Can Lyme Disease Cause Orbital Myositis? Eye Pain, Swelling, and Double Vision
Orbital myositis can cause eye pain that worsens with movement
Other symptoms may include swelling, double vision, and a bulging eye
Two published cases were reported in association with Lyme disease
Orbital myositis is inflammation involving one or more of the extraocular muscles that control eye movement. Although it is frequently idiopathic, orbital myositis can occur in association with systemic inflammatory disorders, infections, or other medical conditions. Two published cases illustrate why Lyme disease may be considered when unexplained orbital inflammation follows tick exposure or an erythema migrans rash.
What is orbital myositis?
Orbital myositis is an inflammatory disorder affecting the muscles surrounding the eye. It is a subtype of orbital inflammation and often develops suddenly.
Symptoms may include:
- Orbital or periorbital pain
- Pain that worsens with eye movement
- Swelling around the eye
- Restricted eye movement
- Double vision, also called diplopia
- Redness of the eye
- Proptosis or exophthalmos, meaning forward bulging of the eye
Pain with eye movement is particularly characteristic because movement stretches and contracts the inflamed extraocular muscles.
Orbital myositis is often idiopathic, meaning no specific cause is identified. However, doctors must also consider thyroid eye disease, autoimmune or inflammatory disorders, orbital cellulitis, sarcoidosis, vasculitis, IgG4-related disease, tumors, and lymphoma. Infectious conditions, including Lyme disease, have also been reported in association with orbital myositis.
Two cases of orbital myositis associated with Lyme disease
In their article, Two Cases of Orbital Myositis as a Rare Feature of Lyme Borreliosis, Sauer and colleagues described two patients with unilateral orbital inflammation attributed to Borrelia infection.
In both cases, MRI showed abnormalities involving the extraocular muscles consistent with orbital myositis. The patients also had epidemiologic and clinical findings that supported consideration of Lyme disease.
Patient #1: Recurrent eye swelling and orbital pain
The first patient was a 68-year-old woman who experienced recurrent episodes of swelling and pain involving her right eye socket.
The episodes:
- Lasted approximately 2 to 4 weeks
- Occurred 2 to 4 times each year
- Resolved spontaneously or after corticosteroids or nonsteroidal anti-inflammatory drugs
Lyme disease was considered because the patient lived in a rural region of France where Lyme disease was endemic. She recalled numerous tick bites and had a history of an erythema migrans rash and joint pain.
Lyme disease testing was positive, and she was treated with doxycycline. According to the report, her orbital symptoms resolved within 3 weeks.
Patient #2: Eye swelling, bulging, and double vision
The second patient was a 13-year-old girl who developed swelling around one eye. Her symptoms were complicated by forward bulging of the eye and horizontal double vision.
MRI showed an abnormal signal involving the right inferior and medial rectus muscles. These extraocular muscles help control the position and movement of the eye.
The adolescent lived in a Lyme-endemic area and recalled a recent tick bite followed by an erythema migrans rash. Lyme disease testing was positive.
She was treated with doxycycline for 4 weeks. Within one month, her ocular symptoms resolved, and the abnormal MRI signal had decreased.
How was Lyme disease linked to orbital myositis?
These cases included several findings that led the authors to associate the orbital inflammation with Lyme disease:
- Residence in regions where Lyme disease was endemic
- A history of tick exposure
- A previous or recent erythema migrans rash
- Positive Lyme disease testing
- MRI evidence of extraocular muscle abnormalities
- Clinical improvement following antibiotic treatment
Nevertheless, these were two case reports. Case reports can alert clinicians to an unusual presentation, but they cannot determine how frequently orbital myositis occurs in Lyme disease or prove that every patient with similar eye symptoms has a tick-borne infection.
When should Lyme disease be considered?
Lyme disease would not be the most common explanation for orbital pain, swelling, or double vision. However, it may deserve consideration when orbital myositis occurs in a patient who has:
- Recent or substantial tick exposure
- A history of an erythema migrans rash
- Other symptoms compatible with Lyme disease
- Residence in or travel to a Lyme-endemic area
- No convincing alternative explanation for the orbital inflammation
The differential diagnosis remains broad. Eye pain, restricted movement, proptosis, double vision, or swelling can also occur with orbital cellulitis, thyroid eye disease, inflammatory disorders, tumors, and other potentially serious conditions.
For that reason, a swollen or painful eye should not automatically be attributed to Lyme disease. Patients require an appropriate ophthalmologic and medical evaluation, particularly when symptoms are acute, severe, or accompanied by changes in vision.
Frequently Asked Questions
Can Lyme disease cause orbital myositis?
Orbital myositis has been reported as a rare manifestation associated with Lyme disease. In two published cases, patients had compatible exposure histories, positive Lyme disease testing, MRI evidence of extraocular muscle abnormalities, and improvement after doxycycline. Because these were case reports, they do not establish how commonly this occurs.
What does orbital myositis feel like?
Orbital myositis commonly causes pain in or around the eye. The pain often becomes worse when the eye moves. Swelling, redness, double vision, limited eye movement, and forward bulging of the eye may also occur.
Why does orbital myositis cause pain with eye movement?
Orbital myositis affects the extraocular muscles responsible for moving the eye. Contracting or stretching an inflamed muscle can make the pain more noticeable during eye movement.
Can Lyme disease cause swelling around the eye?
Eye and eyelid swelling can have many causes. Orbital swelling has been reported in rare cases of Lyme-associated orbital myositis, but more common and potentially urgent explanations must also be investigated.
Can a tick bite cause a swollen eye?
A local tick bite near the eye can produce localized inflammation, while a tick-borne illness may occasionally be associated with ocular manifestations. However, swelling around the eye is not specific to a tick bite or Lyme disease and should be medically evaluated.
How is orbital myositis diagnosed?
Diagnosis usually involves an eye examination and imaging with MRI or CT. Blood tests and other studies may be needed to evaluate possible infectious, inflammatory, thyroid-related, or neoplastic causes. In some situations, additional testing or a biopsy may be necessary.
How was Lyme-associated orbital myositis treated in these cases?
Both patients described by Sauer and colleagues were treated with doxycycline. The adult’s symptoms resolved within approximately 3 weeks. The adolescent’s symptoms resolved, and her MRI abnormalities decreased, within one month. Treatment decisions for an individual patient should be based on the complete clinical evaluation.
When does eye swelling require urgent medical attention?
Prompt evaluation is important when swelling is accompanied by vision loss, severe pain, fever, restricted eye movement, double vision, a bulging eye, severe headache, or rapidly worsening redness. These findings can occur with conditions requiring urgent treatment.
Clinical Takeaway
These two reports demonstrate that orbital myositis has been described in association with Lyme disease in both an adult and a child. They also illustrate the importance of asking about tick exposure, erythema migrans, geographic risk, and accompanying symptoms when the cause of orbital inflammation remains uncertain.
In both patients, MRI showed abnormalities involving the extraocular muscles, and their ocular symptoms improved after doxycycline treatment. Additional research would be necessary to determine how often Lyme disease is responsible for orbital myositis and how reliably testing can distinguish it from other causes.
Lyme disease is an uncommon consideration in orbital myositis, but a history of tick exposure or erythema migrans may provide an important diagnostic clue when eye pain, swelling, or double vision remains unexplained.
Related Articles
Lyme disease associated with eye problems
Growing list of eye problems in Lyme disease
Can Lyme disease cause vision loss?
References
- Sauer A, Speeg-Schatz C, Hansmann Y. Two cases of orbital myositis as a rare feature of Lyme borreliosis. Case Rep Infect Dis. 2011;2011:372470. doi:10.1155/2011/372470. PMID: 22567470; PMCID: PMC3336248. PMC
- Schoser BGH. Ocular myositis: Diagnostic assessment, differential diagnoses, and therapy of a rare muscle disease—five new cases and review. Clin Ophthalmol. 2007;1(1):37–42. PMID: 19668465; PMCID: PMC2699981.
Dr. Daniel Cameron, MD, MPH
Lyme disease clinician with over 30 years of experience and past president of ILADS.
Symptoms • Testing • Coinfections • Recovery • Pediatric • Prevention
