Lyme Disease and Vision Problems: A Case of Optic Neuritis

Welcome to another Inside Lyme case study. In my clinical practice, reviewing real patient cases remains one of the best ways to understand the many ways Lyme disease can present. In this episode, I discuss a 46-year-old woman who developed Lyme disease and vision problems, including severe optic neuritis.

This case was first reported by Jha and colleagues in the Wisconsin Medical Journal in 2018.

Lyme disease can affect the nervous system in many ways, including involvement of the eyes and optic nerve. Patients may develop blurred vision, double vision, optic neuritis, or other visual disturbances when the infection affects neurologic structures.

A 46-year-old woman developed blurred vision that progressively worsened over three weeks.

Her medical history included hypertension, asthma, post-traumatic stress disorder, depression, seizure disorder, and alcohol use disorder. According to the authors, she had not experienced a seizure for 25 years.

She also had a history of Lyme disease ten years earlier that had been treated with a 10-day course of antibiotics.

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The woman described three weeks of worsening blurred vision accompanied by tingling and numbness in both legs. She also reported nausea, weakness, dizziness, and visual hallucinations.

Thirteen days earlier she had been evaluated by an optometrist who identified optic disc edema and advised her to seek emergency care.

She did not immediately go to the emergency room.

When she was eventually evaluated by ophthalmology, the examination confirmed optic neuritis, an inflammatory condition of the optic nerve.

The optic nerve transmits visual signals from the retina to the brain. Inflammation of this nerve can lead to severe vision loss.

Her vision loss was significant. Legal blindness is defined as visual acuity of 20/200 or worse in the better eye after correction. Her visual acuity was 20/400 in both eyes.

She also had impaired color vision in both eyes.

Lyme Disease and Vision Problems

Laboratory testing supported the diagnosis of Lyme disease.

Her blood tests were positive for Lyme IgM and IgG antibodies. Her IgM Western blot was positive. Her IgG Western blot showed three of ten bands.

The CDC surveillance criteria require five of ten IgG bands to be positive. However, clinicians often rely on the overall clinical picture when evaluating suspected Lyme disease.

The doctors could not identify another cause for her optic neuritis.

The authors concluded that the patient fulfilled criteria for acute Lyme disease and that there was strong evidence linking the infection to her optic neuritis.

They suspected the optic neuritis resulted from a new infection rather than her episode of Lyme disease ten years earlier.

The patient was prescribed a two-week course of doxycycline.

After one week of treatment she was admitted to the hospital for alcohol intoxication.

According to the authors, she reported some improvement in her vision after beginning antibiotic therapy.

Unfortunately, the final outcome remains uncertain. The patient left the hospital against medical advice and did not return for follow-up appointments.

The authors therefore could not determine whether her vision ultimately recovered.

They emphasized that Lyme disease should be considered in the differential diagnosis of optic neuritis.

Although uncommon, Lyme disease has been associated with several ocular complications including optic neuritis, uveitis, keratitis, and cranial nerve palsies.

Learn more about neurologic complications of Lyme disease in my overview of neurologic Lyme disease. Additional eye complications are discussed in my page on ocular Lyme disease.

What Can We Learn From This Case?

1. Lyme disease should be considered when evaluating patients with optic neuritis or unexplained vision problems.
2. Ocular complications of Lyme disease may occur even when other symptoms are subtle.

Questions Raised by This Case

1. How often does optic neuritis occur in patients with Lyme disease?
2. What proportion of patients recover vision after treatment?
3. What is the optimal treatment for Lyme disease with ocular involvement?

Treating Tick-Borne Disease

Many patients with tick-borne illness present with complex neurologic or visual symptoms.

Clinicians evaluating patients with unexplained neurologic or ocular complaints should consider tick-borne infections such as Lyme disease.

Greater awareness of these complications may allow earlier recognition and treatment.

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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