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Ocular Lyme Disease: Case Report and Review of the Literature

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Ocular Lyme Disease: Case Report and Review of the Literature Britishournal ofOphthalmology, 1990,74,325-327 325 ORIGINAL ARTICLES Br J Ophthalmol: first published as 10.1136/bjo.74.6.325 on 1 June 1990. Downloaded from Ocular Lyme disease: case report and review ofthe literature Danny J H Kauffmann, Gary P Wormser Abstract she was admitted to a community hospital. Lyme disease is an emerging new spirochaetal A physician removed fragments ofa presumed disease in which ocular complications may insect stringer from her right foot accompanied arise. We have seen a 45-year-old woman who byawhitemucoid discharge. Herwhite bloodcell developed unilateral endophthalmitis leading count was 22 x 109/l with 73% polymorphonuclear to blindness during the course of this disease. leucocytes and 18% band forms, and the erythro- Ocular tissue showed the characteristic cyte sedimentation rate was 48 mm/h. She was spirochete. A literature review shows that the treated empirically with intravenous cefazolin, commonest ocular manifestation of Lyme 6 g a day for seven days, but continued to have disease is a mild conjunctivitis, but other daily fevers up to 40- 10C (104-20F). She was then symptoms may include periorbital oedema, changed to oral tetracycline, 500 mg four times a oculomotor palsies, uveitis, papilloedema, day for seven more days. She responded well to papillitis, interstitial keratitis, and others. this regimen. Ophthalmologists treating patients from Two weeks later, on 25 August 1982, a sting on Lyme disease endemic areas need to be aware the left thigh by a bee caused localerythema. Two of the protean clinical manifestation of this days afterwards she awoke with a painful red left disease. eye. She had no eye complaints previously. The patient treated herself with sulphafurazole (sul- fisoxazone)drops, but sought an ophthalmologist Lyme disease, a tick-borne spirochaetal infec- when the vision decreased in the left eye and tion,' often begins with a characteristic rash, periorbital oedema developed. She was noted to http://bjo.bmj.com/ erythema chronicum migrans.3 Ocular manifes- haveiritisandposteriorsynechiaeandwas treated tations have been infrequently reported, but, as with topical atropine 1% and Predforte 1% the disease is increasing in frequency and occur- (dexamethasone) drops, with resultant breaking ring in new geographical areas,4 more cases with of the synechiae. However, the iritis persisted, ocular involvement can be expected. We report in and despite subconjunctival injection oftriamci- detail the eye findings in a patient previously nolone 40 mg hypopyon developed along with reported on who developed severe, unilateral vitritis. Oral prednisone 60 mg per day was on September 29, 2021 by guest. Protected copyright. endophthalmitis five weeks after erythema begun. The visual acuity nevertheless worsened, chronicum migrans.' Spirochaetes were found in and the prednisone dose was increased to 100 mg the vitreous in specimens obtained at surgery. In daily. She was then transferred to Westchester addition we review the literature ofthe ocular and County Medical Center. neuro-ophthalmic manifestations of Lyme Her visual acuity was 20/20 right eye and hand disease. motions left eye. The results of ocular examina- tion including tension were normal in the right eye. Theleft eye showedmild conjunctival ecchy- Case report mosis and ciliary vessel injection. There was mild On 15 July 1982 a 45-year-old woman from West- periorbital oedema. The ocular rotations were chester County, New York, developed severe full, though splinting ofthe left eye was noted in headache, light headedness, chills, and fever. extreme fields ofgaze. There was no measurable Three days later she also had nausea and vomit- proptosis. The cornea showed microscopic epi- New York Medical ing. On 21 July she noted red lesions on her right thelial oedema with stippled fluorescein College, Valhalla, New staining. York 10595, USA foot and upper arms that looked like insect bites. There was a severe inflammatory reaction in the Department of In addition a large annular erythema with an anterior chamber, with 3+ flare and cells, and a Ophthalmology indurated centre was noted on the right thigh. 20% hypopyon was present. After dilatation of D J H Kauffmann This lesion expanded and developed a bright red the pupil pigment residua were noted on the Division of Infectious outer border with central clearing. She remem- anterior lens surface from the previously treated Diseases, Department of bered having been bitten by many flying insects posteriorsynechiae. Thelenswasotherwiseclear. Medicine during the 4 no G P Wormser July weekend but recalled tick The ocular tension was 18 mmHg. The left bites. She was treated with diphenhydramine Correspondence to: D J H fundus could not be seen, and no red reflex was Kauffmann, MD, 1 Stone hydrochloride 50 mg four times a day and a obtained throughthe cellulardebris in the media. Place, Bronxville, New York cortisone skin ointment for what was to 10708, USA. thought Ophthalmic A and B scan ultrasound revealed be a local skin allergy to insect bites. On 30 July, Accepted for publication diffuse debris in the vitreous cavity, with marked 9 January 1990 because ofdaily fevers, malaise, and skin lesions, thickening of the choroid consistent with a 326 Kauffmann, Wormser TABLE I Ophthalmic and severe panophthalmitis. The retina was attached. which continuously maintained 20/20 vision neuro-ophthalmic The initial impression was severe uveitis ofun- throughout the course ofher disease. manifestations ofLyme Br J Ophthalmol: first published as 10.1136/bjo.74.6.325 on 1 June 1990. Downloaded from disease known aetiology. Prednisone was continued at 100 mg daily and tapered to 60 mg over the next Optic neuritis Discussion Optic perineuritis seven days. Roentgenograms of the chest, skull, Ischaemic optic neuropathy sinuses, orbits, and sacroiliac joints were normal. Our patient presented with a uniocular uveitis Optic atrophy due to Lyme disease which to a Cranial nerve palsies Serological tests for syphilis (FTA-abs, VDRL), progressed Argyll-Robertson pupil antinuclear antibodies, angiotensin converting panendophthalmitis and ultimate destruction of Pupillary areflexia toxo- vision.5 Other of Homer's syndrome enzyme, cryoglobulins, rheumatoid factor, useful uniocular examples Lyme Cortical blindness cara, toxoplasmosis, histoplasmosis, and cyto- related uveal tract involvement include case Papilloedema tuberculin reports of patients with and Conjunctivitis megalovirus were negative. A 5 TU iritis,7 uveitis,89 Keratitis skin test was negative. Serum creatinine and liver choroiditis with exudative retinal detachment.'0 Iritis on 17 The visual outcome of the other reported cases Iridocyclitis enzymeswerenormal. Serumobtained Sep- Panuveitis tember 1982 showed an IgM antibody titre to the was much better. A patient with iritis had spon- Vitritis an titreof 1:512 taneous resolution, and visual acuity in the others Choroiditis Lyme spirochaete of1 :64and IgG Exudative retinal detachments (normal for both < 1:64) determined by indirect improved after the use of specific systemic anti- Retinal vasculitis immunofluorescence. biotics with8 or without9'0 concomitant ocular Retinal haemorrhages Periorbital oedema Eightdaysafteradmission tohospitalandwhile steroids. on prednisone 60mgdaily the patient developed a Additional ocular manifestations of Lyme rapid rise in intraocular pressure in the left eye to disease include conjunctivitis, photophobia, 40 mmHg along with 5 mm proptosis, a conjunc- periorbital oedema, cranial nerve palsies, kera- tival purulent discharge, and the rapid onset of a titis, pupillary abnormalities, papilloedema, dense cataract. Computerised tomography optic neuritis, and optic atrophy (Table I).3 9 11-24 showed no evidence of a lesion to explain the The commonest ocular finding in Lyme disease proptosis. Orbital cellulitis was suspected, and appears to be conjunctivitis. Steere etalin a study nafcillin 12 g/day plus gentamicin 80 mg every of314patientswitherythemachronicum migrans eight hours was given intravenously along with noted conjunctivitis in 35 (11%), photophobia in topical neomycin-polymixin B (Neosporin) and 19 (6%), and periorbital oedema in 10 (3%).3 Un- dexamethasone. The ocular tension was control- fortunately the authors did not elaborate further. ledwithacetazolamide 1 g orally daily and timolol By inference and from our anecdotal experience 0-5% topically. Conjunctival cultures were nega- conjunctivitis isnotveryprominentinthis disease tive for bacteria, fungi, and mycobacteria. and is short-lived. One week later, 19 days after admission, a len- Neurological complications in Lyme disease sectomy and vitrectomy were performed and occur in approximately 10% of cases, and over purulentvitreousmaterial was removed. Intravit- halfofpatients with them have cranial nerve pal- real gentamicin 0-2 mg in 0-1 ml and chloram- sies, most commonly involving the seventh phenicol 0-2 in 0-1 ml were injected and nerve.'2 Oculomotor weakness is infrequent, but [tg http://bjo.bmj.com/ systemic antibiotics were maintained, while sys- may be due to cranial nerve palsy ofthe III, IV, or temic steroids were tapered. Cultures and smears VI cranial nerves. Such palsies may occur indivi- for bacteria, fungi, and acid fast organisms were dually, orin combinationwith one anotherand/or negative, and cytological examination of a fresh with other neurological abnormalities. 12 14 Diplo- vitreous specimen revealed only white cells. One pia is the typical ocular complaint in these in- weeklater
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