Syphilitic keratitis

Parenchymal keratitis in congenital syphilis is regarded as a late manifestation of a common disease. Syphilitic keratitis usually develops at the age of 6 to 20 years, but cases of typical parenchymal keratitis occur both in early childhood and in adulthood. For a long period of time, deep stromal keratitis was considered a manifestation of tuberculosis, and only with the advent of serological diagnostic methods it was found that the cause of the disease is congenital syphilis. Almost all patients with parenchymal keratitis (80-100%) Wasserman's reaction is positive. Currently, a complete triad of symptoms of congenital syphilis (parenchymal keratitis, alteration of the front teeth and deafness) is rare, but always, except for eye disease, reveal any other manifestations of the underlying disease: changes in the bones of the skull, nose, flabbiness and folding of the facial skin, gummous osteomyelitis, inflammation of the knee joints.

Pathogenesis of syphilitic keratitis

As for the pathogenesis of this disease, it is also quite complex. It is known that the main link in the pathogenesis of syphilitic inflammation is vasculitis, and there are no vessels in the cornea. It has now been established that parenchymal keratitis in the fetus and the newborn causes spirochetes that penetrated the cornea during the period of intrauterine development when there were vessels in it. Another pathogenesis of late congenital stromal keratitis, which develops in the absence of blood vessels: anaphylactic reaction of the cornea.

At the end of the intrauterine growth period, when the vessels are reduced, the corneal tissue is sensitized to the products of the spirochaete decay. As a consequence, in the first two decades of life, with the activation of congenital syphilis, when the concentration of decay products in the spirochaete is increased in blood, any provoking factor (trauma, colds) leads to the development of an anaphylactic reaction in the cornea. There are other data that indicate that syphilitic keratitis is caused by a special form of filtering spirochetes.

Symptoms of syphilitic keratitis

Inflammatory process begins with the appearance of unobtrusive point foci in the peripheral part of the cornea, more often in the upper sector. Subjective symptoms and pericorneal injection of vessels are poorly expressed. The number of infiltrates gradually increases, they can occupy the entire cornea. With external examination, the cornea appears diffusely cloudy, like a frosted glass. With biomicroscopy it can be seen that the infiltrates lie deep, have an unequal shape (points, spots, striae); located in different layers, they are superimposed on each other, which gives the impression of a diffuse turbidity. Surface layers, as a rule, are not damaged, epithelial defects are not formed. Optical section of the cornea can be thickened almost 2 times.

There are 3 stages of the inflammatory process. The duration of the initial infiltration period is 3-4 weeks. It is replaced by the stage of neovascularization and the spread of the pathological process by the area of the cornea. To the first infiltrates are suitable deep vessels that promote the resolution of opacities, and next to them there are new foci of inflammation, which also after 3-4 weeks are suitable brushes of deep vessels. Thus, the process slowly spreads from the periphery to the center. Near the limb of turbidity dissolve, but the number of vessels going to new centers in the center increases. By the end of this period, the entire cornea is permeated with a dense network of deep vessels. In this case, surface neovascularization may occur.

In the II stage of the disease, the symptoms of iridocyclitis usually appear, the pericorneal vascular injection increases, the iris pattern fades, the pupil shrinks, precipitates appear, which are difficult to see behind the shadow of corneal infiltrates.

Progression of the disease lasts 2-3 months, then comes the third stage - a period of regression, the duration of which is 1-2 years. During this period, starting from the periphery, the cornea becomes transparent, a part of the vessels empties and disappears, but the visual acuity is not restored for a long time, since the central department is cleaned last.

After the parenchymatous keratitis transferred in the corneal stroma, traces of neglected and separate half-empty vessels, foci of atrophy in the iris and a choroid, remain for life. In most patients visual acuity is restored to 0.4-1.0, they can read and work.

If a child has a parenchymal keratitis, it is necessary to consult a venereologist not only with the child, but also with his family members.

Parenchymal keratitis with acquired syphilis. The disease develops extremely rarely, it is one-sided with mild symptoms. Vascularization of the cornea and iritis are usually absent. The restoration process can subside, leaving no traces. Differential diagnosis is carried out with diffuse tuberculous keratitis.

Hummus keratitis is a focal form of inflammation, rarely seen with acquired syphilis. Gunma is always located in deep layers. The process is complicated by the addition of iridocyclitis. With the breakdown of the focus can form a corneal ulcer. This form of keratitis must be differentiated from deep focal tuberculous keratitis.

Treatment of syphilitic keratitis

The treatment is carried out jointly by the venereologist and ophthalmologist, since the main disease and the cause of keratitis is syphilis. Specific treatment does not prevent the development of parenchymal keratitis on the second eye, but it significantly reduces the frequency of relapses. Patients prescribed penicillin, bicillin, novarsenol, myarsenol, biyohinol, wasarsol, iodine preparations according to the available schemes, desensitizing and vitamin preparations.

Local treatment of syphilitic keratitis is aimed at resorption of infiltrates in the cornea, prevention of iridocyclitis and accidental erosions of the cornea. To prevent the development of iridocyclitis, instillation of mydriatic is prescribed 1 time per day or every other day under the control of the dilatation of the pupil. When irite occurs, the amount of instillation is increased to 4-6 times a day (1% solution of atropine sulfate). If spikes are formed and the pupil does not expand, use electrophoresis with atropine, drops and turuns with adrenaline (1: 1000). A good therapeutic effect is given by corticosteroids (dexazone, dexamethasone) in the form of subconjunctival injections and instillation. Due to the fact that the treatment is carried out for a long period of time (1-2 years), it is necessary to alternate the drugs within the same group of medicines and periodically cancel them. The introduction of mydriatic should also be discontinued for several days. If the pupil does not self-contract, use myotics. As soon as the pupil narrowed, it is expanded again. This procedure is called iris gymnastics. It prevents the fusion of the immobilized wide pupil with the lens.

During the regression of syphilitic keratitis, drops and ointments are prescribed to improve trophism and prevent the formation of corneal erosions.