A retrospective study of 430 patients with uveitis identified seven cases of Lyme-associated uveitis. All seven patients showed steroid resistance but responded rapidly to antibiotic treatment.

The study included patients referred to the hospital between 2003 and 2016. Six of the seven individuals with uveitis due to Lyme disease had reported walking in the forest previously, and two recalled a tick bite.

Clinical Presentation of Lyme-Associated Uveitis

One patient had a history of an erythema migrans rash. Three developed arthritis and one developed a borrelial lymphocytoma. Two of the seven patients had lymphocytic meningitis.

PCR testing was negative in spinal taps for all seven patients, and four were negative by ocular testing. This highlights the diagnostic challenge of Lyme-associated uveitis when laboratory confirmation is limited.

Steroid Resistance: A Key Diagnostic Clue

All seven cases of Lyme-associated uveitis were resistant to cortisone alone, whether administered orally or as topical and subconjunctival injections.

However, all individuals responded rapidly to antibiotics. Six people were treated with intravenous ceftriaxone (1 or 2 g/day for 3 to 4 weeks), and one was treated with oral doxycycline for 4 weeks.

Steroid resistance in uveitis should raise suspicion for infectious causes, including Lyme disease, particularly in endemic areas.

Positive Serology Without Confirmed Lyme Uveitis

An additional five uveitis patients tested positive for Lyme disease but were not classified as having Lyme-associated uveitis. Three of them responded to steroids alone, one failed ceftriaxone treatment, and one was inactive.

Another 25 uveitis patients with positive serologic tests for Lyme disease were classified as having other conditions. Forty percent of these patients suffered from sarcoidosis.

This demonstrates that positive Lyme serology does not always indicate causation, and clinical correlation is essential.

Diagnostic Recommendations

The authors suggest that for patients with unexplained uveitis, serologic testing for Lyme disease should always be guided by:

• Exposure history (forest walks, tick bites)
• Systemic findings suggestive of Lyme disease (rash, arthritis, neurologic symptoms)
• Steroid resistance

These three factors together increase the likelihood that uveitis is Lyme-associated rather than coincidental positive serology.

Frequently Asked Questions

What is uveitis in Lyme disease?

Uveitis in Lyme disease is inflammation of the uveal tract (middle layer of the eye) caused by Borrelia burgdorferi infection. It typically presents with eye pain, redness, light sensitivity, and blurred vision.

How is Lyme-associated uveitis different from other causes?

Lyme-associated uveitis is characteristically steroid-resistant but responds rapidly to antibiotic therapy. This resistance pattern can help differentiate it from autoimmune or idiopathic uveitis.

Can PCR testing confirm Lyme uveitis?

PCR testing is often negative in Lyme-associated uveitis, even when clinical evidence strongly supports the diagnosis. Diagnosis relies on clinical presentation, exposure history, and response to antibiotics.

How is uveitis from Lyme disease treated?

Treatment typically involves intravenous ceftriaxone (1-2 g/day for 3-4 weeks) or oral doxycycline for 4 weeks. Patients usually respond rapidly to antibiotic therapy.

Does positive Lyme serology always mean the uveitis is from Lyme disease?

No. Positive serology can occur in patients whose uveitis has other causes. Clinical correlation including exposure history, systemic symptoms, and steroid resistance is essential for accurate diagnosis.

Clinical Takeaway

Uveitis in Lyme disease should be suspected in patients with steroid-resistant inflammation, particularly in endemic areas or with exposure history. Rapid response to antibiotics and resistance to corticosteroids are key diagnostic features. Positive serology alone is insufficient for diagnosis and must be interpreted in clinical context.