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Syphilitic interstitial keratitis and glaucoma
Last reviewed: 05.07.2025
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Syphilis of the eye can be a congenital or acquired sexually transmitted disease.
In congenital syphilis, as a rule, the anterior segment of the eye is affected with the development of interstitial keratitis and anterior uveitis, and in acquired syphilis, both anterior and posterior uveitis develop. With the development of effective diagnostic methods and antibiotic therapy, syphilitic interstitial keratitis and secondary glaucoma have become rare diseases.
Epidemiology of syphilitic interstitial keratitis
Eye damage from congenital or acquired syphilis can lead to increased intraocular pressure and the development of secondary glaucoma both during the active inflammatory stage and many years after the resolution of the intraocular inflammatory process. Secondary glaucoma develops in 15-20% of adults with a history of interstitial keratitis associated with congenital syphilis. Secondary glaucoma is less common in patients with acquired syphilis.
[ What causes syphilitic interstitial keratitis?
Probably, the reason for the increase in intraocular pressure in the active stage of the disease is the disruption of the outflow of intraocular fluid due to inflammatory cells and proteins found in the intraocular fluid. The formation of synechiae, disruption of the development of the eyeball and subluxation of the lens can lead to narrowing of the angle of the anterior chamber and the development of closed-angle glaucoma. It is believed that the basis for the late manifestation of glaucoma in patients suffering from congenital syphilis is the "endothelialization" of the angle of the anterior chamber, which is revealed during histological examination.
Symptoms of syphilitic interstitial keratitis
Eye damage in congenital syphilis usually manifests itself acutely before the age of 20 and includes the following symptoms: pain, photophobia, lacrimation, decreased visual acuity. In 90% of cases, bilateral damage is observed. Other symptoms of congenital syphilis may also be present: dental deformation (Hutchinson's teeth and purse-string molars), skeletal abnormalities (saddle nose, perforated bone palate, saber-shaped shin and prominent frontal tubercles), deafness, cracks in the skin and dementia. Acquired syphilis of the eye is more often characterized by unilateral damage.
Course of the disease
The course of interstitial keratitis and anterior uveitis lasts from several weeks to several months, after which spontaneous resolution of the process occurs with the preservation of empty vessels in the deep layers of the corneal stroma. Glaucoma is considered a late complication of congenital syphilis. It usually develops in the absence of signs of intraocular inflammation, decades after the resolution of interstitial keratitis. Open-angle and narrow-angle glaucoma develop in these patients with the same frequency.
Diagnosis of syphilitic interstitial keratitis
During an ophthalmologic examination of patients with congenital syphilis, a number of diseases can be detected: acute and chronic anterior uveitis, cataracts, chorioretinitis, retinal vasculitis, optic neuritis, and scleritis. Interstitial keratitis is the most common. During an examination of patients with interstitial keratitis, sectoral corneal edema, corneal opacity, and deep stromal vascularization are detected, which can be so pronounced that the cornea becomes orange-pink in this area. Syphilitic interstitial keratitis often causes anterior uveitis and increased intraocular pressure. During an ophthalmologic examination of patients with acquired syphilis, anterior uveitis, chorioretinitis, and optic neuritis are often detected. Interstitial keratitis in acquired syphilis is rare, usually affecting one eye. When anterior uveitis develops in patients with acquired syphilis, nodular formations of the iris are often detected.
Differential diagnostics
The active stage of ocular syphilis, characterized by interstitial keratitis and anterior uveitis, should be differentiated from processes caused by herpes simplex and herpes zoster, Mycobacterium tuberculosis and leprae, Lyme disease, measles, infectious mononucleosis (Epstein-Barr virus), leishmaniasis and onchocerciasis, sarcoidosis and Cogan syndrome.
Laboratory research
The diagnosis of ocular syphilis is based on positive serological reactions. Veneral disease research lab and rapid plasma reagin studies are insufficient in themselves, so it is necessary to conduct studies aimed at detecting treponemas: adsorption of fluorescent antibodies to treponema, microhemagglutination reaction for the presence of Treponema pallidum. Each patient suffering from syphilitic uveitis should undergo a study of the cerebrospinal fluid in order to exclude asymptomatic neurosyphilis.
Treatment of syphilitic interstitial keratitis
During the active stage of the disease, intraocular pressure is reduced by administering local glucocorticoids, cycloplegics and, if necessary, antiglaucoma drugs. Antibiotic therapy for the systemic disease should also be performed. In narrow-angle and closed-angle glaucoma, laser iridotomy or surgical iridectomy should be performed. In late manifestations of open-angle glaucoma, antiglaucoma drugs are less effective, and surgery may be required to improve filtration. Argon laser trabeculoplasty is ineffective due to the "endothelialization" of the anterior chamber angle.