Spontaneous Venous Pulsations Research Articles

Retinopathy of vivax malaria in adults and its relation with severity parameters

Malarial retinopathy is a set of retinal signs in severe malaria due to falciparum malaria. With increased recognition of severe manifestations of vivax malaria, a systematic study to evaluate retinal changes in vivax malaria could elaborate our knowledge about this neglected entity. This observational study included retinal examination of 104 adult patients (>14 years) with varying severity of vivax malaria admitted to a tertiary care center during peak seasons of 2012 and 2013. Thirty-eight percent of severe cases had a retinal sign as compared to 6% of non-severe cases (p < 0.01). No statistically significant effect of residence or age on the presence of retinopathy was noted. Females were found to be more prone to develop a retinal sign (p < 0.01). Presence of retinal signs was significantly associated with anemia and jaundice. No statistical association was noted for retinal signs to be present in either renal dysfunction or altered thrombocytes count. The most common signs were arteriovenous changes, present in eight cases (19%) of severe malaria and three cases (5%) of non-severe malaria. Retinal hemorrhage was present in five cases (12%) of severe malaria and no case of non-severe malaria. Both superficial and deep hemorrhages were seen including white-centered hemorrhages. Other signs included cotton wool spots, hard exudates, blurred disk margins with spontaneous venous pulsations and bilateral disk edema. A correlation between retinal signs and severity parameters was drawn from the study. This is the first systemic study to evaluate the retinal changes in vivax malaria. Larger prospective studies should be done for further knowledge regarding retinal changes in vivax malaria, especially severe disease. Apart from its clinical significance, it might lead to a better understanding of the pathogenesis of the systemic disease of vivax malaria.

Registration of retinal sequences from new video-ophthalmoscopic camera.

BackgroundAnalysis of fast temporal changes on retinas has become an important part of diagnostic video-ophthalmology. It enables investigation of the hemodynamic processes in retinal tissue, e.g. blood-vessel diameter changes as a result of blood-pressure variation, spontaneous venous pulsation influenced by intracranial-intraocular pressure difference, blood-volume changes as a result of changes in light reflection from retinal tissue, and blood flow using laser speckle contrast imaging. For such applications, image registration of the recorded sequence must be performed.MethodsHere we use a new non-mydriatic video-ophthalmoscope for simple and fast acquisition of low SNR retinal sequences. We introduce a novel, two-step approach for fast image registration. The phase correlation in the first stage removes large eye movements. Lucas-Kanade tracking in the second stage removes small eye movements. We propose robust adaptive selection of the tracking points, which is the most important part of tracking-based approaches. We also describe a method for quantitative evaluation of the registration results, based on vascular tree intensity profiles.ResultsThe achieved registration error evaluated on 23 sequences (5840 frames) is 0.78 ± 0.67 pixels inside the optic disc and 1.39 ± 0.63 pixels outside the optic disc. We compared the results with the commonly used approaches based on Lucas-Kanade tracking and scale-invariant feature transform, which achieved worse results.ConclusionThe proposed method can efficiently correct particular frames of retinal sequences for shift and rotation. The registration results for each frame (shift in X and Y direction and eye rotation) can also be used for eye-movement evaluation during single-spot fixation tasks.

Quantitative Analysis of Fundus-Image Sequences Reveals Phase of Spontaneous Venous Pulsations.

Spontaneous venous pulsation correlates negatively with elevated intracranial pressure and papilledema, and it relates to glaucoma. Yet, its etiology remains unclear. A key element to elucidate its underlying mechanism is the time at which collapse occurs with respect to the heart cycle, but previous reports are contradictory. We assessed this question in healthy subjects using quantitative measurements of both vein diameters and artery lateral displacements; the latter being used as the marker of the ocular systole time. We recorded 5-second fundus sequences with a near-infrared scanning laser ophthalmoscope in 12 young healthy subjects. The image sequences were coregistered, cleaned from microsaccades, and filtered via a principal component analysis to remove nonpulsatile dynamic features. Time courses of arterial lateral displacement and of diameter at sites of spontaneous venous pulsation or proximal to the disk were retrieved from those image sequences and compared. Four subjects displayed both arterial and venous pulsatile waveforms. On those, we observed venous diameter waveforms differing markedly among the subjects, ranging from a waveform matching the typical intraocular pressure waveform to a close replica of the arterial waveform. The heterogeneity in waveforms and arteriovenous phases suggests that the mechanism governing the venous outflow resistance differs among healthy subjects. Further characterizations are necessary to understand the heterogeneous mechanisms governing the venous outflow resistance as this resistance is altered in glaucoma and is instrumental when monitoring intracranial hypertension based on fundus observations.

Direct ophthalmoscopy should be taught to undergraduate medical students-yes.

Direct ophthalmoscopy should be taught to undergraduate medical students-yes.

Correlation of retinal nerve fibre layer thickness and spontaneous retinal venous pulsations in glaucoma and normal controls.

PurposeTo study the relationship between amplitude of spontaneous retinal venous pulsatility (SRVP) and retinal nerve fibre layer (RNFL) thickness in glaucomatous eyes, and to determine if this parameter may be a potential marker for glaucoma severity.Method85 subjects including 50 glaucoma (21 males, 67±10 yrs) and 35 normals (16 males, 62±11 yrs) were studied. SRVP amplitude was measured using the Dynamic Vessel Analyser (DVA, Imedos, Germany) at four regions of the retina simultaneously within one disc diameter from the optic disc—temporal-superior (TS), nasal-superior (NS), temporal-inferior (TI) and nasal-inferior (NI)). This was followed by RNFL thickness measurement using spectral domain optical coherence tomography (Spectralis OCT). The correlation between SRVP amplitude and corresponding sectoral RNFL thickness was assessed by means of non-linear regression (i.e. logarithmic). Linear regression was also applied and slopes were compared using analysis of covariance (ANCOVA).ResultsGreater SRVP amplitude was associated with thicker RNFL. Global SRVP amplitude was significantly lower in glaucoma eyes compared with normals (p<0.0001). The correlation coefficient of the linear regression between RNFL and SRVP at TS, NS, TI and NI quadrants in the glaucoma group were r = 0.5, 0.5, 0.48, 0.62. Mean SRVP amplitude and RNFL thickness for TS, NS, TI and NI quadrants were 4.3±1.5, 3.5±1.3, 4.7±1.6, 3.1±1 μm and 96±30, 75±22, 89±35 and 88±30 μm, respectively. The ANCOVA test showed that the slope of linear regression between the four quadrants was not significant (p>0.05). Since the slopes are not significantly different, it is possible to calculate one slope for all the data. The pooled slope equals 10.8 (i.e. RNFL = 10.8SRVP+41).ConclusionWhile SRVP was present and measurable in all individuals, the amplitude of SRVP is reduced in glaucoma with increasing RNFL loss. Our findings suggest the degree of SRVP may be an additional marker for glaucoma severity. Further studies are needed to determine the mechanism of reduction in SRVP, and whether changes can predict increased risk of progression.

Retinal venous pressure in chronic smokers.

BackgroundThe overall aim of this study was to determine retinal venous pressure (RVP) in healthy chronic smokers and compare values to those of healthy non-smokers.MethodsBoth eyes of 25 healthy chronic smokers and 41 healthy non-smokers were included. Measurements of RVP were performed by means of contact lens ophthalmodynamometry. Ophthalmodynamometry is done by applying increasing force on the eye via a contact lens. If a spontaneous venous pulsation was present, it was noted. If not, the compressive force was increased until the first venous pulsation was detected, and the measurement value was fixed and read. RVP was calculated as the sum of pressure increase induced by the instrument and intraocular pressure.ResultsSmokers had a significantly higher frequency of spontaneous venous pulsations than non-smokers (p < 0.001). Mean values of RVP were slightly lower in smokers than in non-smokers: 15.3 and 15.5 (smokers) versus 15.9 and 16.2 (non-smokers) for the right and left eye, respectively; however, the difference in RVP between the two groups did not reach significance. There was no significant difference in blood pressure between the two groups, but heart rate was significantly higher in smokers (p = 0.043).ConclusionsRVP values may differ in healthy smokers than in non-smokers. Therefore, smoking habits should be considered when interpreting RVP results.

Relationship of spontaneous retinal vein pulsation with ocular circulatory cycle.

PurposeTo determine the timing of spontaneous venous pulsation (SVP) relative to the ocular circulatory cycle by using the movie tool of confocal scanning laser ophthalmoloscope.MethodsA video recording of the fundus was obtained using a confocal scanning laser ophthalmoscope (Spectralis HRA, Heidelberg Engineering, Heidelberg, Germany) at 8 frames/s in 47 eyes (15 glaucoma patients and 32 glaucoma suspects) with visible pulsation of both the central retinal artery (CRA) and vein (CRV). The timing of the maximum and minimum diameters of the CRA (CRAmax and CRAmin, respectively) and CRV (CRVmax and CRVmin, respectively) was identified during four pulse cycles. The interval between CRVmin and CRAmin, and between CRVmax and CRAmax was expressed as the number of frames and as a percentage of the ocular circulatory cycle.ResultsThe ocular circulatory cycle (from one CRAmax to the next) lasted 7.7±1.0 frames (958.8±127.2 ms, mean±SD), with a mean pulse rate of 62.6 beats/min. The diameter of the CRA was increased for 2.4±0.5 frames (301.9±58.8 ms) and decreased for 5.3±0.9 frames (656.9±113.5 ms). CRVmax occurred 1.0±0.2 frames after CRAmax (equivalent to 13.0% of the ocular circulatory cycle), while CRVmin occurred 1.1±0.4 frames after CRAmin (equivalent to 14.6% of the ocular circulatory cycle).ConclusionsDuring SVP, the diameter of the CRV began to decrease at early diastole, and the reduction persisted until early systole. This finding supports that CRV collapse occurs during ocular diastole.

Central retinal venous pulsation pressure in different stages of primary open-angle glaucoma

BackgroundTo evaluate the central retinal venous pulsation pressure (CRVPP) in patients with intraocular pressure (IOP)-controlled early, moderate and advanced open-angle glaucoma and a healthy control group.MethodsCRVPP was measured with a...

Spontaneous Retinal Venous Pulsation and Disc Hemorrhage in Open-Angle Glaucoma

To investigate the relationship of spontaneous venous pulsation (SVP) with disc hemorrhage (DH) in open-angle glaucoma (OAG). Spontaneous venous pulsation was assessed and compared using a confocal scanning laser ophthalmoscope movie tool in 52 eyes of 52 patients with DH, and 111 eyes of 111 patients in without DH. Logistic regression analysis was used to determine the factors associated with the occurrence of DH. The frequency of SVP was 60.7% in overall patients with OAG. The absence of SVP was associated with lower untreated IOP (OR 0.880; P = 0.045), longer axial length (OR 1.654; P = 0.007), and worse visual field mean deviation (OR 0.884; P = 0.035). The absence of SVP was not significantly associated with DH by logistic analysis (OR 0.844; P = 0.626). Better visual field mean deviation (OR 1.098; P = 0.043), lower untreated IOP (OR 0.886; P = 0.021), and the tendency to cold hands (OR 2.688; P = 0.032) were associated with DH. In consecutive patients with OAG, the absence of SVP was not associated with DH.

Compressive Optic Neuropathy Presenting With Psychiatric Symptoms

We report a case of bilateral optic neuropathy presenting with psychiatric symptoms. A 50-year-old woman was admitted with blurry vision in both eyes. She had a 3 months' history of depressed mood. Both optic discs had mild temporal pallor with visible spontaneous venous pulsations. Magnetic resonance imaging of the brain showed a large frontal mass compressing the optic nerves. The tumor was surgically resected, and tissue pathology demonstrated an olfactory groove meningioma.

The Clinical Validity of the Spontaneous Retinal Venous Pulsation

The validity of the clinical dictum "the presence of spontaneous retinal venous pulsation (SVP) excludes raised intracranial pressure" has not been previously tested. We set out to determine the specificity and positive predictive value (PPV) of the presence of SVP to indicate normal intracranial pressure (ICP) in a routine clinical setting. We prospectively recruited patients undergoing lumbar puncture (LP), and 2 clinicians were blinded to the indications for LP and cerebrospinal fluid opening pressure (OP). Interobserver reliability was assessed. There were 106 patients in our cohort with a median age of 44 years (range, 18-79 years) and median body mass index of 27.5 kg/m (range, 18-48 kg/m). SVP was present in 94 of 106 patients (88.7%). Thirteen of 106 (12.3%) patients had high OP (≥30 cmH2O), and SVP was present in 11 of 13 patients (86%) with high OP. The sensitivity (95% confidence interval) of the presence of SVP to exclude raised ICP was 0.89 (0.88-0.92), specificity of 0.15 (0.05-0.37), PPV of 0.88 (0.87-0.9), and negative predictive value of 0.17 (0.05-0.4). Interobserver agreement was moderate for SVP (kappa = 0.42). Although the sensitivity and PPV of the presence of SVP to exclude raised ICP is high, it is not absolute. SVP can be seen in some patients with high ICP. Relying on the presence of SVP to exclude raised ICP may give a false sense of reassurance.

Central Blood Pressure, Arterial Waveform Analysis, and Vascular Risk Factors in Glaucoma

Reduced ocular perfusion pressure has been linked to glaucoma, and increased arterial stiffness is implicated in systemic cardiovascular risk. This study measured central blood pressure (BP) and arterial waveforms derived from pulse tonometry, together with data on systemic and ocular vascular factors relevant to glaucoma status. A total of 126 patients and 66 normal controls were tested, including 90 primary open-angle glaucoma (POAG) patients and 36 normal tension glaucoma (NTG) patients. Glaucoma patients had been followed for at least 3 years and inclusion required several (>4) reliable visual fields such that glaucoma progression could be determined. Radial pulse tonometry and brachial BP data were collected, together with data on disc hemorrhages, spontaneous venous pulsation, peripapillary atrophy, smoking, and medications. Brachial BP or derived central aortic BP parameters generally showed no significant differences between glaucoma patients and normal individuals. The POAG group had a lower pulse pressure, which was also significant in the regression analysis (P<0.002). In the arterial waveform analysis, POAG was associated with a lower brachial form factor than NTG (P<0.001) and higher subendocardial viability ratio (P<0.008). NTG was associated with a lower body mass index, and POAG with a smoking history. There was an increased incidence of disc hemorrhages and a reduced incidence of spontaneous venous pulsations in the progressing group. Derived central BP does not reveal significant differences from controls or in glaucoma subgroups, but a reduced pulse pressure was identified. There may be some changes in arterial pulse waveform shape suggesting possible differences in diastolic perfusion. Disc hemorrhages and loss of spontaneous venous pulsation were associated with disease progression.

Mechanism and clinical application of spontaneous retinal venous pulsations

Spontaneous retinal venous pulsations(SVPs) appears in 90％ of normal persons.It is seen as a rhythmic subtle narrow and expansion of one or more retinal veins on the optic disc.Many researches have demonstrated that SVPs could be applied to the intracranial pressure(ICP) monitoring as well as diagnoses and fellow up of glaucoma.But there is no corresponding domestic research in this field up to now.Although the physiological mechanism of the venous pulsations has been the point of much debate,its potential clinical value attract our attention.The present paper reviewed the progress in current understanding of the mechanism behind the SVPs,the examination method and application of SVPs in clinical study. Key words: Spontaneous retinal venous pulsation; Intracranial pressure; Glaucoma

Relationship of Intraocular Pressure and Frequency of Spontaneous Retinal Venous Pulsation in Primary Open-Angle Glaucoma

To investigate the relationship of intraocular pressure (IOP) and the frequency of spontaneous venous pulsation (SVP) in primary open-angle glaucoma (POAG). Cross-sectional study. A total of 229 eyes of 229 patients with POAG and 205 eyes of 205 glaucoma suspects as a control. The SVP was assessed using a confocal scanning laser ophthalmoscope (Spectralis HRA, Heidelberg Engineering, Heidelberg, Germany) movie tool. Patients with POAG were divided into 3 groups on the basis of the frequency distribution of untreated IOP: lower tertile (IOP ≤ 15 mmHg; group A), middle tertile (IOP >15 and ≤ 21 mmHg; group B), and upper tertile (IOP >21 mmHg; group C). The frequency of SVP was compared between the glaucoma suspects and patients with POAG and among the 3 groups of POAG. Logistic regression analysis was performed to determine the factors associated with the frequency of SVP. Frequency of SVP in patients with POAG and glaucoma suspects. Spontaneous venous pulsation was more frequently found in glaucoma suspects than in patients with POAG (86.3% vs. 53.3%, P<0.0001). Within the POAG group, the frequency of SVP was significantly lower in group A (40.2%) than in group B (57.3%, P = 0.03) and group C (63.9%, P = 0.003). There was no significant difference between groups B and C (P = 0.42). In addition to IOP (P = 0.007), visual field mean deviation (MD) and refractive error were associated with the frequency of SVP (P<0.0001 and P = 0.011, respectively). When analyzed within the same stage of disease, SVP was less frequently found in group A than in group C in early (P = 0.011) and advanced (P = 0.044) glaucoma and marginally less frequently found in moderate glaucoma (P = 0.080). Spontaneous venous pulsation was less common in patients with POAG than in glaucoma suspects. Among the patients with POAG, SVP was less common in patients with low IOP at all stages of disease. These results are consistent with vascular factors having a more significant role in patients with POAG with low IOP than in patients with POAG with higher IOP.

Spontaneous venous pulsation revisited ‐ relevance to glaucoma?

AbstractPurpose Purpose: Address the clinical significance of spontaneous venous pulsation (SVP) assessment in glaucoma patients.Methods Methods: Review of the existing literature on the subject, including own published data. Emphasis on studies that have analyzed this phenomenon using OBF studying technologies.Results Results: Threshold conditions for SVP detection are different in healthy and in glaucoma patients. The variables involved in SVP generation may have a different threshold in normal tension glaucoma (NTG) than the one seen in primary open‐angle glaucoma (POAG) patients. Hemodynamic patterns in POAG reveal a selective venous disturbance in patients lacking SVP, while NTG patients have both arterial and venous changes in their central retinal vessels. Clinically, patients with NTG without a visible SVP have a higher functional damage than their SVP‐positive counterparts.Conclusion Conclusions: The lack of SVP in NTG patients may not only represent a more advanced condition, but also both an arterial and venous dysregulation. More studies are needed to validate these findings.

Lack of spontaneous venous pulsation: possible risk indicator in normal tension glaucoma?

Recently, the absence of spontaneous venous pulsation (SVP) has been suggested as a vascular risk factor for primary open-angle glaucoma (POAG). As the mechanism behind this phenomenon is still unknown, the authors have studied this vascular component using colour Doppler imaging (CDI). A total of 236 patients were divided into three diagnostic groups: healthy controls (81), POAG (86) and normal tension glaucoma (NTG; 69). All subjects were submitted to CDI studies of the retrobulbar circulation, intraocular pressure measurements and assessment of SVP existence. Mann-Whitney, chi-square contingency tables and Spearman correlations were used to explore differences and correlations between variables in the diagnostic groups. Eighty-two percent of healthy controls had SVP (66/81), while a smaller numbers were registered in both glaucoma groups: POAG - 50% (43/86); NTG - 51% (35/69). In NTG patients, but not in POAG patients, the prevalence of the SVP phenomenon decreases with increased glaucoma damage (p = 0.04; p = 0.55, respectively). Overall glaucoma patients from both groups had lower central retinal vein (CRV) velocities than the healthy controls (p < 0.05). NTG patients with SVP had less severe visual field defects (mean defect -6.92 versus -11.1, p < 0.05), higher [correction added after online publication 21 September 2012; the word 'higher' has been inserted to replace the word 'lower'] peak systolic and mean flow velocities in the central retinal artery (p < 0.01; p < 0.05, respectively) as well as higher [correction added after online publication 21 September 2012; the word higher has been inserted to replace the word lower] maximal velocities and RI of the CRV (p < 0.02; p < 0.05, respectively). Glaucoma patients have a decrease in CRV velocities. SVP is less prevalent in glaucoma patients than in healthy individuals. This phenomenon apparently reflects different hemodynamic patterns in the central retinal vessels. This variable may be of particular importance in NTG patients, where it may be associated with more advanced functional damage.

Spontaneous retinal venous pulsatility in patients with cyanotic congenital heart disease

Spontaneous retinal venous pulsations (SRVP) are assessed as a clinical marker for patients with ophthalmic or neurological disorders. The pulsations are influenced by intraocular pressure (IOP), cerebrospinal fluid pressure (CSFp), and retinal venous pressure (RVP). However, little is known about the effect of cyanosis with polycythemia, a common finding in adults with complex congenital heart disease (CHD), on SRVP. This study investigated 11 subjects with long-standing cyanosis secondary to CHD and 11 control subjects to determine if there were measurable differences in resting pulsatility for a given IOP level. Intraocular pressure was measured using Goldman tonometry, and dynamic SRVP was recorded noninvasively using a retinal vessel imaging system. Peak amplitude of SRVP at each cardiac cycle was measured and compared with IOP. Heart rate was also monitored during the tests. Results show that for a similar baseline IOP, SRVP amplitudes are significantly lower in cyanotic patients compared with normal subjects (P < 0.0001). This may be explained by an increased RVP or high CSFp in these patients. Mean venous diameter is also significantly higher in cyanotic patients (P < 0.01), but no significant relationship was found between SRVP or diameter with blood parameters.

P.10 The clinical reliability of spontaneous retinal venous pulsation

Background and AimRhythmic variations in calibre of retinal veins crossing the optic disc indicate normal CSF pressure. Anecdotal observation of SVP in patients with high opening pressure (OP), led us...

Visualization of Fundus Vessel Pulsation Using Principal Component Analysis

Spontaneous venous pulsation is one of the clinical signs with which to rule out elevated intracranial pressure and papilledema. More subtle pulsatile retinal movements are difficult to observe because of eye movements. Recording a fundus movie and aligning (registering) the images helps, but the images still contain distracting microsaccadic distortions and noise. The authors hypothesized that addressing these latter points should allow observation of minute pulsating features in fundus movies. Principal component analysis (PCA), a basic form of blind source analysis, is applied to recorded fundus image sequences. The authors demonstrate this method in 5-second image sequences acquired with a near-infrared SLO (HRA+OCT Spectralis). The images are first registered to correct for eye drift, then microsaccade-distorted images are rejected, and the remaining image sequence is decomposed into principal components. Finally, a movie is constructed using the first five principal components (these had pulsatile features). Each of the processing steps (registration, cleaning, PCA filtering) improves the detection of pulsatile features, ultimately allowing clear visualization of spontaneous venous pulsation. Depending on the subject, additional features can be observed: pulsation amplitude of the arterial tree of approximately 10 μm, pulsation of arterioles down to 70-μm diameter, complete venous collapse, overall optic nerve head tissue pulsation, and mechanical links between veins and arteries. By disentangling pulsatile motion from other dynamic components of retinal images, unprecedented resolution in physiologic motion of retinal vessel structure is achievable.

Bilateral ocular perineuritis as the presenting feature of acute syphilis infection

We describe the case of a 48-year-old man who presented with a 2-month history of recurrent, transient visual obscurations that were not exacerbated by straining or coughing. During this period, he felt unwell with headaches, malaise, and flu-like symptoms. Visual symptoms improved but failed to resolve to two courses of oral amoxicillin prescribed for a presumed upper respiratory tract infection. On examination, he had a normal body mass index. Bilateral disc edema (Fig. 1a) and absent ocular spontaneous venous pulsations were identified. Visual acuity (corrected), color vision, and visual fields were all normal. Slit-lamp examination confirmed disc swelling but was otherwise normal. No other neurological deficits were detected and general medical examination was normal. MRI brain, MR venogram, and MR angiogram were all normal. A lumbar puncture examination revealed an opening pressure of 19 cm of CSF (normal range 12–22 cm of CSF). The CSF white cell was 1, protein 0.32 g/dl (normal range 0.15–0.45) with normal glucose. Positive unmatched oligoclonal bands were detected but there was a normal IgG index. Blood tests, including a full blood count, urea and electrolytes, thyroid function tests, serum protein electrophoresis and anti-nuclear, extractable nuclear antigens, and anti-neutophil cytoplasmic antibodies were normal or negative. An HIV test was negative, however, an initial screen for syphilis demonstrated a positive VDRL and RPR IgM, with a titer of 1:32. Further studies including Treponema pallidum IgM enzyme immunoassay and Treponema pallidum particle agglutination were positive with a titer of [1/80, indicating acute infection. CSF treponemal studies were negative. On further questioning, the patient recalled painless ulceration of his glans penis 12 weeks prior to presentation. He had not sought medical attention and it had resolved spontaneously. He had a long-term female partner but reported unprotected intercourse with another female 16 weeks prior to presentation. We diagnosed ocular perineuritis appearing as bilateral disc swelling as a presenting sign of active syphilis. The patient made a full clinical recovery with resolution of the visual symptoms and signs following appropriate antibiotic therapy. Syphilis has reemerged within Europe and North America since the late 1990s. In Ireland in 2008, 221 cases (4.9/100,000) were reported [1], the majority of which being diagnosed in men who have sex with men. HIV coinfection is associated with higher rates of transmission and increased severity of symptoms [2]. Increases are considered to be a consequence of unprotected sexual encounters rather than antibiotic resistance [3]. Ocular manifestations of syphilis as the presenting feature are limited to case reports and small case series [4–9]. Symptoms can be unilateral or bilateral. The most common ocular presentation is uveitis [8], but chorioretinitis, retinitis, keratitis, retinal vasculitis, and optic neuropathy are reported, occurring at any stage of the disease [10]. Previous reports of syphilis presenting as optic disc swelling as a result of papillitis or perioptic neuritis have been associated with other evidence of central nervous system involvement as demonstrated by a CSF pleocytosis, raised protein, or positive CSF syphilis studies [4–9]. K. O’Connell (&) M. Marnane C. McGuigan Department of Neurology, St. Vincent’s University Hospital, Elm Park, Dublin, Ireland e-mail: kazzoc@hotmail.com