Lyme disease is an infection caused by the Borrelia burgdorferi spirochete, spread by ticks, which can cause multisystemic changes. Although the most well-known symptoms of the disease are skin, joint and nervous system abnormalities, ocular manifestations — although rare — can be clinically significant and lead to severe vision loss. From a medical perspective, it is crucial that these symptoms are recognised at an early stage, as their non-specific nature often leads to late diagnosis and treatment.
The disease can have early and late ophthalmic symptoms. In early Lyme infection, one of the most common ocular signs is nonspecific follicular conjunctivitis, which has been described in several studies. This conjunctivitis is not always severe, often presenting with mild redness and discomfort, but it can be an important warning sign in cases of suspected Lyme infection.
As the disease progresses, especially in the second and third stages, more severe inflammatory eye abnormalities become more common. These include interstitial keratitis, which is characterised by nummular opacities and is often associated with immune-mediated mechanisms. Inflammation of the cornea can cause pain, light sensitivity and blurred vision, and usually requires antibiotic treatment.
Episcleritis and scleritis are less common but well-documented manifestations that lead to inflammation of the sclera (the white, deep, strong connective tissue wall of the eye). These symptoms not only cause redness and pain, but in severe cases can also lead to permanent vision loss through chronic inflammation and scarring.
Other forms of intraocular inflammation include uveitis and vitritis, which can affect the middle and rear segments of the eye. In uveitis, patients report severe sensitivity to light (photophobia), eye pain, blurred vision and the appearance of floating spots (floaters). In vitritis, inflammation in the vitreous body can also cause floaters and decreased visual acuity, and often requires intravenous antibiotic treatment, as traditional eye drop therapy is rarely sufficient.
Retinal and choroidal involvement, such as retinal vasculitis, branch retinal vein occlusion (BRVO) or choroiditis, may occur in the late stages of infection. These posterior segment abnormalities can cause rapid vision loss and may require urgent ophthalmic intervention.
Neuro-ophthalmological symptoms are particularly important when the infection or accompanying inflammation directly affects the optic nerve, the oculomotor nerves or other cranial nerves. Optic neuritis, although rare, can lead to severe vision loss, and bilateral optic neuritis has also been described in connection with Lyme infection. This form occurs particularly when Borrelia reaches the central nervous system and causes chronic inflammation in the nerve tissue.
Cranial nerve palsies, especially paresis of the sixth cranial nerve (n. abducens), can cause double vision (diplopia). In connection with the neurological involvement of Lyme disease, we often see that the inflammation damages not only the optic nerve but also the nerves that innervate the eye muscles, leading to coordination disorders and decreased visual function.
In terms of the spectrum of clinical symptoms, patients may report double vision, light sensitivity, reduced contrast sensitivity, floating spots, blurred vision and visual field loss. These symptoms are non-specific and are therefore often mistakenly associated with other diagnoses, such as viral or autoimmune uveitis, before Lyme infection is suspected.
Diagnosis is particularly challenging in cases of ophthalmic symptoms. The sensitivity and specificity of serological tests (ELISA, Western blot) can vary, so a negative test does not rule out the disease, especially in cases of early or isolated ocular manifestations. If available, direct diagnostic methods should be used. In some cases, PCR testing of intraocular fluid samples is recommended to detect the microorganism.
Treatment is based on targeted antibiotic therapy, which in severe ocular cases often begins with intravenous antibiotics and is then continued orally. The use of anti-inflammatory corticosteroids is recommended only in combination with antibiotics, especially in cases of intraocular inflammation, while close cooperation between ophthalmologists and infectious disease specialists is key to optimising treatment.
In summary, although the ophthalmic manifestations of Lyme disease are relatively rare, they are of great clinical significance. In patients suspected of having Lyme infection, thorough examination of ophthalmic symptoms is essential for early detection, appropriate treatment and improvement of long-term visual prognosis. Ophthalmic symptoms usually appear in a multisystemic context with other manifestations of the disease, therefore a multidisciplinary approach is recommended.
Sources:
https://pubmed.ncbi.nlm.nih.gov/7832219/
https://pubmed.ncbi.nlm.nih.gov/7726193/
https://pubmed.ncbi.nlm.nih.gov/35321665/
https://pubmed.ncbi.nlm.nih.gov/10711899/
(C) Lyme Borreliosis Foundation
