eMedicine Specialties > Ophthalmology > Infectious Disease

Lyme Disease: Differential Diagnoses & Workup

Author: Gerald W Zaidman, MD, Professor of Clinical Ophthalmology, New York Medical College; Chief of Cornea Service; Director, Department of Ophthalmology, Westchester Medical Center
Contributor Information and Disclosures

Updated: Aug 26, 2009

Differential Diagnoses

Abducens Nerve Palsy
Ocular Manifestations of Syphilis
Abducens Nerve Palsy
Oculomotor Nerve Palsy
ARMD, Nonexudative
Optic Neuritis, Adult
Bell Palsy
Optic Neuritis, Childhood
Branch Retinal Artery Occlusion
Papilledema
Branch Retinal Vein Occlusion
Rocky Mountain Spotted Fever
Conjunctivitis, Viral
Sarcoidosis
Diplopia
Scleritis
Endophthalmitis, Bacterial
Sudden Visual Loss
Episcleritis
Synechia, Peripheral Anterior
Extraocular Muscles, Actions
Trochlear Nerve Palsy
Herpes Simplex
Tuberculosis
Herpes Zoster
Uveitis, Anterior, Childhood
Horner Syndrome
Uveitis, Anterior, Granulomatous
Keratitis, Herpes Simplex
Uveitis, Anterior, Nongranulomatous
Keratitis, Interstitial
Uveitis, Classification
Neovascularization, Corneal, CL-related
Uveitis, Intermediate
Nonpseudophakic Cystoid Macular Edema
Uveitis, Juvenile Idiopathic Arthritis

Other Problems to Be Considered

Macular edema
Orbital myositis
Orbital pseudotumor
Choroidal neovascular membrane
Paralytic strabismus

Workup

Laboratory Studies

  • Because many patients with suspected Lyme disease do not recall the tick bite or skin rash, laboratory tests are important in establishing the diagnosis. However, much confusion can occur in the interpretation of the tests used for Lyme disease.
    • The organism and its DNA can be detected in cerebrospinal fluid (CSF), urine, and sera but only early in the disease. Polymerase chain reaction (PCR) is superior to culture, but it is not standardized and not widely available.
    • The two most frequently used tests are the immunofluorescent assay (IFA) and the enzyme-linked immunosorbent assay (ELISA). The principal limitation of these serologic tests has been the high frequency of both false-negative results and false-positive results. False-negative results occur during the acute phase of Lyme disease before patients have developed a sufficient antibody response to give a positive serologic test. False-positive results are due to serologic cross-reactivity among Lyme disease, syphilis, Rocky Mountain spotted fever, and other disorders.
    • To improve diagnostic ability, some laboratories use the immunoblot (Western blot) test. This test is more specific, sensitive, and reliable than the ELISA.
    • The National Conference on Lyme Disease recommends a 2-step protocol for disease testing. The first step is to use either Lyme IFA or Lyme ELISA. A Venereal Disease Research Laboratory (VDRL) test and a fluorescent treponemal antibody-absorption (FTA-ABS) test should be completed at the same time. Any positive or equivocal test mandates that immunoglobulin G (IgG) and immunoglobulin M (IgM) immunoblots be performed.

Imaging Studies

  • In patients with orbital disease possibly associated with Lyme disease, MRI and contrast-enhanced CT scans may be helpful. 

More on Lyme Disease

Overview: Lyme Disease
Differential Diagnoses & Workup: Lyme Disease
Treatment & Medication: Lyme Disease
Follow-up: Lyme Disease
References
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References

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  10. Rothermel H, Hedges TR 3rd, Steere AC. Optic neuropathy in children with Lyme disease. Pediatrics. Aug 2001;108(2):477-81. [Medline].

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Further Reading

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Keywords

Lyme disease, borreliosis, Lyme borreliosis, ticks, tick bite, tick-borne disease, tick-borne illness, infection, Borrelia burgdorferi, B burgdorferi, ocular Lyme disease, Lyme uveitis, arthropod-related disease, spirochetal disorder, ocular manifestations of Lyme disease

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Contributor Information and Disclosures

Author

Gerald W Zaidman, MD, Professor of Clinical Ophthalmology, New York Medical College; Chief of Cornea Service; Director, Department of Ophthalmology, Westchester Medical Center
Gerald W Zaidman, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, American Medical Association, American Society of Cataract and Refractive Surgery, American Uveitis Society, Association for Research in Vision and Ophthalmology, Medical Society of the State of New York, Medical Society of Virginia, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Medical Editor

Kilbourn Gordon III, MD, FACEP, Urgent Care Physician
Kilbourn Gordon III, MD, FACEP is a member of the following medical societies: American Academy of Ophthalmology and Wilderness Medical Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

R Christopher Walton, MD, Professor, Director of Uveitis and Ocular Inflammatory Disease Service, Department of Ophthalmology, Assistant Dean for Graduate Medical Education, University of Tennessee College of Medicine; Consulting Staff, Regional Medical Center, Memphis Veterans Affairs Medical Center, St Jude Children's Research Hospital
R Christopher Walton, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Healthcare Executives, American Uveitis Society, Association for Research in Vision and Ophthalmology, and Retina Society
Disclosure: Nothing to disclose.

CME Editor

Lance L Brown, OD, MD, Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri
Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD, Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences
Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology
Disclosure: Nothing to disclose.

 
 
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