Letters to the Editor
ment after clear-lens extraction in 41 eyes with high axial
myopia. Retina 1996; 16:3-6.
5. Ripandelli G. Reply [letter]. Retina 1997; 17:78-9.
Syphilis Exposure and Uveitis
Dear Editor:
Barile and Flynn recently reported the results of a retro-
spective review of syphilis exposure in patients with uve-
itis (Ophthalmology 1997; 104:1605-9). The authors re-
ported that 18 of 44 patients with presumed syphilitic
uveitis underwent cerebrospinal fluid (CSF) analysis and
that all of these studies were normal. In this series, how-
ever, two patients had posterior uveitis, three patients
had panuveitis, and three patients had concurrent HIV
infection. Were these patients among those who under-
went CSF analysis? I was wondering if the authors could
comment on the need for CSF analysis in patients with
posterior uveitis, panuveitis, optic neuropathy, or retinal
vascular invovement compared to patients with anterior
or intermediate uveitis? Is optic nerve involvement or
posterior uveitis a sign of central nervous system disease?
If so, are these findings alone an indication for CSF neuro-
syphilis regimen of penicillin treatment regardless of CSF
results?
ANDREW G.LEE, MD
Houston, Texas
Authors’ reply
Dear Editor:
Dr. Lee poses interesting questions regarding the need
for CSF studies in patients with presumed syphilitic uve-
itis when the yield of such studies is likely to be low. In
our own study, patients with presumed syphilitic uveitis
who underwent CSF analysis included one of two patients
with posterior uveitis and one of three patients with pan-
uveitis. One patient with posterior uveitis was empirically
treated with a neurosyphilis regimen without obtaining a
lumbar puncture. One of the two patients with panuveitis
did not recieve CSF analysis because of resistance on the
part of the primary care physician, and the other patient
was noncompliant with a recommended lumbar puncture.
The need for CSF examination in patients with pre-
sumed syphilitic uveitis remains controversial. If one con-
diders uveitis only a risk factor for neurosyphilis, CSF
analysis is prudent when antibiotic treatment follows the
recommended regimen for latent syphilis.’ The difficulty
lies in the low yield of CSF serologic studies even in
clinical cases of neurosyphilis.2Z3 If one considers uveitis a
sign of neurosyphilis and treats accordingly, it is arguable
whether CSF analysis is necessary at all. In this case,
however, the detection of even mild CSF abnormalities
in cell profile may allow one to monitor response to treat-
ment.*
The question of which patterns and locations of uveitis
suggest the presence of neurosyphilis is also important.
Unfortunately our study does not contain sufficient infor-
mation to answer this question. Because three of the five
patients in our study with presumed syphilitic panuveitis
or posterior uveitis did not undergo lumbar puncture, we
are unable to meaningfully comment on the CSF profiles
of such “high risk” cases. It is quite reasonable, as Dr.
Lee suggests, to consider posterior segment involvement
an indication for a neurosyphilis regimen regardless of
CSF findings. Concurrent HIV infection also argues for
a neurosyphilis regimen.4 In short, it seems reasonable to
rule out an abnormal CSF profile when treating for latent
syphilis or administer treatment for neurosyphilis in
“high risk” cases.
GAETANO BARILE, MD
THOMAS E. FLYNN, MD
New York, New York
References
1. Centers for Disease Control. 1989 Sexually Transmited
Diseases Treatment Guidelines. MMWR 1989;38(No. 5-
8):5- 15.
2. Burke JM, Schaberg DR. Neurosyphilis in the antibiotic
era. Neurology 1985;35:1368-71.
3. Davis LE, Schmitt JW. Clinical significance of cerebrospinal
fluid tests for neurosyphilis. Ann Neurol 1989;25:50-5.
4. Tramont EC. Syphilis in the AIDS era [editorial]. N Engl
J Med 1987;316:1600-1.
Microsurgery for Eyelid Margin Tumors
Dear Editor:
The paper entitled “Laser Microsurgery for Superficial
Tl-T2 Basal Cell Carcinoma of the Eyelid Margins” by
Bandieramonte et al (Ophthalmology 1997; 104:1179-
84) covered important ground, but we do think it im-
portant to clearly delineate the advantages of this surgical
method. The carbon dioxide laser has not yet been ap-
preciated for its full potential in oculoplastic surgery. Ear-
lier, we published a paper with comparable content and
similar findings.’ While we agree with the authors’ con-
clusions, we would like to add the following observations
based on our experience:
1. We also find the microscope to be very important
in the assessment of the tumor margin, but we be-
lieve that a hand-held surgical laser gives more free-
dom during the procedure, especially when separat-
ing the tumor from tissue along the base. Since the
superpulse mode diminishes the carbonization zone,
it is of further help in the assessment of the tumor
margins.
2. We do not use any postoperative antibiotic treat-
ment, and we have not observed suppuration of the
wounds. We consider CO, laser a superior tech-
nique to traditional surgical cutting because we be-
lieve it to be the most accurate method of tumor
delineation.* As blood and lymphatic vessels are
coagulated, there is no edema formation and mini-
mal wound pain. Furthermore, since repair is poor
in scar tissue, the recurrence control is also im-
proved. Finally, because of the “no touch tech-
nique,” intraoperative tumor spread is also mini-
mized.
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