Double Vision Lyme Disease: When Eye Symptoms Signal Neuroborreliosis
Double vision can signal neurologic Lyme disease
Cranial nerves may be affected
Early treatment often leads to recovery
Double vision Lyme disease is an uncommon but important neurologic sign that may indicate cranial nerve involvement.
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A 69-year-old man presented with headache and double vision, highlighting how Lyme neuroborreliosis can affect eye movement through cranial nerve dysfunction.
These findings are part of a broader group of eye symptoms of Lyme disease, which may reflect neurologic or inflammatory involvement.
One month earlier, he had been hiking in a rural area of New York but did not recall a tick bite or rash.
Double Vision as the Presenting Symptom
Five days after the onset of headache, he developed double vision when both eyes were open.
Covering one eye eliminated the symptom—confirming true diplopia.
Although Lyme disease can affect the nervous system, eye movement abnormalities are uncommon and may delay diagnosis.
Examination revealed a left-sided cranial nerve III palsy. The remainder of the neurologic exam was normal.
Cranial Nerve Involvement in Lyme Disease
Most Lyme-related cranial neuropathies involve the facial nerve (cranial nerve VII). In contrast, cranial nerve III involvement is rare.
Cranial nerve III controls eye movement, eyelid elevation, and pupil function.
When affected, patients may develop:
- Double vision (diplopia)
- Drooping eyelid (ptosis)
- Restricted eye movement
- Abnormal pupil responses
This type of presentation may be overlooked without awareness of neurologic Lyme disease.
Diagnostic Testing
Serologic testing was positive by ELISA, with Western blot confirming multiple IgG bands.
Cerebrospinal fluid testing supported the diagnosis, although results may vary in neurologic Lyme disease.
Clinical findings remain essential, especially when laboratory results are inconclusive—an issue discussed in Lyme disease testing limitations.
Treatment and Outcome
The patient was treated with four weeks of intravenous ceftriaxone.
His double vision and headache resolved completely.
This outcome highlights that neurologic Lyme disease is often reversible with appropriate therapy.
Why This Case Matters
Double vision typically raises concern for stroke, tumor, or other neurologic conditions.
Lyme disease is often overlooked as a cause of cranial nerve palsy—especially without a known tick bite.
Failure to consider Lyme disease may delay diagnosis and treatment.
Clinical Perspective
Lyme disease should be included in the differential diagnosis of unexplained cranial nerve palsies—particularly in endemic regions.
Even in the absence of rash or known tick exposure, neurologic symptoms may be the first clue.
Early recognition improves outcomes and helps prevent complications.
Clinical Takeaway
Double vision from Lyme disease is rare but treatable.
When cranial nerve dysfunction is unexplained, Lyme neuroborreliosis should be considered.
Frequently Asked Questions
Can Lyme disease cause double vision?
Yes. Lyme disease can affect cranial nerves controlling eye movement, leading to diplopia.
Which nerve is involved?
Cranial nerve III is one possible cause, though facial nerve involvement is more common overall.
Is this condition reversible?
Often yes. Many patients recover fully with appropriate antibiotic treatment.
Does a tick bite need to be recalled?
No. Many patients do not remember a tick bite or rash.
When should Lyme disease be considered?
When unexplained neurologic symptoms occur, especially in endemic regions.
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
I have had lyme now ( or some form of it ,in it’ ) for over 30 years. I was told MS,Lou Ger, over active nerves ,floaters in my eyes, many more with the most used ,” it’s all in Your head”. My guestion is will lyme attack the whites of a persons eyes ? I have dark gray lines showing up in the whites of my eyes ,that a doctor told me the thinning of the white section and what I was seeing was the the inner eye. Also two years ago during an eye exam I lost the sight in my right eye for a period of about 5 min.’s The doctor told me it was normal. I have come to think there is nothing normal with lyme over the years. Ant ideas ?
I have had 3 blood test for lyme all come back negative have burning feet headache on and off,brain fog short term memory loss eye problems I feel like its lyme
What are the parallels between
neuroborreliosis and neurosyphilis?
Both are caused by spirochetes.
There are many parallels.
many
Your doctor will have to use clinical judgment
Your vision loss may have been an optical migraine. You will need to be seen to rule out a retinal tear. I am not familiar with the full spectrum of eye finding. I have reviewed the paper to share what I learned. You may want to include a doctor who works with Lyme disease for the entire picture.
I have tinnitus, double vision, and knee pain. I have been to my ophthalmologist, neurologist, ENT, and family doctor. I also had a MRI brain scan that all came out negative. I also have developed insomnia. After seeing your blogs I am now calling my family doctor to ask for a Lyme disease test which none have suggested I do live in upstate New York where Lyme disease is prevalent. I am happy that I found you. Oddly enough I am hoping the Lyme disease test is positive. What do you suppose the odds are that I have Lyme disease? Thank you.
I find other symptoms including tinnitus and knee pain helpful in identifying Lyme disease even if the tests are negative.
Sounds familiar
17 months blood work came back negative/ inconclusive
It turned out
LYME DISEASE
Keep on your doctors
My son has what we think is congenital Lyme, diagnosed in his 20’s. Symptoms of fatigue, anxiety, and attention issues all his life, and he started getting double vision before diagnosis, and then head pressure 24/7 in one spot a year or so later. I also have Lyme, and have head pressure but in a different spot, also 24/7. Could his double vision be caused by Lyme? He’s not treating at the moment, so this has been there for about 3 years now. Not sure if it’s unrelated, or could be related to Lyme.
There are a broad range of visual disturbance issues in patients in my practice. I will add a thorough evaluation for a tick borne illness on top of your ophthalmologist.
Do the nervous and vision symptoms disappear after successful treatment of the disease? Does the patient in this article have any symptoms?
“His diplopia resolved and he was asymptomatic two months after initiation of therapy.” wrote the authors. I have patients who remain ill after treatment.
I started having diploma symptoms in Winter 2018. After many visits with ophthalmologists and neurologists who pursued demyelinating causes I was tested and was positive for Lyme. After many courses of oral antibiotics the symptoms subsided. I’ve had a couple short reoccurrences (1-2 days) but I’ve now had it for a week+. The doctors I saw were never willing to say the symptoms were as a direct result of Lyme. What type of doctor should I be seeing?
I would typically consult with a doctor experienced in treating Lyme disease. I would also typically continue careful followup with any ophthalmologist or Neurologist my patient is working with. Call my office at 914-666-4665 if you have any questions.
I developed double vision in 2013. About two years later, I finally got tested for Lyme and was treated by you with oral antibiotics for about a year where my symptoms lessened a great deal. Since then I have had two additional Lyme screenings whereby one came up clean and another had two or three positives. Within the last two years the double vision has gotten much worse and is still in both eyes. My eye doc diagnosed it as conversion insufficiency and wanted me to try their therapy treatments. I did not due to cost, however, could this be Lyme? Since last seeing you I been diagnosed with psoriatic arthritis although I am seronegative for inflammation and the medications tried did not improve any symptoms. I have several autoimmune disorders as well, could this all still be related to Lyme?
I am glad you were successfully treated in 2013. I am sorry to hear you have developed eye issues. I would typically revisit a doctor experienced in treating Lyme disease again in addition to you current doctors. I hope you find an answer soon.
I was bitten by a nymph about 1 year ago and I too am experiencing the sam double vision problems and when I cover my right eye my
Vision corrects. I’m on the way for an MRI today if the brain and hope and pray that I get the right diagnosis.
I pray that you get the right diagnosis. I find patients with a tick borne infection other symptoms that help in the diagnosis.
This man is not the only case. I had a Partial 3rd nerve palsy of my right eye in 2018 and a 4th nerve palsy on the right in 2021. Diagnosed with Lyme after that by a Functional doc. Infectious disease clinic declined to see me because conventional lab test was negative. Thank goodness for doxycycline (cleared my vision in 3 days after we doubled my initial dose) and functional medicine docs!! Reach out to me, Dr. Cameron, if you want any more about my story. My Neuro-ophthalmologist had no idea Lyme could cause this. Word HAS to get out about this! If she knew that in 2018, who knows, maybe the second palsy might never have happened had I gotten diagnosed and treated the first time!
Thanks for sharing.