Can Lyme Disease Cause Double Vision? Cranial Nerve Palsy Explained

Lyme disease can rarely cause double vision
Inflammation may affect the cranial nerves controlling eye movement
Prompt diagnosis and antibiotic treatment can lead to recovery

Can Lyme disease cause double vision? Yes. Lyme disease can rarely cause double vision (diplopia) when Lyme neuroborreliosis affects one of the cranial nerves responsible for controlling eye movement. Although facial nerve palsy is the most common cranial neuropathy, inflammation involving the third, fourth, or sixth cranial nerves may disrupt eye alignment and lead to double vision.

Lyme disease has been associated with a variety of vision problems, including blurred vision, double vision, eye pain, and, rarely, vision loss. Prompt recognition of neurologic Lyme disease is important because many patients improve with appropriate antibiotic treatment.

A published case report describes a 69-year-old man who developed headache and double vision after hiking in a rural area of New York. His symptoms were ultimately attributed to Lyme disease involving the third cranial nerve.

A patient develops headache and double vision

In their report, Dixit and colleagues describe a 69-year-old man who presented to an emergency department in New York City complaining of headache and double vision.

One month earlier, the man had been hiking in a rural area of New York. He did not recall a tick bite or notice an erythema migrans rash.

Two weeks later, he developed a headache that, according to the authors, “localized to the right occipital region, and gradually moved to his right orbit.”

Five days later, he noticed double vision whenever both eyes were open. Covering his right eye eliminated the double vision, a finding consistent with binocular diplopia caused by eye misalignment.

“Although Lyme is known to affect the neurological system it usually does not manifest in the extraocular muscles,” the authors wrote.

Why can Lyme disease cause double vision?

Normal binocular vision depends on precise coordination of both eyes. Cranial nerves III (oculomotor), IV (trochlear), and VI (abducens) control the muscles responsible for eye movement.

Inflammation affecting one of these nerves can prevent the eyes from moving together, causing the brain to receive two different images. The result is binocular diplopia, or double vision.

The third cranial nerve also controls several eye muscles, raises the upper eyelid, and helps regulate pupil size. In this patient, physical examination revealed an isolated left third cranial nerve palsy. The remainder of his neurologic examination was normal.

Approximately 75% of Lyme-associated cranial neuropathies involve the facial nerve. Ocular motor nerve palsies are much less common. Among these, sixth cranial nerve palsy has been reported more often than isolated third cranial nerve involvement.

At the time of publication, the authors noted that this appeared to be the first reported case of isolated third cranial nerve palsy associated with Lyme neuroborreliosis.

[bctt tweet=”Lyme disease can rarely cause double vision through cranial nerve palsy.” username=”DrDanielCameron”]

How was Lyme disease diagnosed?

Serologic testing was positive by enzyme-linked immunosorbent assay (ELISA). Western blot testing demonstrated five of the ten reported IgG bands.

The patient also underwent lumbar puncture. Cerebrospinal fluid tested positive by ELISA, although the cerebrospinal fluid-to-serum antibody ratio was negative.

Diagnosing neurologic Lyme disease requires consideration of the patient’s exposure history, clinical presentation, physical examination, and laboratory findings. Cerebrospinal fluid analysis may provide supportive evidence but should always be interpreted within the overall clinical context.

How was the double vision treated?

The man was treated with a four-week course of intravenous ceftriaxone. His headache and double vision resolved following treatment.

This case highlights that prompt recognition of Lyme neuroborreliosis can lead to complete recovery, even when an uncommon cranial nerve palsy is present.

“Although neuroborreliosis is commonly associated with facial nerve palsy,” Dixit and colleagues wrote, “it may account for otherwise unexplained neurological manifestations and warrants evaluation with lumbar puncture and CSF studies.”

This report reminds clinicians to consider Lyme disease in the differential diagnosis of an otherwise unexplained cranial nerve palsy, particularly in patients with possible tick exposure in endemic areas.

Can Lyme disease cause double vision when the MRI is normal?

Yes. A normal or nonspecific MRI does not necessarily exclude Lyme neuroborreliosis or cranial nerve involvement.

A 2026 case report described a 54-year-old woman with persistent headaches followed by double vision and sixth cranial nerve palsy. Her brain MRI showed only small white-matter findings considered age-appropriate and did not identify a structural explanation for her symptoms.

Cerebrospinal fluid analysis revealed marked lymphocytic inflammation and intrathecal production of antibodies to Borrelia, supporting a diagnosis of Lyme neuroborreliosis. The patient improved after beginning intravenous ceftriaxone.

The case illustrates that imaging and cerebrospinal fluid provide different information. MRI may help exclude certain structural disorders, while spinal fluid analysis may reveal inflammation that is not apparent on imaging.

Can Lyme disease affect vision in other ways?

Yes. Lyme disease has been associated with a variety of ocular manifestations and vision problems. Reported symptoms include blurred vision, double vision, eye pain, light sensitivity, optic nerve involvement, uveitis, retinal inflammation, and, in rare cases, vision loss.

Many of these ocular complications are uncommon, and most visual symptoms have causes other than Lyme disease. Nevertheless, Lyme disease should be considered when new neurologic or ocular symptoms develop after possible tick exposure.

Patients who experience sudden vision loss, persistent double vision, severe eye pain, drooping of the eyelid, unequal pupils, weakness, or other acute neurologic symptoms should seek prompt medical evaluation.

In another review, Sathiamoorthi and Smith summarized ocular manifestations of tick-borne diseases. They noted that although some ocular complications may be self-limited, delayed diagnosis can result in permanent visual impairment and, in rare cases, blindness.

Frequently Asked Questions

Can Lyme disease cause double vision?

Yes. Although uncommon, Lyme disease can cause double vision (diplopia) when inflammation affects the cranial nerves controlling eye movement. Facial nerve palsy is far more common, but involvement of the third, fourth, and sixth cranial nerves has also been reported.

Can Lyme disease cause double vision with a normal MRI?

Yes. Published cases describe Lyme neuroborreliosis presenting with double vision even when MRI does not identify a structural explanation. However, new double vision requires prompt evaluation for other neurological, vascular, and ophthalmologic causes.

Can Lyme disease affect your eyes?

Yes. Lyme disease has been associated with blurred vision, double vision, eye pain, light sensitivity, optic nerve involvement, uveitis, retinal inflammation, and other ocular manifestations. Most eye problems have causes other than Lyme disease, but Lyme neuroborreliosis should be considered when compatible symptoms occur after possible tick exposure.

Can Lyme disease cause blurry vision?

Yes. Blurry vision has been reported in patients with Lyme disease. It may result from ocular inflammation, neurologic involvement, or other eye disorders. Because blurry vision has many potential causes, persistent or sudden visual changes require prompt medical evaluation.

Can Lyme disease cause blindness?

Permanent blindness from Lyme disease is rare. However, delayed recognition of certain ocular complications may increase the risk of lasting vision impairment. Early diagnosis and appropriate treatment generally improve the likelihood of recovery.

Clinical Takeaway

Although facial nerve palsy remains the most common cranial neuropathy associated with Lyme disease, these cases illustrate that Lyme neuroborreliosis can rarely present with double vision caused by third or sixth cranial nerve palsy.

Clinicians should consider Lyme disease in patients with unexplained diplopia who have lived in or traveled to endemic areas. A normal or nonspecific MRI does not necessarily exclude cranial nerve involvement or inflammation associated with Lyme neuroborreliosis.

Early recognition and appropriate antibiotic treatment can lead to recovery and may help prevent long-term neurologic or visual complications.

Related Articles

Can Lyme Disease Cause Vision Problems? Binocular Vision Dysfunction Explained

Can Lyme Disease Cause Vision Loss?

Eye Problems in Tick-Borne Diseases Other Than Lyme

Can Lyme Disease Affect the Brain?

References

1. Dixit A, Garcia Y, Tesoriero L, Berman C, Rizzo V. Diplopia: A Rare Manifestation of Neuroborreliosis. Case Rep Neurol Med. 2018;2018:9720843. doi:10.1155/2018/9720843.
2. Sobczak M, Morajko A, Urantowka N, Moszko K, Labuz-Roszak B. The Hidden Face of Lyme Disease: Neuroinfection With Cranial Nerve Involvement. Cureus. 2026;18(2):e103747. doi:10.7759/cureus.103747.
3. Sathiamoorthi S, Smith WM. The Eye and Tick-Borne Disease in the United States. Curr Opin Ophthalmol. 2016;27(6):530-537.

This article is for informational purposes only and does not constitute medical advice, diagnosis, or treatment.

---

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