The spectrum of ocular findings in patients with LD varies with disease stage. The most common ocular manifestation of early stage 1 disease is a follicular conjunctivitis, which occurs in approximately 11% of patients; less commonly present is episcleritis (see BCSC Section 1, Update on General Medicine, and Section 8, External Disease and Cornea, for further discussion and the differential diagnosis).
Intraocular inflammatory disease is reported most often in stage 2 and, less frequently, in stage 3 disease; it may manifest as anterior uveitis, intermediate uveitis, posterior uveitis, or panuveitis. Intermediate uveitis is one of the most common intraocular presentations. Vitritis may be severe and accompanied by a granulomatous anterior chamber reaction, papillitis, neuroretinitis, choroiditis, retinal vasculitis, and exudative retinal detachment (Fig 10-8).
A distinct clinical entity of peripheral multifocal choroiditis has been described in patients with LD; it is characterized by multiple, small, round, punched-out lesions associated with vitritis, similar to those present in sarcoidosis. Choroidal involvement may lead to pigment epithelial clumping resembling the inflammatory changes that occur with syphilis or rubella. Retinal vasculitis, found in association with peripheral multifocal choroiditis or vasculitic branch retinal vein occlusion, may be more common than previously known.
Neuro-ophthalmic manifestations include involvement of multiple cranial nerves (II, III, IV, V, VI, and, most commonly, VII) unilaterally or bilaterally, either sequentially or simultaneously. Optic nerve findings include optic neuritis, papilledema associated with meningitis, and most commonly papillitis. Horner syndrome has also been reported.
Keratitis is the most common ocular manifestation of stage 3 disease; much less common is episcleritis. Both may present months to years after the onset of infection. Typically, infiltrates are bilateral, patchy, focal, and stromal; subepithelial infiltrates with indistinct borders, peripheral keratitis with stromal edema, and corneal neovascularization can also occur. The keratitis is thought to represent an immune phenomenon rather than an infectious process because it responds to topical corticosteroids alone.
Figure 10-8 Fundus photograph revealing dense vitreous cells and haze in Lyme disease vitritis.
(Courtesy of John D. Sheppard Jr, MD.)
Excerpted from BCSC 2020-2021 series: Section 9 - Uveitis and Ocular Inflammation. For more information and to purchase the entire series, please visit https://www.aao.org/bcsc.