Neuroborreliosis: Add Lyme Disease to Your Differential

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Ocular manifestations of Lyme disease may be more prevalent than commonly thought, a small prospective Swedish study suggests.

The study, conducted in western Sweden, found that the majority of patients diagnosed with neuroborreli­osis (typically found in stage 2 of Lyme disease) had ophthalmic signs and symptoms.¹ The most frequent findings were blurred vision, diplopia, photophobia, redness, sixth nerve involvement, and palpebral dias­tasis resulting from facial palsy. Moreover, there was a positive correlation between signs and symptoms and cerebrospinal fluid (CSF) antibody titres.

Study rationale. The research team was motivated in part by evidence that “ticks are increasing in number and becoming more widespread in the northern parts of Europe,” said coauthor Marita A. Grönlund, MD, PhD, at Sahlgrenska University Hospital in Gothenburg, Sweden.

And although previous studies have documented the ocular manifestations of Lyme disease, they have been case reports and case studies, she noted. “There­fore, we and our coworkers at the [hospital’s] depart­ment of infectious diseases thought that it was of great importance to further evaluate and follow up ophthal­mic symptoms and findings in individuals diagnosed with neuroborreliosis verified by CSF analysis.”

Study specifics. Over a 6-year period, 24 patients who had either been diagnosed with Lyme disease or were strong suspects were referred to the hospital’s department of ophthalmology. All were tested for Bor­relia burgdorferi antibodies no later than 2 days after admission and underwent lumbar puncture no later than 3 days after admission.

Results. Neuroborreliosis was confirmed in 16 patients, while 2 patients were classified as possible cases. Diagnosis was negative in 4 patients and un­known in the remaining 2. Of the 18 patients classified as definite or possible, 14 (78%) had ophthalmic signs and symptoms. All patients improved except for 1 with fulminant papilledema; this patient still had optic disc atrophy and affected visual fields at last follow-up.

A surprise. In contrast with previous studies, the researchers found no evidence of either conjunctivitis or uveitis, Dr. Grönlund said. The reason for this remains unknown.

Take-home message. “For ophthalmologists, there might be reason to think twice about neuroborreliosis not only in subjects with facial palsy but also in those with [new-onset] diplopia and/or sixth nerve affection,” Dr. Grönlund concluded.

—Jean Shaw

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1 Škiljić D et al. Acta Ophthalmol. Published online Aug. 26, 2018.

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Relevant financial disclosures—Dr. Grönlund: None.

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