Emerging syphilitic optic neuropathy: critical review and recommendations.

BACKGROUND: Infection with Treponema pallidum causes multiorgan manifestations including isolated optic nerve involvement at any stage of the disease. This is of particular interest for resulting in severe visual impairment, which is reversible if treated adequately.

PURPOSE: To review clinical and diagnostic findings in patients with optic nerve affection in neurosyphilis and to focus on the visual outcome after administering adjunctive cortisone to the standard therapy regimes with penicillin G.

METHODS/PATIENTS: The review is based on a retrospective case serial of 4 patients (three males: mean age 40 years, range 37-42 years; one female: mean age 62 years) with optic nerve involvement in neurosyphilis treated in our hospital, and on a literature review of recent publications. Patients were treated with systemic penicillin either with or without adjunctive cortisone. The major outcome measure of therapy was improvement of visual acuity.

RESULTS: Visual outcome in our case serial showed total restoration if cortisone was also administered. The bibliographic survey, which was based on 60 patients, also revealed a better improvement of vision when antibiotic medication was combined with cortisone.

CONCLUSIONS: The data show that the causal therapy of choice is undoubtedly penicillin G, with adjunctive steroids playing a crucial role in improvement of optic nerve functional outcome. Physicians should consider the use of cortisone in SON whenever clinically harmless, although prospective randomized multicenter studies are required to support this recommendation.