Questions Ophthalmology Trainees Ask About Ocular Syphilis: A Question-Driven Narrative Review

Syphilis is undergoing a global resurgence, and ocular syphilis, although uncommon, is a sight-threatening manifestation that poses recurrent diagnostic and management difficulties for clinicians in training. The objective of this review was to identify the most frequent questions regarding ocular syphilis raised by ophthalmology residents and to answer them by evaluating the current literature. This was a narrative review informed by a question-based educational needs assessment. Between 2024 and 2025, a standardized invitation was distributed to ophthalmology residents through several international uveitis societies. Questions were submitted voluntarily and anonymously, and overlapping items were consolidated and grouped into thematic domains while preserving their original intent. For each domain, a focused appraisal of the peer-reviewed literature, including the 2021 Centers for Disease Control and Prevention (CDC) sexually transmitted infection treatment guidelines and the 2024 CDC laboratory recommendations for syphilis testing, was synthesized into a direct answer. Of the 53 residents who responded, 18 submitted questions concerning ocular syphilis. These 18 respondents submitted 26 syphilis-related questions, which were consolidated into 15 questions across seven domains: epidemiology, staging, laboratory diagnosis, imaging, systemic evaluation, treatment, and follow-up. They concentrated on serologic interpretation, systemic evaluation, and the logistics of treatment rather than on the clinical recognition of uveitis, clustering at the interface between ophthalmology and infectious disease. Several recurring premises, including the assumptions that ocular syphilis corresponds to a single stage, that imaging can establish the diagnosis, and that lumbar puncture is always required, were found to be outdated or oversimplified. Ocular syphilis is best managed with a neurosyphilis treatment regimen: diagnosed through the combined use of treponemal and nontreponemal serologic tests, supported but not defined by characteristic posterior segment imaging patterns, and monitored with serial nontreponemal titers in shared care with infectious disease services. HIV testing should be strongly recommended in every patient. A question-driven format targets the specific uncertainties faced by residents and may serve as a template for educational reviews in other uveitic entities.