JAN 08, 2018
In this multicenter study, the authors retrospectively identified predictors of treatment success in syphilitic uveitis (SU).
The review included 66 patients (95 eyes) treated for syphilitic uveitis. Approximately half of the cohort was HIV positive. Patients were assessed for uveitis activity at 1 week and 1 month after treatment, and at the last follow-up.
Patients were divided into 4 treatment groups:
- group A: ≥14 days of IV penicillin G (close to the standard of care; 27 patients)
- group B: ≥5 days of IV penicillin G followed by ceftriaxone or benzathine penicillin G (pragmatic approach; 14 patients)
- group C: ceftriaxone or benzathine penicillin G (nonvalidated treatment regimens; 8 patients)
- group D: oral doxycycline (1 patient)
Of the 4 treatment regimens, there was a suggestion of higher 1-month recovery rates with group B.
A multivariate analysis showed that improvements at 1 week were associated with better results at 1 month. Importantly, patients who received periocular dexamethasone injections and methylprednisolone pulses were more likely to have a poor response to treatment. Recovery rate was 85% at the last follow-up.
Retrospective non-randomized data is not definitive. While there was evidence that patients who had steroid injections or pulses had a more limited response to antibiotic therapy, they were likely individuals with worse uveitis; since the study was not randomized it is impossible to decide definitively what role such adjunctive steroid therapies may play.
There were small numbers for group C and only 1 patient in group D. The study also utilized records from a tertiary care center, which may not reflect the community profile. Additionally, the ‘last follow up’ is often not a useful measure.
The standard of care for SU—intravenous penicillin G for at least 2 weeks—may not be the only effective regimen. Be circumspect about using adjunctive periocular steroids or intravenous pulse. Finally, remember that penicillin does not always make syphilitic uveitis instantly go away—it may not go away completely, not at 1 month and not even at ‘last follow up.’