Lyme borreliosis. Ocular manifestations 
OCULAR MANIFESTATIONS OF 
L YME BORRELIOSIS 
F. Strle 
SUMMARY 
Ocular manifestations can occur in ali stages of Lyme borreliosis. Eye involvement can be one of the first 
and even the only obvious manifestation of the disease. The eye may be involved as a consequence of an 
extraocular manifestation of borrelial infection or primarily by inflammation of ocular tissues. Conjunctivitis, 
episcleritis, keratitis, iridocyclitis, retina! vasculitis, choroiditis, optic neuropathy, panuveitis and panophthalmitis 
have been described. Eye manifestations seem to be rare and are often difficult to diagnose. The extent, 
character and frequency of the eye findings in Lyme borreliosis have yet to be clearly defined. 
Long-standing intraocular inflammation may result in loss of vision; the data on therapeutic efficacy are 
limited but it seems that prompt systemic antibiotic treatment is effective and leads to recovery of visual 
acuity. Patients with ocular involvement possibly related to Lyme borreliosis need to be carefully and fully 
evaluated in order to rule out ali other possible etiologies, however, even suspected ocular Lyme borreliosis 
should be treated with antibiotic~. 
KEY WORDS: 
Lyme borreliosis, manifestations, eye symptoms, review 
INTRODUCTION 
Lyme borreliosis is a multi-system illness caused 
by Borrelia burgdo,feri and transmitted by ticks (in 
Europe by Ixodes ricinus ticks) (1,2,3). There is a 
strong experimental and clinical evidence for ocular 
involvement in Lyme borreliosis ( 4). However, eye 
acta dermatovenerologica A.P.A. Vol 3, 94, No 1/2 
manifestations seem to be rare and are often difficult 
to diagnose. 
The eye may be involved as a consequence of an 
extraocular manifestation of borrelial infection or 
primarily by inflammation of ocular tissues. Similar 
to syphilis, Lyme borreliosis seem to be a great 
imitator of ocular inflammation (5). 
71 
Lyme bo"eliosis. Ocular manifestations 
CLINICAL FEATURES 
OCULAR MANIFESTATIONS 
Conjunctivitis 
Conjunctivitis develops early in the course of 
Lyme borreliosis. Usually it is closely associated 
with erythema migrans and probably represents a 
manifestation of the early disseminated stage of 
Lyme borreliosis. 
Conjunctivitis was the first reported ocular Lyme 
borreliosis manifestation (6). It was found in 35 out 
of 314 patients (11 % ) with erythema migrans (6) 
and is therefore the most common eye manifestation 
of early Lyme disease in the USA. In Europe 
conjunctivitis is discovered less often. It was reported 
in only one of 104 patients with erythema migrans 
in Munich, Germany (7), and in 5.4% (23 out of 
425) of patients with typical erythema migrans in 
Ljubljana, Slovenia (5). The prevalence in the last 
group was significantly higher in patients with more 
than one skin lesion than in patients with solitary 
erythema migrans (5) which points to the conclusion 
that conjunctivitis is a manifestation of the early 
disseminated (second stage) Lyme borreliosis (2,5). 
It is usually mild, short-lived and does not require 
special treatment. In our patients with erythema 
migrans the duration of conjunctivitis ranged from 2 
days to 6 weeks (median 8 days) before treatment 
and 1 to 28 days ( median 4 days) after inducing 
antibiotic therapy (5) . 
There is also a report of bilateral chronic follicular 
conjunctivitis which the authors attribute to the late 
borrelial infection (8) . 
Episcleritis 
There are two reports of patients with episcleritis 
associated with late Lyme borreliosis (8,9). 
Keratitis 
Keratitis is a manifestation of late borrelial infection. 
It is similar to syphilitic keratitis and can become 
manifest months to years after the onset of Lyme 
borreliosis with painless, progressive blurring of vision. 
Photophobia can be the first symptom. Multiple 
infiltrates at ali levels of the corneal stroma can be 
seen with episodic recurrences and changing loca-
lization. Response to topical steroids is usually good. 
However, there is a possible progression into 
neovascularization and scarring. There are severa! 
reports on borrelial keratitis, predominantly in 
72 
American literature (5,9-13). 
lridocyclitis 
lridocyclitis may be present in early disseminate 
as well as in late Lyme borreliosis. 
Granulomatous inflammation of iris and ciliary 
body with posterior synechia and cellular infiltration 
of the vitreous body was described in some patients 
from the USA (14-17) and also from Europe (5). 
One patient developed panophthalmitis .leading to 
blindness in spite of treatment with multiple i.v. and 
oral antibiotics and topical, subconjunctival and systemic 
corticosteroids (18,19). However, this seems to be 
an exception; in the majority of patients response to 
antibiotic treatment (usually i.v.) was good. The 
efficacy is difficult to asses because there is not 
enough information on natura! course of borrelial 
eye manifestations and because many patients were 
treated simultaneously with topical or systemic 
prednisone. 
We saw a 33 year-old female patient (5) who had 
erythema migrans at the site of a tick bite. In the 
following weeks arthralgias, paresthesias and mild 
headache appeared. Three months after the beginning 
of erythema migrans unilateral iridocyclitis was found. 
Results of cerebrospinal fluid examination were in 
normal range. B. burgdorferi serological tests (IFA) 
showed elevated antibody titers (IgM 1:512, IgG 
1:1024). The patient was treated with ceftriaxone 2 
g i.v. for 14 days. Iridocyclitis improved substantially 
and extraocular symptoms disappeared with the 
exception of mild intermittent pain in large joints. 
Retina) vasculitis 
The onset of retina! vasculitis is most likely at the 
tirne of early disseminate infection. It may show a 
en.ranic course (5). Inflammation of the retina! vessels 
leads to a breakdown of the inner blood-retina 
barrier and is followed by an outflow of blood 
proteins and cells and infiltration of the vitreous 
body. The consequence is vitreous clouding (5,20,21). 
Occlusive retina! vasculitis may cause larger local 
ischemic retina! areas which can lead to preretinal 
neovascularization ( 5 ,22). 
Choroiditis 
Choroiditis belongs to early disseminate borrelial 
infection. It seems that it is the most common 
intraocular borrelial manifestation. In the ·recent 
series of 19 patients with intraocular involvement 
seen at University Eye Hospital, Erlagen and De-
acta dermatovenerologica A.P.A. Vol 3, 94, No 1/2 
Lyme borreliosis. Ocular manifestations 
partment of Infectious Diseases, Ljubljana 63% (12 
out of 19 patients) had choroiditis (5). 
The inflammation of the choroid may be unilateral 
or bilateral, focal (5,23) disseminated (5,21,24) or 
diffuse with inflammatory exudative retina! detachment 
(5,25-27). In the majority of patients there is a 
prompt' response to antibiotic treatment (5). 
Optic neuropathy 
There are relatively numerous reports on the 
optic nerve involvement in the course of early 
disseminate and late Lyme borreliosis. Depending 
on severity and duration of the different optic 
neuropathies, atrophy of the optic nerve can develop 
and result in poor visual acuity or in almost complete 
blindness (5). 
The most common borrelial manifestation involving 
the optic nerve is papilledema i.e. optic disc edema 
caused by increased intracranial pressure. In the 
acute phase of the disease visual acuity in these 
patients is typically good. Papilledema is most 
commonly observed in children with early disseminated 
infection who usually had cerbrospinal fluid pleocytosis 
(4,28-34). In patients with normal cerebrospinal fluid 
edema of optic disc is designated as pseudotumor 
cerebri. However, in some patients a spina! tap 
performed early in the presentation of the disease, 
might fail to detect cerebrospinal fluid pleocytosis 
or elevated protein but subsequent taps show abnormal 
cerebrospinal fluid results (29). Papilledema uniformly 
do well with complete resolution after treatment 
with i.v. ceftriaxone (4). 
In ischemic optic neuropathy due to occlusion of 
the posterior ciliary arteries, the disc edema can be 
segmenta! with corresponding segmenta! visual field 
loss (5,35,36) . 
Papillitis is a nondemyelinating inflammation of 
the optic nerve head leading to sudden loss of 
vision. It is the manifestation of the early borrelial 
disseminate infection (5,17,37). 
In neuroretinitis, papillitis is associated with vasculitis 
of the peripapillary retina! vessels (5,34,38-40). 
Retrobulbar neuritis was reported in patients with 
late borrelial encephalomyelitis (32). It should be 
stressed that in demyelinating neuritis the optic 
nerve head is not involved because the myelin 
sheath begins behind the globe. 
Panuveitis 
In panuveitis ali parts of the uvea (iris, ciliary 
body and choroid) are inflamed. Some patients with 
panuveitis of borrelial etiology were reported. (26,41). 
acta dennatovenerologica A.P.A. Vol 3, 94, No 1/2 
Panophthalmitis 
In panophthalmitis ali tissues of the eye are 
involved. There is a report of a patient with Lyme 
borreliosis who developed panophthalmitis in spite 
of the treatment with antibiotics and corticosteroids 
(18,19). 
OCULAR INVOLVEMENT DUE TO 
EXTRAOCULAR MANIFESTATIONS 
Cranial nerve palsy 
In peripheral facial palsy, which i:s a common sign 
of Lyme borreliosis ( 42), lack of surface protection 
can lead to exposure keratoconjunctivitis or corneal 
ulceration ( 4,5). Because the duration of facial palsy 
is usually short, exposure problems can be treated 
with ocular lubricants (4) . 
Involvement of ocular motor nerves, which is 
much less often than peripheral facial palsy, results 
in diplopia ( 4,5). The sixth nerve is most commonly 
involved, followed by the third and fourth cranial 
nerve. ( 4,42-44 ). 
Miscellaneous 
There have been isolated reports of pupillary 
abnormalities associated with Lyme borreliosis such 
as a patient with Argyll Robertson-like pupil (30) 
and a patient with reversible preganglionic Horner's 
syndrome (33). 
Orbita! myositis has been described in a child 
with erythema migrans, peripheral facial palsy asso-
ciated with CSF pleocytosis and knee arthritis ( 45) . 
Occipital cortex lesions due to focal encephalitis 
or cerebral vasculitis may cause homonymous visual 
field defects ( 46,47). 
DIAGNOSIS AND DIFFERENTIAL 
DIAGNOSIS 
Despite multiple descriptions of the eye involvement, 
the extent and character of the eye findings in 
Lyme borreliosis have yet to be clearly defined (4). 
It is very difficult to prove that an ocular sign is of 
borrelial etiology. 
In Lyme borreliosis there is no pathognomonic 
eye manifestation which would allow a definite 
clinical diagnosis and intraocular material which 
would serve for isolation of the etiological agent is 
usually not available from humans. Even the diagnosis 
of definite Lyme borreliosis does not entirely confirm 
73 
Lyme borreliosis. Ocular manifestations 
that ali clinical signs and/or symptoms are causally 
related to the B. burgdorferi infection i.e. the associated 
ocular findings may be coincidental and unrelated 
to the presence of Lyme borreliosis. In praxis, 
serology is often the main aid in diagnosis. However, 
serologic testing has many limitations: differences in 
specificity and sensitivity of various serological assays, 
interlaboratory variability, the absence of antibody 
farmation particularly in the early stage of the 
disease, false positive results in some other infec-
tions like syphilis and high background rate of 
seropositivity in some endemic regions without the 
ability to differentiate between past exposure and 
active ongoing infection (3-5,48-50). 
Despite these limitations there is a firm evidence 
far ocular involvement in Lyme borreliosis ( 4,5). 
However, in an individual patient other possible 
causes have to be actively searched far and ruled 
out. The spectrum of ocular manifestations seen in 
Lyme borreliosis is well known in ocular syphilis 
but there are also many other illnesses that may 
mimic borrelial ocular involvement ( 4,5,51). Granu-
lomatous iridocyclitis or choroiditis can be due to 
bacterial illnesses (tuberculosis, syphilis, leprosy), fungal 
infections, or immunologic processes of unclear etiology 
such as sarcoidosis, Vogt-Koyanagi-Harada syndrome, 
or Still's disease. Optic neuropathies and retina! 
vasculitis are seen in encephalitis disseminata or 
may be induced by viruses (varicella-zoster virus). 
Some other illnesses may have ocular presentation 
similar to Lyme borreliosis including certain vira! 
infections and postviral syndromes, vasculitis, 
lymphoma, Behcet disease and others. 
TREATMENT 
There are no comparative therapeutic studies in 
Lyme borreliosis patients with ophthalmic mani-
festations. 
Knowledge is based on the results of treatment in 
relatively small number of patients with ocular 
involvement associated with Lyme borreliosis; in 
some of them the diagnosis of Lyme borreliosis is 
doubtful. In addition, the assessment of the treatment 
efficacy is difficult because in the majority of borrelial 
ocular manifestations natura! course is not known. 
General recommendation far antibiotic treatment 
of intraocular inflammation would be to use the 
agents effective in treatment of Lyme borreliosis, 
with pharmacokinetics and in dosage which enable 
high enough concentrations of the agent intraoculary 
(in some antibiotics diffusion of the drug from the 
blood into the aqueous humour of the eye is 
substantially limited). 
In ocular involvement corticosteroids are often 
used ( 4,5). As a rule they should be combined with 
an appropriate antibiotic treatment (5). Accompanying 
systemic corticosteroid therapy is thought to reduce 
the extent of damage caused by the inflammatory 
reaction in severe uveitis and orbita! myositis. Keratitis 
responds well to topical steroids ( 4,5,52). 
In uveitis it is necessary to keep the pupil dilated 
( 4,5,52). 
CONCLUSION 
Ocular manifestations can occur in ali stages of 
Lyme borreliosis. Eye involvement can be one of 
the first and even the only obvious manifestation of 
the disease. Long-standing intraocular inflammation 
may result in loss of vision; the data on therapeutic 
efficacy are limited but it seems that prompt systemic 
antibiotic treatment is effective and leads to recovery 
of visual acuity. Patients with ocular involvement 
possibly related to Lyme borreliosis need to be 
carefully and fully evaluated to rule out ali other 
possible etiologies. However, even suspected ocular 
Lyme borreliosis should be treated with antibiotics. 
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AUTHOR'S ADDRESS 
76 
Franc Strle, MD, PhD, professor of infectious diseases 
Department of lnfectious Diseases 
University Medica! Centre Ljubljana, Japljeva 2, 61000 Ljubljana, Slovenia 
acta dermatovenerologica A.P.A. Vol 3, 94, No 1/2