the right eye was 20/200.
Case 4 A 32-year-old man presented with decreased vision in the right eye of 1-week duration. Best-corrected visual
acuity was 20/200 on the right and 20/25 on the left. Anterior segment examination on the right showed mild conjunctival injection, 360-degree posterior synechiae, and 3+ cell, 2+ flare with fibrin in the anterior chamber. Anterior segment examination on the left was normal. The posterior segment examination on the right was limited secondary to poor dilation and anterior chamber inflammation. B-scan did not demonstrate an RD or dense vitritis. Posterior segment examination on the left was unremarkable. Labs were sent and the patient was found to be HIV, RPR (titer 1:1024), and FTA-ABS positive. Treatment with intravenous penicillin G 2.4 million units every 4 h for 14 days was then initiated and completed. One month later, the patient presented with total RD, a superior retinal tear and proliferative vitreoretinopathy stage D, indicating fixed folds in all four quadrants, in the right eye. There was 2+ vitritis but no active anterior inflammation or retinitis. No posterior vitreous detachment was appreciated. The left eye had optic nerve head swelling but no retinal involvement. Surgical repair, including vitrectomy, membrane peel, endolaser photocoagulation, and silicone oil tamponade, was performed. Vitreous separation was achieved during the surgery. Following surgery, hourly prednisolone acetate drops were used to control postoperative inflammation for the first week, followed by a taper. Two months later, the retina redetached and was repaired with vitrectomy, endolaser photocoagulation, and silicone oil tamponade. Traction detachment with subretinal fluid and epiretinal membrane folds developed 1 month after the second surgery; therefore, a third vitrectomy was performed with membrane peeling. To aid in visualization, cataract surgery was also completed prior to the third vitrectomy. Six months after the initial surgery, a fourth vitrectomy with endolaser photocoagulation and silicone oil tamponade was performed for recurrent detachment. The patient’s retina is attached 10 months after the initial surgery with silicone oil in his right eye. Best-corrected visual acuity is 20/100 OD, 20/20 OS.
DISCUSSION We present 4 cases of rhegmatogenous retinal detachment as a complication of moderate to severe acute syphilitic panuveitis. All 4 patients were men and 3 were HIV positive. One of the eyes was noted to have an exudative RD preceding the development of a rhegmatogenous detachment. Three eyes developed total RD, including one in a funnel configuration, and all cases had proliferative vitreoretinopathy. Two of the 4 patients had recurrent RD following initial surgical repair. All retinas were ultimately reattached. Ocular Immunology & Inflammation
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Retinal Detachment and Acute Syphilitic Panuveitis Our literature review identified 7 additional cases in 4 patients of rhegmatogenous RD in association with acute syphilitic panuveitis.13–15 With the addition of our 4 cases, we present a total of 11 eyes in 8 patients (7 men, 1 woman) with rhegmatogenous RD secondary to syphilis. The average age at presentation was 42.5 years (range 32–56 years, median 43.5 years) and 75% were HIV positive. All patients had positive syphilis serologies (RPR, TPHA, VDRL, or FTA-Abs), and cerebrospinal fluid was positive in 37.5%. Two of the 11 eyes (18.2%) underwent diagnostic vitrectomy and 1 of those eyes was positive for VDRL in the vitreous fluid. Three eyes (27.3%) were noted to have an exudative RD prior to developing a rhegmatogenous detachment. Total RD was observed in 4 eyes (36.4%) and 1 eye had a giant retinal tear. Visual acuity at presentation was poor, at 20/200 or worse in 8 of 11 eyes (72.7%); however, 2 eyes (18.2%) had vision 20/ 40 or better and 1 eye (9.1%) had vision worse than 20/40 but better than 20/200 (Table 1). Prior exudative RD was noted in 2 of the 11 cases.14 In all cases, the rhegmatogenous retinal detachment occurred a few weeks to months after the treatment of syphilis as the inflammation was resolving or had resolved, likely the result of vitreous contraction following acute inflammation. In at least 4 of the 7 eyes, the retinal breaks occurred in areas of previous retinitis.13–15 Proliferative vitreoretinopathy was reported in 5 of the 11 eyes.13–15 Retinal detachment repair consisted of both scleral buckling and vitrectomy surgery for 7 of 11 eyes (63.6%). One eye (9.1%) was repaired with scleral buckle and 2 eyes (18.2%) with vitrectomy. Cryotherapy alone was performed on an eye with a giant retinal tear and no associated detachment. Of the 9 eyes that underwent vitrectomy surgery, silicone oil tamponade was placed in 6 eyes and C3F8 gas bubble tamponade was placed in 3 eyes. Four of the 11 eyes (46.4%) had recurrent RD and 3 of these eyes underwent an additional vitrectomy surgery. Three of 4 eyes with redetachments had previously undergone both vitrectomy and scleral buckling surgery with placement of gas bubble tamponade. The fourth eye with recurrent rhegmatogenous RD had initial vitrectomy surgery with endolaser photocoagulation and silicone oil tamponade. Of the 2 eyes treated with vitrectomy alone,13–15 1 redetached three more times and each time vitrectomy, endolaser photocoagulation, and silicone oil tamponade were performed for repair. Given the success of other cases with combined scleral buckling and vitrectomy procedures, it is possible that a buckle may be beneficial in eyes with areas of healed retinitis and prior vitreous inflammation. There is retrospective and anecdotal evidence supporting the use of a combined approach and in many vitreoretinal surgical centers, scleral buckle in combination with vitrectomy for more complicated cases is the !
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treatment of choice.16–19 The second eye that underwent vitrectomy surgery alone was complicated by a giant retinal tear with associated RD. This case was successfully managed with vitrectomy, endolaser photocoagulation, and silicone oil tamponade (Table 1). Another variable that may aid in successful reattachment of the retina is the use of silicone oil rather than C3F8 gas bubble as a retinal tamponade. In our small series, 3 of the 4 cases with recurrent RD had perfluoropropane gas bubble placed in the initial surgery. It is possible silicone oil tamponade in these complicated retinal detachments is of some benefit in providing retinal stability. The fourth case with recurrent RD was initially managed with vitrectomy, endolaser photocoagulation, and silicone oil tamponade and had multiple redetachments, as described above (Table 1). A lensectomy was performed in 4 cases as part of the surgical repair. Three of these cases resulted in successful retinal reattachment. The case that had redetachment of the retina had been initially managed with scleral buckling, lensectomy, vitrectomy, endolaser photocoagulation, and C3F8 gas bubble tamponade (Table 1). Lensectomy allows for more extensive vitreous removal anteriorly, which may contribute to successful reattachment of the retina. Analysis of all 11 cases appears to suggest a successful initial surgical approach to rhegmatogenous RD repair secondary to syphilitic panuveitis was scleral buckling, vitrectomy, endolaser photocoagulation, and placement of silicone oil tamponade (Table 1). In the 4 eyes managed with this surgical approach, the retina remained attached. Ten of the 11 eyes (91%) were attached at the most recent reported visit with 27% of eyes having vision of 20/40 or better. Another 5 eyes (45%) had vision worse than 20/40 but better than 20/200, and 3 eyes (27%) had visual result of 20/200 or worse. Of the 3 eyes with poor visual result, all presented with vision worse than 20/200. Moreover, visual acuity appeared to be associated with successful initial retinal reattachment. Of the 4 cases with recurrent RD, 2 eyes had outcome BCVA less than 20/200 at last visit, including 1 eye with a chronic macula-off RD. All of the eyes with final vision of 20/40 or better underwent a single surgical repair. Of the 3 eyes with a total retinal detachment, BCVA at last visit was surprisingly good, with 1 eye measuring 20/40 and 2 eyes 20/50.13–15 In conclusion, we present 4 new cases of rhegmatogenous RD secondary to moderate to severe acute syphilis panuveitis. Seven cases have been previously reported in the literature.13–15 Of the 11 total cases, 4 had recurrent RD following initial surgical repair. In our experience, scleral buckling, vitrectomy, endolaser photocoagulation, and silicone oil tamponade provide patient the best chance for anatomical reattachment following a single surgery.
Pournaras et al. (2006)15
Williams et al. (1996)14
Previously Passo and Published Rosenbaum Cases (1988)13
Author (Year)
M
M
M
F
F
M
M
40
40
33
33
45
45
Gender
42
Age (years)
+
+
+(172)
+(172)
+
HIV status (CD4 count) Diagnostic Study
Mild anterior chamber Serum + VDRL, cellular reaction with Cerebral spinal posterior synechiae. fluid + for VDRL Posteriorly, there was 3+ vitritis with perivascular retinal pigment epithelial clumping and inferior exudative retinal detachment. Mild anterior chamber Serum + VDRL, cellular reaction, 2+ Cerebral spinal vitritis with a fluid + for VDRL sheathed vessel in the inferotemporal quadrant, perivascular retinal pigment epithelial clumping and inferior exudative retinal detachment. 2+ anterior chamber Serum + TPHA cell and flare with and VDRL severe vitritis (1:32), Cerebral spinal fluid + VDRL 2+ anterior chamber Serum + TPHA cell and flare with and VDRL severe vitritis (1:32), Cerebral spinal fluid + VDRL
Dense panuveitis with Serum + VDRL retinitis superotemporally and inferotemporally
The anterior chamber Serum + RPR and had 4+ cell and flare FTA-ABS, with keratic precipiCerebral spinal tates and posterior fluid + for FTAsynechiae. ABS Posteriorly, there was optic disc swelling, peripapillary sheathing of retinal vessels, and many small, white subretinal deposits throughout the periphery Dense panuveitis with Serum + VDRL, retinitis superoVitreous temporally fluid + VDRL
Inflammation
No
No
No
No
No
Yes
No
Diagnostic Vitrectomy Performed
Left Eye
Right Eye
Left Eye
Right Eye
Left Eye
Right Eye
Left Eye
Eye with detachment
No
No
Yes
Yes
No
No
No
Prior Exudative Detachment Type of Repair
Yes
No
No
No
Giant retinal tear Vitrectomy, endowith detachment laser, silicone oil
No
Initial exudative Scleral buckle, Yes, required detachment vitrectomy, lenvitrectomy, followed by sectomy, internal membrane tractional drainage of sub- peel, endolaser, detachment retinal fluid, silicone oil secondary to endolaser, perproliferative fluoropropane vitreoretinopagas thy, which led to rhegmatogenous breaks Giant retinal tear, CryophotoNo not associated coagulation with detachment
Total detachment Scleral buckle, with horseshoe vitrectomy, tear in superomembrane peel, temporal quadinternal drairant in area of nage of subrethealed retinitis inal fluid, endolaser, silicone oil Near total Scleral buckle, detachment with vitrectomy, breaks in areas membrane peel, of healed retina internal draiwith dense epir- nage of subretetinal inal fluid, membranes endolaser, silicone oil Exudative Scleral buckle, detachment vitrectomy, lenfollowed by sectomy, internal rhegmatogenous drainage of subdetachment retinal fluid, endolaser, perfluoropropane gas
Rhegmatogenous Scleral buckle retinal detachment, left eye
Description of Detachment
Re-detachment, type of secondary repair
TABLE 1. Summary of Previously Reported and Current Cases of Rhegamatogenous Retinal Detachment with Syphilitic Panuveitis.
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Attached
Attached
Attached*
Macula detached
Attached
Attached
Attached
Final Outcome
LP
HM
HM
20/40
2/200
5/200
CF at 2 Ft
Initial BestCorrected Visual Acuity
HM
20/30
20/25
3/200
20/50
20/50
20/60
Best-Corrected Visual Acuity at Last Visit
NR
NR
10
10
8
8
25
Duration of Follow-Up (months)
Summary
Current Cases
47
56
(2)
(3)
M
M
M
+
+(200)
No
No
2 of 11 eyes (18.2%) underwent diagnostic vitrectomy
Serum + RPR and FTA-ABS
8 of 8 patients (100%) had positive serologies, 3 of 8 patients (37.5%) also had positive CSF, 1 patient had positive vitreal fluid
No
Yes
Serum + RPR and FTA-ABS
2+ conjunctival injec- Serum + RPR tion, 4+ cell in the anterior chamber with posterior synechiae and trace hypopyon. Posteriorly, there was 2+ vitritis with a large area of active retinitis in the superotemporal quadrant. Circumlimbal injecSerum + RPR tion with trace cell in the anterior chamber with posterior synechiae. Posteriorly, there was 3+ vitreous inflammation.
Mild conjunctival injection, trace cell and flare in the anterior chamber with posterior synechiae, 3+ vitritis, choroidal detachment. Optic nerve swelling developed two months later with serous retinal detachment and associated retinitis along the inferotemporal arcade. (4) 32 M + Mild conjunctival injection, 360-degree posterior synechiae, 3+ cell and 2+ flare with fibrin in the anterior chamber. There was no view to the posterior pole, Bscan did not show dense vitritis or retinal detachment. 6 of 8 All eyes had moderate 7 of 8 n = 11 eyes Mean: patients patients to severe vitritis. (8 patients) 42.5 (75.0%c) Moderate to severe Mediaanterior chamber male HIV+ n: 43.5 inflammation in 7 of Range: (87.5%) 11 eyes (63.6%) 32–56
45
(1)
6 of 11 (54.5%) right eye
Right Eye
Right Eye
Left Eye
Right Eye
3 of 11 eyes (27.3%) had prior exudative detachment
No
Yes
No
No
No
No
Attached
Attached
HM
20/200
10/200
20/40
4 of 11 eyes 1 of 11 eyes (9%) 10 of 11 eyes (1) 18.2% 3 of 11 eyes (36.4%) had a was repaired with (27.2%) required (90.9%) remained (2 eyes) presented with 20/ total retinal scleral buckle additional surattached at last 40 vision or detachment; 1 of only; 7 of 11 eyes gery: two eyes visit better 11 (9.1%) had a (63.6%) were had a previous (2) 9.1% (1 eye) giant retinal tear repaired with scleral buckle had vision both scleral plus vitrectomy; worse than 20/ buckle and one eye had 40 but better vitrectomy; 2 of vitrectomy alone than 20/200 11 eyes (18.2%) (3) 72.7% (8 with virectomy eyes) had vision only; the giant 20/200 or worse tear was treated with cryotherapy only (9.1%).
Attached Total detachment Vitrectomy, mem- Yes, requiring three additional with proliferabrane peel, surgeries includtive vitreoretino- endolaser, silicone oil ing vitrectomy, pathy and membrane peel, superior retinal endolaser, silitear cone oil
Scleral buckle, lensectomy, vitrectomy, membrane peel, internal drainage of subretinal fluid, endolaser, silicone oil Total detachment Scleral buckle, with proliferalensectomy, tive vitreoretino- vitrectomy, pathy and membrane peel, inferior retinal endolaser, silibreaks cone oil
Total retinal detachment in funnel configuration
Inferior macula- Scleral buckle, Yes, required len- Attached off rhegmatovitrectomy, sectomy, vitrectgenous detachmembrane peel, omy, membrane ment with internal draipeel, endolaser, retinal breaks in nage of subretperfluoroprothe inferoteminal fluid, pane gas poral periphery endolaser, perfluoropropane gas
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10
18
6
108 (9 years)
(1) 27.3% Mean: 25.7 (3 eyes) had final Median: 10 vision of 20/40 Range: 4–108 vision or better (2) 45.5% (5 eyes) had vision worse than 20/40 but better than 20/ 200 (3) 27.3% (3 eyes) had vision 20/200 or worse
20/100
20/200
20/40
20/80
DECLARATION OF INTEREST The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper. This study was supported in part by the Pacific Vision Foundation and the Retina Foundation.
9.
10.
11.
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comprehensive review of the literature. Retina. 2012;32: 1915–1941. DeLuise VP, Clark 3rd SW, Smith JL. Syphilitic retinal detachment and uveal effusion. Am J Ophthalmol. 1982;94: 757–761. Jumper JM, Machemer R, Gallemore RP, Jaffe GJ. Exudative retinal detachment and retinitis associated with acquired syphilitic uveitis. Retina. 2000;20:190–194. Diaz-Valle D, Allen DP, Sanchez AA, et al. Simultaneous bilateral exudative retinal detachment and peripheral necrotizing retinitis as presenting manifestations of concurrent HIV and syphilis infection. Ocul Immunol Inflamm. 2005;13:459–462. Pan SW, Yusof NS, Hitam WH, et al. Syphilitic uveitis: report of 3 cases. Int J Ophthalmol. 2010;3:361–364. Passo MS, Rosenbaum JT. Ocular syphilis in patients with human immunodeficiency virus infection. Am J Ophthalmol. 1988;106:1–6. Williams JK, Kirsch LS, Russack V, Freeman WR. Rhegmatogenous retinal detachments in HIV-positive patients with ocular syphilis. Ophthalmic Surg Lasers. 1996;27:699–705. Pournaras JA, Laffitte E, Guex-Crosier Y. Bilateral giant retinal tear and retinal detachment in a young emmetropic man after Jarish-Herxheimer reaction in ocular syphilis. Klin Monbl Augenheilkd. 2006;223:447–449. Adelman RA, Parnes AJ, Sipperley JO, et al. Strategy for the management of complex retinal detachments: The European vitreo-retinal society retinal detachment study report 2. Ophthalmology. 2013;120:1809–1813. Mansouri A, Almony A, Shah GK, et al. Recurrent retinal detachment: does initial treatment matter? Br J Ophthalmol. 2010;94:1344–1347. Heimann H, Bartz-Schmidt KU, Bornfeld N, et al. Scleral buckling versus primary vitrectomy in rhegmatogenous retinal detachment study group: a prospective randomized multicenter clinical study. Ophthalmology. 2007;114: 2142–2154. Sharma T, Challa JK, Ravishankar KV, et al. Scleral buckling for retinal detachment. Retina. 1994;14:338–343.
Rhegmatogenous Retinal Detachment in Patients with Acute Syphilitic Panuveitis Sara J. Haug, MD, PhD, 1,2, Ako Takakura, MD, 1, J. Michael Jumper, MD, 1,2, David Heiden, MD, 2, H. Richard McDonald, MD, 1,2, Robert N. Johnson, MD, 1,2, Arthur D. Fu, MD, 1,2, Brandon J. Lujan, MD, 1,2,3, and Emmett T. Cunningham, Jr., MD, PhD, MPH, 1,2,4,5 Ocul Immunol Inflamm Downloaded from informahealthcare.com by Nyu Medical Center on 07/21/15 For personal use only.
1
Department of Ophthalmology, California Pacific Medical Center, San Francisco, California, USA, 2West Coast Retina Medical Group, San Francisco, California, USA, 3Department of Vision Science, School of Optometry, University of California, Berkeley, California, USA, 4Department of Ophthalmology, Stanford University School of Medicine, Stanford, California, USA, and 5The Francis I. Proctor Foundation, UCSF School of Medicine, San Francisco, California, USA
ABSTRACT Purpose: To describe the clinical characteristics and surgical management of rhegmatogenous retinal detachment (RD) in patients with acute syphilitic panuveitis. Methods: Retrospective case series and comprehensive literature review. Results: Including present and previously reported cases, we identified 11 eyes in 8 patients with acute syphilitic panuveitis that developed a rhegmatogenous RD. Seven of 11 eyes (63.6%) were repaired with a combined scleral buckling, vitrectomy, and endolaser photocoagulation surgery; 1 eye (9.1%) was repaired with scleral buckling only; and 2 eyes (18.2%) with vitrectomy only. Cryotherapy was used to treat a giant retinal tear in 1 eye (9.1%). Four eyes (36.4%) redetached and 3 underwent a second vitrectomy surgery. Conclusions: Although uncommon, rhegmatogenous RD can occur in patients with moderate to severe acute syphilitic panuveitis. We believe scleral buckling, vitrectomy, endolaser photocoagulation, and silicone oil tamponade give the best chance for successful retinal reattachment. Keywords: Giant retinal tear, lues, proliferative vitreoretinopathy, retina detachment, retinitis, syphilis, uveitis
Acquired syphilis is a serious sexually transmitted disease caused by the spirochete Treponema pallidum.1,2 The World Health Organization has estimated that the total annual incidence of syphilis worldwide exceeds 11 million, with over 90% infections occurring in the developing world and being both undiagnosed and latent.3 In the United States, the annual rate of primary and secondary syphilis reached its lowest recorded level in 2000, but then increased steadily for over a decade.4 A similar resurgence in incidence was observed in Europe during this timeframe.5,6 Much of these increases have been driven by an increase in high-risk sexual behavior, particularly among men who have sex with men (MSM).
Ocular inflammation is an uncommon manifestation of syphilis, but can be the presenting sign of infection.1,2 Common complications of ocular syphilis include anterior uveitis, vitritis, papillitis, chorioretinitis, and retinitis, often with superficial retinal precipitates and retinal vasculitis.1,2,7,8 While exudative retinal detachments (RD) are well known to occur in eyes with syphilitic chorioretinitis,8–12 reports of rhegmatogenous RD in eyes with acute syphilitic uveitis are uncommon.13–15 We present here four new cases of rhegmatogenous RD that occurred in the setting of acute syphilitic panuveitis, followed by a comprehensive review of previously reported cases.
Received 8 August 2013; revised 19 March 2014; accepted 13 May 2014; published online 24 June 2014 Correspondence: Sara J. Haug, MD, PhD, West Coast Retina Medical Group, Inc., 1445 Bush Street, San Francisco, CA 94109, USA. E-mail: [email protected]
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FIGURE 1. Color photomontage of the right eye showing an area of syphilitic retinitis and vasculitis in the temporal mid-periphery of case 1.
CASE REPORTS Case 1 A 45-year old man with a 20-year history of HIV infection and a recent CD4 count of 200 cells/uL presented with pain and blurry vision in the left eye of unknown duration. Best-corrected visual acuity (BCVA) at presentation was 20/40 in the right eye and 10/200 in the left. Anterior segment examination on the left showed severe inflammation with hypopyon and scattered posterior synechiae. Posterior segment examination on the left revealed moderately severe vitritis and a large area of active retinitis in the superotemporal fundus. The right eye was initially unaffected, but over the next weeks developed optic disc swelling and an area of retinal whitening in the temporal mid-periphery (Figure 1). Syphilis serologies were notable for a positive rapid plasma reagin (RPR) test at 1:1024, prompting treatment for neurosyphilis with a 10-day course of intravenous penicillin. Three weeks following completion of penicillin treatment, the patient developed an inferior maculaoff rhegmatogenous RD in the right eye with multiple retinal breaks in the inferotemporal periphery. The rhegmatogenous breaks and detachment were not in an area of prior retinitis; most likely these were the result of vitreous contraction given the previous inflammation and now healed retinitis. At the time of the detachment, there was no active retinitis or vasculitis. The vitreous was dense and the view posteriorly was hazy, but there did not appear to be cells in the vitreous at the time of detachment nor was there a complete posterior vitreous detachment. The patient underwent placement of a scleral buckle with vitrectomy, membranectomy, endolaser photocoagulation, and gas–fluid exchange with C3F8 gas. Following the surgery, the patient was treated with hourly prednisolone acetate drops in the surgical eye for the first week and then slowly tapered. The patient was followed weekly after the initial
FIGURE 2. Color photomontage of the right eye of case 1 following second successful retinal detachment repair.
postoperative visit for the first 3 weeks to monitor the inflammation, then the visit interval was increased to every few weeks. Four months after the initial surgery, the retina redetached due to proliferative vitreoretinopathy and required lensectomy, vitrectomy, membrane peel, and endolaser photocoagulation with gas–fluid exchange. At his most recent follow-up visit approximately 9 years after initial presentation, the right retina was attached (Figure 2) and his BCVA was 20/80 on the right and 20/20 on the left with no evidence of active inflammation in either eye.
Case 2 A 47-year old man with a history of HIV infection and recently diagnosed and treated bilateral syphilitic panuveitis was referred for management of his uveitis. Best-corrected visual acuity was 20/160 on the right and 10/200 on the left. Anterior segment Ocular Immunology & Inflammation
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Retinal Detachment and Acute Syphilitic Panuveitis
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FIGURE 3. Color photomontages of the (A) right and (B) left eyes of case 2 at presentation.
examination showed trace cells in the anterior chamber and anterior vitreous bilaterally. Posterior segment examination on the right showed moderate vitreous inflammation, a sclerotic arteriole off the inferonasal aspect of the optic disc, and resolving superficial retinal precipitates in the mid-periphery (Figure 3A). Posterior segment examination on the left showed severe vitreous inflammation with barely visible large retinal vessels and optic disc (grade 3+; Figure 3B). Approximately 2 weeks later, the patient returned with acutely decreased vision on the left. His BCVA was 20/100 on the right and hand motion (HM) on the left. Anterior segment examination showed no inflammation in either eye, and posterior examination on the right showed marked improvement of the vitreous inflammation. Posterior examination on the left revealed a total rhegmatogenous RD in a funnel configuration with an attached hyaloid (Figure 4). No active posterior inflammation was observed. The patient underwent scleral buckling, vitrectomy, membranectomy, lensectomy, endolaser photocoagulation, and air–fluid exchange with silicone oil tamponade (Figure 5). During the surgery, it was noted there was an area of atrophic retina approximately 5 disc diameters in size with bare retinal pigment epithelium in the superonasal quadrant. A posterior vitreous detachment (PVD) was induced during surgery and the hyaloid peeled to the vitreous base. Proliferative membranes causing retinal folds were peeled with forceps, most notably around the optic disc. For control of postoperative inflammation, the patient was given prednisolone acetate eyedrops to be used 4 times daily the first week after surgery and tapered over the next 3 weeks. In addition, the patient had been started on oral prednisone previously and was continued on his prednisone taper. Three months post-operatively, an intraocular lens was placed at the time of silicone oil removal. Six months after the RD repair, best-corrected visual acuity is 20/32 on the right and 20/40 on the !
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FIGURE 4. B-scan ultrasonography of the left eye of case 2 showing a total rhegmatogenous retinal detachment in a funnel configuration.
left, with no evidence of active inflammation in either eye.
Case 3 A 56-year-old man with no past medical or ocular history presented with 3 months of decreased vision in the right eye. Best-corrected visual acuity was HM on the right and 20/30 on the left. Anterior segment examination on the right showed mild conjunctival injection and trace anterior chamber cell and flare. There was posterior synechiae and a dense posterior subcapsular cataract with significant phacodonesis and vitritis. The anterior segment examination on the left was normal. Posterior segment examination on the right revealed choroidal detachment throughout the periphery, particularly in the inferotemporal and
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FIGURE 5. Color photomontage of the left eye of case 2 following a scleral buckle, vitrectomy, membranectomy, lensectomy, endolaser, and air-fluid exchange with silicone oil placement.
superonasal periphery, but no associated retinal tear or detachment. The posterior segment examination on the left was unremarkable. The patient was found to be RPR and FTA-ABS positive and started on intravenous penicillin therapy for neurosyphilis. Six weeks after initial presentation, the choroidal detachment on the right resolved and there was severe elevation of his intraocular pressure. He also developed serous RD with associated retinitis along the inferotemporal arcade. The patient was then lost to follow-up without adequate treatment of the syphilis. Three months later, patient re-presented and completed IV penicillin therapy. His BCVA was HM OD with proliferative vitreoretinopathy and a maculaoff rhegmatogenous RD in the inferior and temporal quadrants, which corresponds to the location of the previous serous detachment. A star fold with proliferative membranes was observed inferotemporally along the inferior arcade. No PVD was appreciated. The left eye remained unaffected with BCVA of 20/20. The patient was given oral prednisone 70 mg per day for 3 days, followed by a slow taper. Surgical repair was done for the rhegmatogenous RD, which included scleral buckling, lensectomy, vitrectomy, membrane peeling (including subretinal membrane dissection), endolaser photocoagulation, and placement of silicone oil. Four months after the initial repair, the silicone oil was removed and the retina remains attached. Best-corrected visual acuity in the right eye was 20/200.
Case 4 A 32-year-old man presented with decreased vision in the right eye of 1-week duration. Best-corrected visual
acuity was 20/200 on the right and 20/25 on the left. Anterior segment examination on the right showed mild conjunctival injection, 360-degree posterior synechiae, and 3+ cell, 2+ flare with fibrin in the anterior chamber. Anterior segment examination on the left was normal. The posterior segment examination on the right was limited secondary to poor dilation and anterior chamber inflammation. B-scan did not demonstrate an RD or dense vitritis. Posterior segment examination on the left was unremarkable. Labs were sent and the patient was found to be HIV, RPR (titer 1:1024), and FTA-ABS positive. Treatment with intravenous penicillin G 2.4 million units every 4 h for 14 days was then initiated and completed. One month later, the patient presented with total RD, a superior retinal tear and proliferative vitreoretinopathy stage D, indicating fixed folds in all four quadrants, in the right eye. There was 2+ vitritis but no active anterior inflammation or retinitis. No posterior vitreous detachment was appreciated. The left eye had optic nerve head swelling but no retinal involvement. Surgical repair, including vitrectomy, membrane peel, endolaser photocoagulation, and silicone oil tamponade, was performed. Vitreous separation was achieved during the surgery. Following surgery, hourly prednisolone acetate drops were used to control postoperative inflammation for the first week, followed by a taper. Two months later, the retina redetached and was repaired with vitrectomy, endolaser photocoagulation, and silicone oil tamponade. Traction detachment with subretinal fluid and epiretinal membrane folds developed 1 month after the second surgery; therefore, a third vitrectomy was performed with membrane peeling. To aid in visualization, cataract surgery was also completed prior to the third vitrectomy. Six months after the initial surgery, a fourth vitrectomy with endolaser photocoagulation and silicone oil tamponade was performed for recurrent detachment. The patient’s retina is attached 10 months after the initial surgery with silicone oil in his right eye. Best-corrected visual acuity is 20/100 OD, 20/20 OS.
DISCUSSION We present 4 cases of rhegmatogenous retinal detachment as a complication of moderate to severe acute syphilitic panuveitis. All 4 patients were men and 3 were HIV positive. One of the eyes was noted to have an exudative RD preceding the development of a rhegmatogenous detachment. Three eyes developed total RD, including one in a funnel configuration, and all cases had proliferative vitreoretinopathy. Two of the 4 patients had recurrent RD following initial surgical repair. All retinas were ultimately reattached. Ocular Immunology & Inflammation
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Retinal Detachment and Acute Syphilitic Panuveitis Our literature review identified 7 additional cases in 4 patients of rhegmatogenous RD in association with acute syphilitic panuveitis.13–15 With the addition of our 4 cases, we present a total of 11 eyes in 8 patients (7 men, 1 woman) with rhegmatogenous RD secondary to syphilis. The average age at presentation was 42.5 years (range 32–56 years, median 43.5 years) and 75% were HIV positive. All patients had positive syphilis serologies (RPR, TPHA, VDRL, or FTA-Abs), and cerebrospinal fluid was positive in 37.5%. Two of the 11 eyes (18.2%) underwent diagnostic vitrectomy and 1 of those eyes was positive for VDRL in the vitreous fluid. Three eyes (27.3%) were noted to have an exudative RD prior to developing a rhegmatogenous detachment. Total RD was observed in 4 eyes (36.4%) and 1 eye had a giant retinal tear. Visual acuity at presentation was poor, at 20/200 or worse in 8 of 11 eyes (72.7%); however, 2 eyes (18.2%) had vision 20/ 40 or better and 1 eye (9.1%) had vision worse than 20/40 but better than 20/200 (Table 1). Prior exudative RD was noted in 2 of the 11 cases.14 In all cases, the rhegmatogenous retinal detachment occurred a few weeks to months after the treatment of syphilis as the inflammation was resolving or had resolved, likely the result of vitreous contraction following acute inflammation. In at least 4 of the 7 eyes, the retinal breaks occurred in areas of previous retinitis.13–15 Proliferative vitreoretinopathy was reported in 5 of the 11 eyes.13–15 Retinal detachment repair consisted of both scleral buckling and vitrectomy surgery for 7 of 11 eyes (63.6%). One eye (9.1%) was repaired with scleral buckle and 2 eyes (18.2%) with vitrectomy. Cryotherapy alone was performed on an eye with a giant retinal tear and no associated detachment. Of the 9 eyes that underwent vitrectomy surgery, silicone oil tamponade was placed in 6 eyes and C3F8 gas bubble tamponade was placed in 3 eyes. Four of the 11 eyes (46.4%) had recurrent RD and 3 of these eyes underwent an additional vitrectomy surgery. Three of 4 eyes with redetachments had previously undergone both vitrectomy and scleral buckling surgery with placement of gas bubble tamponade. The fourth eye with recurrent rhegmatogenous RD had initial vitrectomy surgery with endolaser photocoagulation and silicone oil tamponade. Of the 2 eyes treated with vitrectomy alone,13–15 1 redetached three more times and each time vitrectomy, endolaser photocoagulation, and silicone oil tamponade were performed for repair. Given the success of other cases with combined scleral buckling and vitrectomy procedures, it is possible that a buckle may be beneficial in eyes with areas of healed retinitis and prior vitreous inflammation. There is retrospective and anecdotal evidence supporting the use of a combined approach and in many vitreoretinal surgical centers, scleral buckle in combination with vitrectomy for more complicated cases is the !
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treatment of choice.16–19 The second eye that underwent vitrectomy surgery alone was complicated by a giant retinal tear with associated RD. This case was successfully managed with vitrectomy, endolaser photocoagulation, and silicone oil tamponade (Table 1). Another variable that may aid in successful reattachment of the retina is the use of silicone oil rather than C3F8 gas bubble as a retinal tamponade. In our small series, 3 of the 4 cases with recurrent RD had perfluoropropane gas bubble placed in the initial surgery. It is possible silicone oil tamponade in these complicated retinal detachments is of some benefit in providing retinal stability. The fourth case with recurrent RD was initially managed with vitrectomy, endolaser photocoagulation, and silicone oil tamponade and had multiple redetachments, as described above (Table 1). A lensectomy was performed in 4 cases as part of the surgical repair. Three of these cases resulted in successful retinal reattachment. The case that had redetachment of the retina had been initially managed with scleral buckling, lensectomy, vitrectomy, endolaser photocoagulation, and C3F8 gas bubble tamponade (Table 1). Lensectomy allows for more extensive vitreous removal anteriorly, which may contribute to successful reattachment of the retina. Analysis of all 11 cases appears to suggest a successful initial surgical approach to rhegmatogenous RD repair secondary to syphilitic panuveitis was scleral buckling, vitrectomy, endolaser photocoagulation, and placement of silicone oil tamponade (Table 1). In the 4 eyes managed with this surgical approach, the retina remained attached. Ten of the 11 eyes (91%) were attached at the most recent reported visit with 27% of eyes having vision of 20/40 or better. Another 5 eyes (45%) had vision worse than 20/40 but better than 20/200, and 3 eyes (27%) had visual result of 20/200 or worse. Of the 3 eyes with poor visual result, all presented with vision worse than 20/200. Moreover, visual acuity appeared to be associated with successful initial retinal reattachment. Of the 4 cases with recurrent RD, 2 eyes had outcome BCVA less than 20/200 at last visit, including 1 eye with a chronic macula-off RD. All of the eyes with final vision of 20/40 or better underwent a single surgical repair. Of the 3 eyes with a total retinal detachment, BCVA at last visit was surprisingly good, with 1 eye measuring 20/40 and 2 eyes 20/50.13–15 In conclusion, we present 4 new cases of rhegmatogenous RD secondary to moderate to severe acute syphilis panuveitis. Seven cases have been previously reported in the literature.13–15 Of the 11 total cases, 4 had recurrent RD following initial surgical repair. In our experience, scleral buckling, vitrectomy, endolaser photocoagulation, and silicone oil tamponade provide patient the best chance for anatomical reattachment following a single surgery.
Pournaras et al. (2006)15
Williams et al. (1996)14
Previously Passo and Published Rosenbaum Cases (1988)13
Author (Year)
M
M
M
F
F
M
M
40
40
33
33
45
45
Gender
42
Age (years)
+
+
+(172)
+(172)
+
HIV status (CD4 count) Diagnostic Study
Mild anterior chamber Serum + VDRL, cellular reaction with Cerebral spinal posterior synechiae. fluid + for VDRL Posteriorly, there was 3+ vitritis with perivascular retinal pigment epithelial clumping and inferior exudative retinal detachment. Mild anterior chamber Serum + VDRL, cellular reaction, 2+ Cerebral spinal vitritis with a fluid + for VDRL sheathed vessel in the inferotemporal quadrant, perivascular retinal pigment epithelial clumping and inferior exudative retinal detachment. 2+ anterior chamber Serum + TPHA cell and flare with and VDRL severe vitritis (1:32), Cerebral spinal fluid + VDRL 2+ anterior chamber Serum + TPHA cell and flare with and VDRL severe vitritis (1:32), Cerebral spinal fluid + VDRL
Dense panuveitis with Serum + VDRL retinitis superotemporally and inferotemporally
The anterior chamber Serum + RPR and had 4+ cell and flare FTA-ABS, with keratic precipiCerebral spinal tates and posterior fluid + for FTAsynechiae. ABS Posteriorly, there was optic disc swelling, peripapillary sheathing of retinal vessels, and many small, white subretinal deposits throughout the periphery Dense panuveitis with Serum + VDRL, retinitis superoVitreous temporally fluid + VDRL
Inflammation
No
No
No
No
No
Yes
No
Diagnostic Vitrectomy Performed
Left Eye
Right Eye
Left Eye
Right Eye
Left Eye
Right Eye
Left Eye
Eye with detachment
No
No
Yes
Yes
No
No
No
Prior Exudative Detachment Type of Repair
Yes
No
No
No
Giant retinal tear Vitrectomy, endowith detachment laser, silicone oil
No
Initial exudative Scleral buckle, Yes, required detachment vitrectomy, lenvitrectomy, followed by sectomy, internal membrane tractional drainage of sub- peel, endolaser, detachment retinal fluid, silicone oil secondary to endolaser, perproliferative fluoropropane vitreoretinopagas thy, which led to rhegmatogenous breaks Giant retinal tear, CryophotoNo not associated coagulation with detachment
Total detachment Scleral buckle, with horseshoe vitrectomy, tear in superomembrane peel, temporal quadinternal drairant in area of nage of subrethealed retinitis inal fluid, endolaser, silicone oil Near total Scleral buckle, detachment with vitrectomy, breaks in areas membrane peel, of healed retina internal draiwith dense epir- nage of subretetinal inal fluid, membranes endolaser, silicone oil Exudative Scleral buckle, detachment vitrectomy, lenfollowed by sectomy, internal rhegmatogenous drainage of subdetachment retinal fluid, endolaser, perfluoropropane gas
Rhegmatogenous Scleral buckle retinal detachment, left eye
Description of Detachment
Re-detachment, type of secondary repair
TABLE 1. Summary of Previously Reported and Current Cases of Rhegamatogenous Retinal Detachment with Syphilitic Panuveitis.
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Attached
Attached
Attached*
Macula detached
Attached
Attached
Attached
Final Outcome
LP
HM
HM
20/40
2/200
5/200
CF at 2 Ft
Initial BestCorrected Visual Acuity
HM
20/30
20/25
3/200
20/50
20/50
20/60
Best-Corrected Visual Acuity at Last Visit
NR
NR
10
10
8
8
25
Duration of Follow-Up (months)
Summary
Current Cases
47
56
(2)
(3)
M
M
M
+
+(200)
No
No
2 of 11 eyes (18.2%) underwent diagnostic vitrectomy
Serum + RPR and FTA-ABS
8 of 8 patients (100%) had positive serologies, 3 of 8 patients (37.5%) also had positive CSF, 1 patient had positive vitreal fluid
No
Yes
Serum + RPR and FTA-ABS
2+ conjunctival injec- Serum + RPR tion, 4+ cell in the anterior chamber with posterior synechiae and trace hypopyon. Posteriorly, there was 2+ vitritis with a large area of active retinitis in the superotemporal quadrant. Circumlimbal injecSerum + RPR tion with trace cell in the anterior chamber with posterior synechiae. Posteriorly, there was 3+ vitreous inflammation.
Mild conjunctival injection, trace cell and flare in the anterior chamber with posterior synechiae, 3+ vitritis, choroidal detachment. Optic nerve swelling developed two months later with serous retinal detachment and associated retinitis along the inferotemporal arcade. (4) 32 M + Mild conjunctival injection, 360-degree posterior synechiae, 3+ cell and 2+ flare with fibrin in the anterior chamber. There was no view to the posterior pole, Bscan did not show dense vitritis or retinal detachment. 6 of 8 All eyes had moderate 7 of 8 n = 11 eyes Mean: patients patients to severe vitritis. (8 patients) 42.5 (75.0%c) Moderate to severe Mediaanterior chamber male HIV+ n: 43.5 inflammation in 7 of Range: (87.5%) 11 eyes (63.6%) 32–56
45
(1)
6 of 11 (54.5%) right eye
Right Eye
Right Eye
Left Eye
Right Eye
3 of 11 eyes (27.3%) had prior exudative detachment
No
Yes
No
No
No
No
Attached
Attached
HM
20/200
10/200
20/40
4 of 11 eyes 1 of 11 eyes (9%) 10 of 11 eyes (1) 18.2% 3 of 11 eyes (36.4%) had a was repaired with (27.2%) required (90.9%) remained (2 eyes) presented with 20/ total retinal scleral buckle additional surattached at last 40 vision or detachment; 1 of only; 7 of 11 eyes gery: two eyes visit better 11 (9.1%) had a (63.6%) were had a previous (2) 9.1% (1 eye) giant retinal tear repaired with scleral buckle had vision both scleral plus vitrectomy; worse than 20/ buckle and one eye had 40 but better vitrectomy; 2 of vitrectomy alone than 20/200 11 eyes (18.2%) (3) 72.7% (8 with virectomy eyes) had vision only; the giant 20/200 or worse tear was treated with cryotherapy only (9.1%).
Attached Total detachment Vitrectomy, mem- Yes, requiring three additional with proliferabrane peel, surgeries includtive vitreoretino- endolaser, silicone oil ing vitrectomy, pathy and membrane peel, superior retinal endolaser, silitear cone oil
Scleral buckle, lensectomy, vitrectomy, membrane peel, internal drainage of subretinal fluid, endolaser, silicone oil Total detachment Scleral buckle, with proliferalensectomy, tive vitreoretino- vitrectomy, pathy and membrane peel, inferior retinal endolaser, silibreaks cone oil
Total retinal detachment in funnel configuration
Inferior macula- Scleral buckle, Yes, required len- Attached off rhegmatovitrectomy, sectomy, vitrectgenous detachmembrane peel, omy, membrane ment with internal draipeel, endolaser, retinal breaks in nage of subretperfluoroprothe inferoteminal fluid, pane gas poral periphery endolaser, perfluoropropane gas
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10
18
6
108 (9 years)
(1) 27.3% Mean: 25.7 (3 eyes) had final Median: 10 vision of 20/40 Range: 4–108 vision or better (2) 45.5% (5 eyes) had vision worse than 20/40 but better than 20/ 200 (3) 27.3% (3 eyes) had vision 20/200 or worse
20/100
20/200
20/40
20/80
DECLARATION OF INTEREST The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper. This study was supported in part by the Pacific Vision Foundation and the Retina Foundation.
9.
10.
11.
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