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Show ~ 1992 Raven Press, Ltd., New York Rapid Response of Syphilitic Optic Neuritis to Posterior Sub- Tenon's Steroid Injection Robert L. Tomsak, M. D., Lisa D. Lystad, M. D., M. Bashar Katirji, M. D., and Thomas C. Brassel, M. D. An HIV- positive man with subacute syphilitic meningitis developed severe bilateral visual loss from optic neuritis. His visual acuity improved remarkably within 24 hours after single posterior sub- Tenon's injections of triamcinolone ( Kenalog) were given. Periocular steroid injections should be considered as an adjunctive treatment of syphilitic optic neuritis. . Key Words: Neurosyphilis- Human immunodefiCIency virus- Optic neuritis- Periocular steroids. From the Department of Ophthalmology ( R. L. T., T. CB.), Department of Neurology ( M. B. K.). and Division of Neuroophthalmology ( R. L. T, L. D. L.). University Hospitals of Cleveland and Case Western Reserve University School of Medicine, Cleveland, Ohio, U. S. A. . Address correspondence and reprint requests to Dr. Robert L. Tomsak, Lakeside 3200 A, 2074 Abington Road, Cleveland, OH + l106. lJSA. 6 Zambrano et al. ( 1) described an AIDS patient with bilateral blindness from retrobulbar syphilitic optic neuritis whose vision slowly improved in one eye over 2.5 months during and after intravenous ( i. v.) penicillin therapy. Herein we describe a similar patient in whom remarkable visual improvement occured within 24 hours after single posterior sub- Tenon's steroid injections. CASE REPORT A 56- year- old black man was admitted to the University Hospitals of Cleveland for intravenous treatment of subacute syphilitic meningitis. Two months before admission he developed slowly progressive visual loss in both eyes, greater in the right than in the left. and began to have difficulty walking. One month before admission, he was diagnosed with bilateral uveitis and was treated with topical ophthalmic steroid and cycloplegic eye drops. He had a reactive serum VORL with a titer of 1: 64 and tested positively for HIV- 1 at that time. Physical exam was remarkable for a hyperpigmented rash with desquamation on both palms and soles. Neurologic exam showed mild truncal ataxia, a partial right peripheral facial palsy, and mild hearing loss bilaterally. Serum FTA- ABS was reactive on admission, and spinal fluid examination showed 69 white cells, predominantly lymphocytes, a protein of 126 mg/ dl, a glucose of 41 mg/ dl ( serum glucose 120 mg/ dl), and a reactive VORL ( titer not done). Neuro- ophthalmologic examination on August 7, 1991, after 40 million units of IV penicillin ( 4 million U i. v. every 4 hours) disclosed visual acuities of no light perception ( NLP) 00 and hand movements ( HM) at 3 feet OS. A partial right peripheral seventh nerve palsy was present. Both pupils were pharmacologically SYPHILITIC OPTIC NEURITIS 7 dilated. Slit lamp exam showed moderate cells and flare 00 and mild flare OS. The right vitreous was hazy because of a moderately severe cellular infiltrate, and 1+ cells were also present in the left vitreous. Both optic discs were slightly swollen. The retinal details on the right were obscured by the vitreous haze, but there were no signs of cytomegalovirus retinitis or other obvious abnormalities. Aside from the optic disc, the left fundus appeared normal. The visual dysfunction was too severe to be explained by the media haze, and syphilitic optic neuritis and uveitis were diagnosed. The patient was given bilateral posterior subTenon's injections of triamcinolone acetonide ( Kenalog) ( E. R. Squibb & Sons Inc., Princeton NJ) 40 mg by the method of Smith and Nozik ( 2). The following day, vision had improved to light perception with projection 00 and 20/ 50 OS ( Table 1). By August 23, 1991, visual function was 20/ 40 minus 00 and 20/ 25 - 2 OS. Visual fields by Goldmann technique showed a peripheral inferior altitudinal defect 00 and bilateral blind spot enlargement greater in the right than in the left. During hospitalization, the patient received a to- TABLE 1. Progression of visual acuities after sub- Tenon's injections Visual acuities tal i. v. dose of 432 million U penicillin, Serologic followup on August 29, 1991, showed an unchanged serum VORL titer of 1: 64. Spinal fluid VORL was nonreactive on September 19, 1991. DISCUSSION There is some evidence that periocular triamcinolone injections hasten visual improvement, but not ultimate visual acuities, in idiopathic optic neuritis, especially during the first week after injection ( 3). Improvement of vision within days of administering methylprednisolone i. v, to optic neuritis patients has also been reported ( 4). However, the rapid visual improvement demonstrated by our patient following posterior sub- Tenon's triamcinolone injections was unusually dramatic. The pathogenesis of syphilitic optic neuritis includes inflammatory and demyelinating events, sometimes leading to optic atrophy ( 1). Our patient's rapid visual response suggests that some of these processes are steroid sensitive. Posterior sub- Tenon's steroid injections should be considered as an adjunctive treatment of syphilitic optic neuritis. Note: The patient was last seen 12/ 18/ 91 with visual acuities of 20/ 40 00 and 20/ 25 OS. The uveitis had cleared completely. REFERENCES NLP. no light perception; HM, hand movements; LP. light perception. • Date of posterior sub- Tenon's injections of triamcinolone. Date 8/ 7/ 91 · 8/ 8/ 91 8/ 14/ 91 8/ 23/ 91 9/ 19/ 91 9/ 27/ 91 00 NLP LP 20/ 50 20/ 40 20/ 50 20/ 30 as HM 20/ 50 20/ 50 20/ 25 20/ 25 20/ 30 1. Zambrano W, Perez GM, Smith JL. Acute syphilitic blindness in AIDS. I Clin Nel/ ro- ophthalmology 1987; 7: 1- 5. 2. Smith RE, Nozik RA. Uveitis: a Clinical Approach to Diagnosis and Management. Baltimore: Williams and Wilkins, 1983: 59~ 3 3. Bird AC, Leaver PK, Gould ES, McDonald I. Assessment of intraconal steroids in the treatment of retrobulbar neuritis. In: Glaser jS, Smith JL, eds. Nel/ ro- ophthalmology: Symposium of the Unil'ersity of Miami and the Bascom Palmer Eye Illstitute, vol. 9. St. Louis: CV Mosby, 1977: 154- 9. 4. Spoor TC, Rockwell DL. Treatment of optic neuritis with intravenous megadose corticosteroids: a consecutive series . Ophthalmology 1988; 95: 131~. I Clin Neuro- ophthalmol, Vol. 12, No. 1, 1992 |
