Clinical and Organizational Determinants of a Frequently Delayed Diagnosis of Ocular Syphilis in a French Referral Center

Summary

Ocular syphilis diagnosis is often delayed, despite private practice ophthalmologists being first to see the patient. Dx usually not made by tertiary care specialists. Retrospective, French, 72 patients.

Abstract

Purpose: To identify clinical and organizational factors associated with diagnostic delays in ocular syphilis, where ocular manifestations led to the diagnosis.

Design: Monocentric, retrospective, cohort study.

Participants: Seventy-two adult patients (89 eyes) diagnosed with ocular syphilis between January 01, 2004 and December 31, 2023, and treated in the Infectious and Tropical Diseases Department of Bordeaux University Hospital (France).

Main outcome measures: Diagnostic delays defined as the time between the onset of the first symptom and the diagnosis classified into four groups: ≤1 week, >1-4 weeks, >4-12 weeks, and >12 weeks METHODS: Each patient’s diagnostic pathway, from the first report of symptoms to the diagnosis, was reconstructed. The various time intervals were determined. Clinical and organizational factors were assessed to determine their impact on diagnostic delays.

Results: Panuveitis (56%) and posterior uveitis (26%) were the most common presentations. All diagnoses were made by ophthalmologists in a tertiary care center, although 80% of patients first consulted a private practice ophthalmologist and 25% a non-ophthalmologist physician. The diagnosis was made within one month of symptom onset in 74% of patients, and within the first week in 28% of them. Only patients who initially consulted a private practice experienced delays between >4 and 12 weeks (15.3%) and >12 weeks (11.1%). Latent syphilis (β = +42.1 days; P = .007) and posterior uveitis (β = +73.3 days; P < .001) were associated with longer diagnostic delays, while ocular pain (β = -41.0 days; P = .007) and extraocular signs (β = -40.7 days; P = .007) were predictive of shorter delays. Longer diagnostic delays correlated significantly with poorer visual outcomes (P = .02).

Conclusions: Ophthalmologists in private practice are often the first clinicians that patients consult, and since ocular manifestations often lead to the diagnosis of syphilis, they play a crucial role in its detection. These findings highlight the importance of raising awareness among front-line physicians, routinely prescribing syphilis serology in the presence of unexplained uveitis or vision loss, systematically questioning patients about their sexual history and systemic symptoms, and implementing targeted educational programs for clinicians.