Beyond placoid lesions: Tomographic clues for ocular syphilis in the emergency department

Abstract Ocular syphilis is a diagnostic chameleon in the emergency department (ED). We report a consecutive ED series highlighting a characteristic macular optical coherence tomography (OCT) signature. Eight patients (10 eyes) presented within 7 days of symptom onset with posterior uveitis or chorioretinitis and had serologic confirmation of syphilis. Macular OCT, fundus findings, lumbar puncture results, treatment, and outcomes were reviewed. All affected eyes showed retinal pigment epithelium thickening and irregularity with nodular hyperreflective elevations, along with ellipsoid zone disruption and relative preservation of the external limiting membrane. Phenotypes spanned placoid and non-placoid disease; in two eyes, placoid lesions were clinically subtle but evident on fundus autofluorescence. Guideline-concordant therapy (intravenous penicillin in most cases; ceftriaxone otherwise) was initiated on the day of diagnosis. At 1–6 months of follow-up, patients demonstrated anatomic improvement, and final best-corrected visual acuity ranged from 20/20 to 20/40. Recognizing this ED OCT constellation may expedite serologic testing and treatment across syphilis phenotypes and is associated with favorable early visual outcomes.