eMedicine Specialties > Ophthalmology > Infectious Disease

Lyme Disease

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

Updated: Jul 25, 2008

Introduction

Background

Lyme disease is the most common arthropod-related disease in the United States, Europe, and portions of Japan.

Lyme disease is transmitted by the bite of an Ixodes tick infected with Borrelia burgdorferi. Ehrlichiosis and babesiosis are also transmitted by the Ixodes tick. The disease is a multisystem spirochetal disorder that can mimic many other diseases. As in syphilis, another spirochetal illness, Lyme disease occurs in 3 stages.

Pathophysiology

The pathogenesis of Lyme disease is not well understood, but the symptoms are believed to be due to direct infection and a delayed hypersensitivity mechanism. A controversial aspect of the disease is the form of the disease known as late or chronic Lyme disease. Some patients may develop chronic or relapsing inflammation (including uveitis). It is unknown if these patients truly have Lyme disease and if they represent treatment failures, a persistence of organism, an infection with another tick borne pathogen, or an autoimmune phenomenon.

Frequency

United States

Of the cases of Lyme disease, 75% occur during the summer months. Clusters of Lyme disease occur in 3 geographic areas of the United States, as follows: the Northeast, especially in southern Connecticut, WestchesterCounty, and Long Island in the state of New York; the Midwest, in Minnesota and Wisconsin; and the Northwest, in Washington, Oregon, and northern California.

Race

No racial predilection exists.

Sex

No sexual predilection exists.

Age

With Lyme disease, there is a bimodal distribution of age groups with 2 peaks, one in children aged 5-14 years and one in adults aged 30-59 years.

Clinical

History

• The clinical manifestations of untreated Lyme disease occur in 3 stages.
• Stage 1 is the localized bull's eye skin rash of erythema chronicum migrans. This pathognomonic skin rash begins 3-30 days after the tick bite; however, as many as 18% of patients can present without the skin rash.
• Stage 2 follows weeks to months later. These patients may develop neurologic (15%), cardiac (5%), or arthritic (60%) manifestations. Neurologic signs can include cranial neuropathy (especially Bell palsy), meningitis, headache, or neuritis. 
• In stage 3, the most common manifestation is chronic Lyme arthritis. Chronic neurologic syndromes include neuropsychiatric disease and peripheral neuropathy.

Physical

• Ocular manifestations of Lyme disease may involve any portion of the eye and vary depending on the stage of the disease.
• In stage 1 Lyme disease, the ocular manifestations are conjunctivitis and photophobia. These symptoms are mild and transient, and ophthalmologists usually are not consulted.
• During stage 2 Lyme disease, significant ophthalmic complications first appear. The most common are various neuro-ophthalmologic signs. Typically, the patient may first present with cranial nerve VII palsy (Bell palsy). Some patients may present with the triad of Lyme neuroborreliosis consisting of cranial nerve palsy, meningitis, and radiculopathy. Blurred vision also can be noted during this stage, secondary to papilledema, optic atrophy, optic or retrobulbar neuritis, or pseudotumor cerebri. Optic nerve disease may be unilateral or bilateral and solitary or associated with other neurologic or neuro-ophthalmologic manifestations. Some evidence exists that children are more predisposed to optic nerve disease than adults.
• In late stage 2 or stage 3 Lyme disease, most of the severe ocular manifestations of the disease are seen. These include episcleritis, symblepharon, keratitis, iritis, posterior or intermediate uveitis, pars planitis, vitreitis, chorioretinitis, exudative retinal detachment, retinal pigment epithelial detachment, cystoid macular edema, branch artery occlusion, retinal vasculitis, orbital myositis, and cranial nerve palsies. Of this group, keratitis, vitreitis, and pars planitis are the most common. The keratitis usually is a bilateral, patchy, nummular stromal keratitis. Posterior segment inflammatory disease generally presents as a bilateral pars planitis associated with granulomatous iritis and vitreitis. Many of these patients also have granulomatous keratic precipitates and posterior synechiae.

Causes

Lyme disease is caused by the spirochete B burgdorferi.

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