Lyme Disease and Double Vision (Diplopia)

Prefer to read? Read the full written case report here.

In this podcast episode, I discuss a 69-year-old man with Lyme disease and double vision (diplopia) caused by a 3rd cranial nerve palsy rather than the more common 7th nerve palsy seen in Lyme disease.

While facial nerve palsy is a well-known neurologic complication of Lyme disease, involvement of the third cranial nerve is rare.

This case was first reported by Dixit and colleagues in the journal Case Reports in Neurological Medicine in 2018.

Patient Presentation

A 69-year-old man was evaluated in an emergency room in New York City in August with headaches and diplopia. Diplopia is the perception of two images of a single object.

Diplopia may occur when the nerves controlling the eye muscles are weakened or damaged, causing the eyes to move out of alignment.

Head injury, brain tumors, stroke, and even an incorrect eyeglass prescription can cause diplopia.

The patient had a history of type 2 diabetes and hypertension. He had been hiking in a rural area of New York but did not recall a tick bite or rash.

His headache began abruptly one week earlier in the right occipital region and gradually moved toward his right orbit. Within five days he developed diplopia.

He experienced double vision when both eyes were open. When he covered his right eye, his vision returned to normal.

Neurologic examination revealed a left-sided 3rd cranial nerve palsy. The third cranial nerve controls most of the muscles responsible for eye movement. It also controls the upper eyelid and the muscles responsible for pupil constriction.

Diagnostic Testing

The patient underwent extensive testing. Blood tests for Lyme disease were strongly positive, including a highly elevated Lyme titer, two of three IgM Western blot bands, and five of ten IgG Western blot bands.

A spinal tap also showed a highly elevated Lyme antibody titer. For Lyme disease to be confirmed in the spinal fluid, the antibody level in the spinal fluid must exceed the antibody level found in the blood.

The diagnosis of Lyme disease was further supported by pleocytosis in the spinal fluid. Pleocytosis refers to an increased number of white blood cells in the spinal fluid. While as few as seven white blood cells may support the diagnosis, this patient had 74.

Treatment and Outcome

The patient was treated for oculomotor nerve palsy secondary to Lyme meningitis. He received acyclovir along with four weeks of intravenous ceftriaxone.

His diplopia resolved and he remained symptom-free two months after starting treatment.

Clinical Context

Facial nerve palsy is much more common in Lyme disease than the 3rd nerve palsy described in this case. Facial nerve palsy, often called Bell’s palsy, affects the 7th cranial nerve and leads to weakness or paralysis on one side of the face. In rare cases, Lyme disease can affect both sides of the face.

Cranial nerve involvement is one of the neurologic manifestations of Lyme disease and may occur when the infection affects the central nervous system.

Lyme disease may also cause a range of ocular manifestations including conjunctivitis, keratitis, and extraocular muscle palsies.

Eye symptoms of Lyme disease can include double vision (diplopia), eye muscle weakness, blurred vision, and other neurologic eye problems.

What Can We Learn From This Case?

Key takeaways from this case of Lyme disease and double vision:

1. Lyme disease can affect the cranial nerves. In this case, the patient developed double vision due to a 3rd cranial nerve palsy rather than the more typical 7th nerve palsy.
2. Neurologic manifestations of Lyme disease, including cranial nerve palsies, may improve with appropriate antibiotic treatment.

Questions Raised by This Case

How often does Lyme disease affect the eyes?

I have discussed a wide range of eye problems related to Lyme disease in previous articles and podcast episodes. See Growing list of eye problems in Lyme disease and Eye problems in tick-borne diseases other than Lyme.

How can Lyme disease with eye involvement be diagnosed if the tests are negative?

This remains a clinical challenge requiring careful evaluation of symptoms, exposure history, and response to treatment.

Treating Tick-Borne Disease

Many patients with tick-borne diseases present with complex symptoms, as highlighted in this Inside Lyme Podcast series.

Clinicians evaluating patients with unexplained diplopia or cranial nerve palsy should consider tick-borne infections in the differential diagnosis, particularly in regions where Lyme disease is endemic.

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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