Lyme Optic Neuritis: A Rare Cause of Bilateral Vision Loss

Lyme optic neuritis is a rare neurologic complication of Lyme disease that can cause inflammation of the optic nerve and progressive visual loss. Unlike typical optic neuritis, which is usually unilateral and painful, Lyme-associated optic neuritis often presents with bilateral optic nerve swelling and painless vision changes.

A 48-year-old woman with multiple sclerosis presented to her primary care physician with fever and sore throat. Three weeks later she returned with photophobia, eye pressure sensation, blurry vision, pain with eye movements, and a central scotoma.

A scotoma refers to a blind or blurry spot in the visual field while surrounding areas appear normal.

MRI and fundus examination confirmed the diagnosis of bilateral optic neuritis associated with Lyme disease.

Two months prior to her visit, the woman had removed a tick from her leg but had not developed a rash. Lyme disease testing returned positive by Western blot.

Treatment and Recovery

The woman was hospitalized and treated with intravenous methylprednisolone (1 g/day for 3 days) due to the degree of optic nerve swelling, along with intravenous ceftriaxone (2 g/day for 25 days) to treat Lyme disease.

Within one week of hospitalization, the patient reported that her visual symptoms had resolved and she returned to her baseline neurologic status.

Clinicians working in Lyme-endemic regions should consider Lyme borreliosis when patients present with bilateral optic nerve head swelling and progressive visual symptoms.

Systematic Review of Lyme Optic Neuritis

Lu and colleagues conducted a systematic review and identified 11 reported cases of optic neuritis associated with Lyme disease. The investigators examined cases with strong evidence linking Borrelia burgdorferi infection to optic nerve inflammation.

The most commonly reported symptoms were:

• Blurry vision (11 cases)
• Headache (7 cases)
• Scotoma or blind spots (3 cases)
• Pain with eye movements (3 cases)

Additional symptoms included:

• Neurologic symptoms such as paresthesia (3 cases) and ataxia (1 case)
• Joint pain (3 cases)
• Nonspecific symptoms including fatigue, weakness, and myalgia (3 cases)

How Lyme Optic Neuritis Differs From Typical Optic Neuritis

Only 2 of the 11 reported patients had a classic erythema migrans rash, and most did not recall a tick bite. Moderate vision loss was reported in 8 of the cases.

Most patients improved with either antibiotic therapy alone or a combination of antibiotics and corticosteroids.

Typical optic neuritis—often associated with multiple sclerosis—usually presents with acute, painful, unilateral vision loss. In contrast, Lyme-associated optic neuritis often presents differently.

In Lyme disease patients, optic neuritis frequently manifests with:

• Bilateral optic nerve involvement
• Painless or mildly painful vision loss
• Moderate visual decline (often better than 20/200)
• Gradual or progressive symptom onset

This distinct clinical pattern may help clinicians recognize Lyme-associated optic neuritis earlier in endemic areas.

Frequently Asked Questions

What is optic neuritis in Lyme disease?

Lyme optic neuritis is inflammation of the optic nerve caused by infection with Borrelia burgdorferi. It may lead to visual loss, scotoma, and optic nerve swelling.

How is Lyme optic neuritis different from MS-related optic neuritis?

Lyme optic neuritis often presents as bilateral and progressive, while multiple sclerosis–related optic neuritis is typically unilateral, painful, and acute. However, both conditions can occasionally overlap.

What symptoms occur with Lyme optic neuritis?

Symptoms may include blurry vision, scotoma, photophobia, headache, and pain with eye movement. Neurologic symptoms such as paresthesia may also occur.

How is Lyme-associated optic neuritis treated?

Treatment typically includes intravenous antibiotics such as ceftriaxone for 2 to 4 weeks. Corticosteroids may be used when significant optic nerve swelling is present.

Do patients recover vision after treatment?

Yes. Most reported cases improve significantly with appropriate antibiotic therapy, and many patients recover normal or near-normal vision.

Clinical Takeaway

Lyme optic neuritis is an uncommon but important manifestation of Lyme disease. Unlike typical optic neuritis, Lyme-associated cases often present with bilateral optic nerve swelling and painless visual changes.

In regions where Lyme disease is endemic, clinicians should consider Lyme borreliosis when patients develop unexplained bilateral optic neuritis, particularly when symptoms follow a possible tick exposure.