Rapidly Progressive Bilateral Syphilitic Optic Neuritis in an Elderly Patient: A Case Report

Syphilitic optic neuritis (SON), caused by Treponema pallidum infection, typically demonstrates favorable visual outcomes when promptly diagnosed and appropriately treated with high-dose intravenous penicillin therapy. However, certain patient factors including advanced age, severe initial visual impairment, and rapid disease progression may influence treatment outcomes. This case report aims to highlight the clinical challenges and poor prognostic factors associated with SON in elderly patients by presenting a rare case of rapidly progressive bilateral visual dysfunction despite optimal medical management. To achieve this objective, we present a detailed case analysis involving comprehensive ophthalmologic examination, laboratory investigations, and treatment response evaluation in an 80-year-old woman who developed acute bilateral vision loss. This study presents a comprehensive case report involving the systematic documentation, clinical analysis, and treatment outcomes of bilateral SON with neuroretinitis manifestation selected based on the unusual demographic presentation and a typical treatment response. Significant and concerning findings indicate that despite early diagnosis confirmed by positive serological tests (RPR 2.9 R.U., TPHA 6.24 R.U.) and prompt initiation of high-dose intravenous benzylpenicillin potassium therapy (18 million units daily for 14 days), visual function recovery was minimal, with persistent severe visual impairment in both eyes at one-month follow-up. However, inflammatory signs including optic disc swelling and peripapillary exudates showed marked improvement, though RPR titers remained persistently low-positive. Advanced therapeutic interventions including sub-Tenon triamcinolone acetonide injections and oral amoxicillin supplementation were employed because RPR titers had not turned negative, and vision improvement had not been achieved. Our case demonstrates that SON in elderly patients may exhibit poor visual prognosis despite appropriate treatment protocols. Hence, patient age and initial disease severity are significant prognostic factors, and, unquestionably, this represents an important clinical consideration for ophthalmologists managing ocular syphilis. For this reason, early recognition and aggressive treatment initiation remain crucial, though visual recovery expectations should be tempered in elderly patients with severe initial presentations.