The use of non-mydriatic ocular fundus imaging in the emergency department for detection of ocular syphilis presenting as presumed "papilledema": a case series.

Background: Ocular syphilis and neurosyphilis can present as seemingly "isolated" bilateral optic disc edema mimicking papilledema from intracranial hypertension. As a result, patients are often sent to the emergency department (ED) for "papilledema work-up," which can lead to delayed or missed ocular syphilis diagnosis since serologic testing for syphilis is not routinely performed in patients with presumed "papilledema." Our study describes eight patients initially referred to our ED for "papilledema" workup who were ultimately diagnosed with ocular syphilis based on characteristic findings seen on non-mydriatic ocular fundus photography and optical coherence tomography nerve/macula (NMFP-OCT) obtained in the ED. Objective: To describe the ocular imaging findings seen on non-mydriatic ocular fundus photography and optical coherence tomography (NMFP-OCT) in the ED and clinical outcomes of patients with ocular syphilis who presented to the ED with presumed "papilledema". Materials and methods: Descriptive case series study involving prospective collection of all consecutive adult patients presenting to our general ED between 6/14/2023 to 9/21/2025 for "papilledema work-up," who were subsequently diagnosed with ocular syphilis. Clinical findings on NMFP-OCT were reviewed. Results: From 6/14/2023 to 9/21/2025, 8/318 patients (2.5%) who underwent our "papilledema protocol" were ultimately diagnosed with ocular syphilis. All 8 patients had bilateral optic disc edema on ocular imaging, triggering our "papilledema protocol" in the ED. Visual acuities ranged from 20/20 to hand motion. 5/8 (63%) patients had outer retinal abnormalities and 7/8 (88%) had vitreous cells, which were remotely identified on NMFP-OCT imaging obtained in the ED by ED staff. 7/8 (88%) patients underwent attempted lumbar puncture (LP), but LP was unsuccessful in 1/7 patients. 5/6 (83%) patients with LP performed in the ED had normal CSF-opening pressure; 4/6 (67%) had elevated CSF nucleated cells [range 7-24]; 3/6 (50%) patients had reactive CSF VDRL. All patients had serologic positive RPR/syphilis IgG-IgM. All patients received 14 days of IV penicillin G. 4/8 (50%) patients were lost to follow-up. Among patients who were seen in outpatient follow-up, ranging from 2 weeks to 8 months after initial presentation, all were found to have improving or resolution of disc edema. Conclusion: Syphilis may present as seemingly "isolated" bilateral disc edema in the ED. Remote interpretation of NMFP-OCT obtained in the ED allowed for detection of subtle outer retinal changes and vitreous cells, heightening suspicion for ocular syphilis and triggering confirmatory serologic testing.