【摘要】 报告1例年长患者因梅毒继发的术后葡萄膜炎。
方法：一例76岁的马来西亚男性患者，双眼为未成熟期白内障，右眼顺利进行了白内障超声乳化术，既往无葡萄膜炎病史。术后5d，右眼突然出现视物模糊，眼部检查发现角膜弥漫性水肿、中度前房反应和眼压升高。
结果：局部应用抗生素和类固醇药物效果良好，眼压经用抗青光眼药得到控制。然而，术后3wk，右眼再次发生疼痛、红肿、视物模糊，眼部检查显示严重的前葡萄膜炎伴有羊脂状角膜后沉积物出现，VDRL和TPHA阳性证实为梅毒，通过全身注射青霉素类药物和局部应用类固醇药物，病情明显好转。
结论：这个病例证明在年长患者梅毒是未被充分认识的引起术后葡萄膜炎的病因，应用青霉素可获得快速显著的治疗效果。
【关键词】 梅毒 术后葡萄膜炎
INTRODUCTION
Severe ocular uveitis presenting after cataract operation for the first time in patients older than 60 years of age generally has been considered uncommon and it is believed that an initial uveitic episode in old age most likely represents a disease masquerading as uveitis rather than a primary inflammatory reaction[1]. With the life expectancy increases, the ophthalmologist should bear in mind potentially underrecognized causes of ocular uveitis post cataract operation that will cause morbidity and visual impairment in this age group[2]. Uveitis presenting for the first time in the elderly especially after phacoemulsification due to syphilis is rare. Special attention to its particular ways of presentation, complications and management are needed to be addressed, so that this underrecognized cause is not forgotten and early treatment can be initiated. We report a case of post cataract operation secondary to syphilis in an elderly patient.
CASE REPORT
A 76yearold Malay man with bilateral immature cataract and chronic obstructive pulmonary disease (COPD) underwent uneventful right phacoemulsification under local anesthesia on September 18,2007. Postoperatively the vision in the right eye was 6/12 and improved to 6/9 with pinhole. He was discharged well. On day 5 after the operation, he developed sudden onset of blurring of vision in the right eye upon awaking up in the morning. It was associated with mild pain and redness. There was no history of trauma. On examination, the visual acuity of the right eye was hand movement with good light projection in all quadrants. The conjunctiva was injected and the cornea was hazy with generalized epithelial edema. There was moderate anterior chamber reaction with mild keratic precipitate. There was no hypopyon. The intraocular pressure was elevated to 36mmHg. The intraocular lens was stable. There was poor view of the fundus. The ultrasound B scan revealed mild vitreous opacity with normal flat retina.
He was diagnosed to have postoperative uveitis with secondary raised intraocular pressure. He was started on oral acetozolamide 250mg four times per day. In view of his COPD problem the patient was given topical betoxolol twice per day. He was also started on topical ciprofloxacin and topical prednisolone. His condition improved dramatically after 2 days. The cornea was clear with quiet anterior chamber. Upon discharge the visual acuity in the right eye was 6/36 improved with pinhole to 6/18. The fundal view was clear with no sign of vitritis. However, 3 weeks later, he presented again with similar complaints including pain, redness and poor vision. On examination, visual acuity in the right eye was counting finger. The cornea was edematous with presence of mutton fat keratic precipitates on the central and inferior part of the endothelium(Figure 1). There was also severe anterior chamber reaction(Figure 2). The intraocular pressure was 25mmHg. The fundus was not able to visualize due to severe vitritis. The ultrasound B scan revealed dense vitreous opacity. Systemic examination revealed normal findings. There was no sign of neurological deficit.
This patient was diagnosed to have right granulomatous panuveitis. He was admitted and thorough investigations were performed. He was screened for tuberculosis and venereal disease. The Mantoux and chest radiograph were normal. The sputum was also negative for tuberculosis. All the serum investigations were within normal limit except for VDRL (1:16 titre) and TPHA that were positive. Repeated results of TPHA also showed positive finding. He was referred to physician who started the patient with benzathine penicillin 2.4 mega unit weekly for 4 weeks. Patient was also started on topical ciprofloxacin and topical prednisolone. He was also given guttae betoxolol twice per day and guttae dorzolamide to control the intraocular pressure. The condition improved markedly with the treatment(Figure 3). The final visual acuity on discharge was 6/36 improved with pinhole to 6/12. Patient was followed up regularly at the eye clinic with no signs of relapse.
DISCUSSION
Clinically significant ocular uveitis post phacoemulsification was not common due to less inflammation induced by phacoemulsification[3]. Ocular uveitis presenting for the first time in the elderly does not seem to be particularly uncommon. Chatzistefanou et al[4] reported as 10.4% while Estafanous et al[5] reported as 21.8% cases of ocular uveitis presenting for the first time in elderly. Smith et al[1]stated that primary uveitis of whatever origin rarely, makes its first appearance in old age. The operation performed may activate the immune process and cause the inactive latent syphilis to become prominent and flare up.
Syphilis cause only 4.2% out of all the ocular uveitis cases reported so far. However, there is no reported case of syphilis as a cause of post phacoemulsification uveitis so far as initial presentation in the elderly. Hong et al[6] reported that syphilitic uveitis most commonly presented with severe anterior chamber reaction (92.9%), followed by vitritis (28.6%) and keratic precipitates (28.6%). Our patient presented with all the common presentations suggestive of uveitic syphilis, i.e. severe anterior chamber reaction, vitritis and keratic precipitates. Syphilis also known as a "great masquerader" of ocular uveitis. Therefore, in a few of the previously reported cases, aqueous sampling for treponema pallidum was taken and sent for dark field microscopy and immunofluorescent test in a suspected case without confirmatory blood and serological investigations. In our patient, the serum VDRL and TPHA were positive. There was no previous and recent systemic manifestations detected in our case. This suggested that ocular uveitis may be the initial manifestation of syphilis especially in older age group.
Syphilis is a sexually transmitted, chronic, systemic infection caused by the spirochete treponema pallidum. If left untreated, the disease progresses through 5 stages namely primary, secondary, latent, tertiary and quaternary syphilis with the potential of causing significant morbidity to any major organ of the body. Ocular manifestations of syphilis were interstitial keratitis, anterior, intermediate, and posterior or panuveitis, chorioretinitis, retinitis, retinal vasculitis, cranial nerve palsy and optic neuropathy that can occur at any stage of the disease[7]. With the emerging increased incidence of human immunodeficiency virus (HIV), syphilis is now increasing too[8].
Ocular syphilis has even regained attention as a "new epidemic". Involvement of the eye may be the initial presenting manifestation of syphilis and often associated with delayed diagnosis and treatment, which may result in irreversible visual loss and structural changes. Therefore, we should have a high degree of clinical suspicion for early diagnosis and treatment, especially in those without systemic symptoms. From the aspect of public health, early diagnosis of syphilis also helps to control the spread of infection. It is known that venereal disease research laboratory (VDRL) can be non reactive in immunocompetent and immunosuppressed syphilitic patients, and patients with concurrent HIV infection may be seronegative on all serologic tests for syphilis[9]. Ophthalmologists bear the responsibility of early diagnosis.
Increased frequency of detection of this subset of uveitis, as reported recently, is because of the rise in its prevalence, result of better awareness of its presence and consequence of the increasing prevalence of the geriatric population worldwide. Hong et al[6] reported that ocular syphilis commonly presented as panuveitis (78.6%), anterior uveitis (14.3%) and posterior uveitis (7.1%). Our case presented as panuveitis and this also supported well the diagnosis of syphilis clinically. Hong et al[6] also reported that ocular syphilis occurred unilaterally (25%) and bilaterally in (75%) of the cases. Our case presented unilaterally. Early diagnosis and treatment will usually preserve the visual acuity and ocular function. As ocular syphilis can mimic any type of ocular inflammation and may be the initial presentation of syphilis, ophthalmologists must have a high degree of clinical suspicion in unspecific ocular inflammation. Early diagnosis and treatment are imperative to save the eyes.
Ocular syphilis treatment is the same as neurosyphilis. There are a few regimes of treatment introduced but the current treatment for ocular syphilis is benzathine penicillin 2.4 million units given intramuscularly weekly for four weeks. Following treatment, the antibody titers were monitored for evidence of response or treatment failure[7]. The prognosis of the patients with ocular syphilis usually results in full visual recovery, if clinically diagnosed and appropriate treatment given early in its course. If syphilitic intraocular inflammation was left untreated, a chronic progressive intraocular inflammation may ensue later and lead to secondary glaucoma, chronic vitritis, retinal necrosis, optic atrophy and phthisis bulbi[10].
In conclusion, this case illustrates a rare case of syphilis as an underrecognized cause of uveitis post cataract operation that occurred in the elderly as initial presentation. The early diagnosis will certainly improve the visual acuity outcome of the patient due to high sensitivity of this disease to penicillin.
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