The Tick Did It, Twice! Alina Reznik, OD Optometry Resident Lynn Community Health Center Abstract: A tick bite leads a 36-year-old male to Optometry due to bilateral lagophthalmos secondary to bilateral seventh nerve facial weakness. Lyme disease necessitates early detection, diagnosis, along with systemic and ocular treatment to accelerate patient recovery. I. Case History A 36-year-old Hispanic male, referred by primary care, presented for a problem focused exam. Never had an eye exam. Patient reported symptoms of burning, dryness and tearing in both eyes secondarily to the inability to close his eyes, right >left. He also reported new onset severe headaches along with changes in his face for the past week. Patient reported that he “cannot close his eyes.” Patient works in landscaping and reported pulling 2 ticks off his back a few weeks ago. No history of trauma, no other remarkable systemic, medical, ocular or family history. II. Pertinent findings External exam was positive for lagophthalmos OD>OS. On slit lamp exam, patient had 1+scurfs, 1+ capped glands, 2+ diffuse corneal superficial punctate keratitis with accumulation inferiorly (right>left), open anterior chamber with no cells and flare OU. Fundus examination was normal with no posterior inflammation or abnormalities. Patient had no external skin rashes, no vesicles on face and body. Neurological examination: (Will include patient facial photos from all three encounters showing neurological improvement with time and treatment) -Initial encounter: Patient was incapable of fully shutting his eyes. Palpebral fissure size while shutting eyes: OD 9mm, OS 4mm. Absence of forehead winkles above both eyes Show me your teeth? Unable to show teeth, nor move the superior or inferior facial muscles. Flattening of nasolabial fold. -9 day follow up: Palpebral fissure size while shutting eyes: OD 8mm, OS 3mm. Absence of forehead winkles above right eye, slight improvement above left eye. Show me your teeth? Minor movement on left nasolabial fold, no movement on right side of face. - 23 day follow up: Palpebral fissure size while shutting eyes: OD 7mm, full lid closure/ Absence of forehead winkles above right eye, slight improvement above left eye. Show me your teeth? No movement on right side of face. Almost full recovery of movement of left nasolabial fold. Laboratory studies: Blood work came back positive for Lyme, and negative for Varicella Zoster. (+) IGM WESTERN BLOT (-) IGG WESTERN BLOT (-) IGM VARICELLA (+) IGG VARICELLA (indicates immunity) Other testing: EKG – Normal III. Differential diagnosis • Lyme disease (Primary) • Bell’s Palsy (idiopathic) • Ramsay–Hunt syndrome • Guillain–Barre syndrome • Sarcoidosis IV. Diagnosis and discussion Borrelia burgdorferi is a bacterium that is transmitted by the blacklegged deer tick (Ixodes scapularis) on the East coast and the western-blacklegged tick (Ixodes pacificus) on the Pacific coast. These specific ticks are the only known vectors that can spread the disease. This disease occurs primarily in young and middle aged men who spend time outdoors for work or recreation. The Centers for Disease Control and Protection (CDC) estimated that about 300,000 patients are diagnosed with Lyme disease in the United States each year. Fourteen particular states in the Northeast and upper Midwest account for 96% of all reported cases. When Lyme disease is a differential diagnosis, consider patient history and symptoms, geographical location, as well as blood testing and its limitations. An in depth patient history and list of symptoms are fundamental in directing a clinician’s management plan. Considered “The Great Imitator,” Lyme can manifest in a variety of ways, such as, unilateral and bilateral facial palsies, constitutional symptoms, erythema migraines (bulls-eye rash), severe joint pain and swelling. Facial palsies can be idiopathic (Bell’s palsy) or due to an underlying systemic cause. Bilateral peripheral facial palsies are exceedingly rare (0.3% to 2.0%) and usually associated with systemic conditions such as Lyme disease in (36%), Guillain–Barre syndrome (5%), trauma (4%), sarcoidosis (0.9%), and AIDS (0.9%). Facial palsies are separated into peripheral facial palsies (total weakness of superior and inferior portions of the face) and central facial palsies (inferior facial weakness only). A lesion to the ipsilateral facial nerve or central lesion in the pons usually causes a peripheral facial palsy. On the other hand, a lesion to the cerebral cortex will cause a central facial palsy. A neurological workup will help differentiate between the two types of palsies. Asking the patient questions such as “close your eyes” and “show me your teeth,” will help determine if the patient has upper facial weakness or lower facial weakness respectively. Rarely are patient signs and symptoms conclusive and therefore laboratory testing is strongly advised. The CDC encourages doctors to follow a two-tier system, which first screens for antibodies with Enzyme-linked Immunosorbent Assay (ELISA) and then confirm the condition with Western Blot. Research shows that ELISA has low specificity and the Western Blot has high sensitivity. Studies concluded that 52% of chronically ill Lyme patients tested negative by ELISA and positive by Western Blot. CDC standards for reporting Lyme disease requires 5 positive protein bands out of 10 on the Western Blot. It’s important to keep in mind laboratory interpretation variability. Some Lyme specialists will consider specific positive bands (even if there are less than 5) as highly indicative of Lyme, especially if the patient shows strong Lyme-like symptoms. Timing also plays a role in disease detection. A study revealed that there are three stages of Lyme disease: early local infection, early disseminated infection, and late disseminated infection. In the early stages, antibodies may be undetectable leading to a false-negative ELISA results and therefore, clinicians should retest patients with increased Lyme suspicion. Other testing for Lyme includes CSF analysis, polymerase chain reaction (PCR), culture testing and antigen detection. (Will include chart of united stats showing endemic tick areas and a chart deciphering peripheral vs central facial palsies) V. Treatment, management The patient’s exposure keratitis secondary to lagophthalmos in both eyes was managed with aggressive dry eye therapy. The patient was recommended to use Celluvisc 1gtt OU every 3-4 hours in both eyes, Refresh PM 1/4 ribbon into lower lids before bed QHS and tap tarsorrhaphy while sleeping. Following the eye examination the patient was immediately referred to urgent care for evaluation. Urgent care completed a physical examination and prescribed the patient Prednisone 20 mg p.o. 3 tablets once daily for 7 days and valacyclovir 1 gram p.o. t.i.d for 7 days. Laboratory testing was ordered in urgent care at the initial visit. Blood work came back positive for Lyme disease; the patient was then prescribed doxycycline hyclate (vibramycin) 100 mg capsule p.o. b.i.d. Due to the growing severity of the patient’s condition while on oral antibiotics, neurology changed the patient’s treatment plan to ceftriaxone infusions for 14 days and continued oral prednisone. Once the patient finished IV infusions, he was placed on amoxicillin 500 mg capsule p.o. t.i.d and Prednisone taper. The patient’s facial weakness moderately improved during the antibiotic regiment where full left eyelid closure and movement of left nasolabial fold was achieved. While the right size of the patient’s face mildly improved. Dry eye therapy was also successful with greater corneal integrity and eye comfort. Lagophthalmous secondary to seventh nerve pasly causes varying degrees of exposure keratitis. Treatment may include artificial tears q.i.d., lubricating ointment q.h.s., tape tarsorrhaphy q.h.s., moisture chamber, eyelid gold weight implant, or amniotic membrane graft for corneas unresponsive to traditional treatments. When confronted with a facial plasy of unknown etiology (Bell’s Palsy), many practitioners prescribe a combination of corticosteroids (prednisone 60 mg p.o. q.d. for 4 days, tapering to 5 mg q.d. over 10 days) and antivirals (acyclovir 400 mg p.o. 5 times per day for 7 days or valacyclovir 1 g p.o. t.i.d. for 7 days). This treatment plan is still under debate due to variable study results. Some conclude improved rate and degree of recovery (when treatment is initiated within 4 days of symptoms) or reduced risk of future recurrent symptoms, while others showed no change in efficacy or recovery time. The standard therapy for Lyme disease includes an antibiotic, such as Doxycycline 100 mg p.o. b.i.d. for 10 to 21 days or amoxicillin 500 mg p.o. t.i.d. If neurological symptoms exacerbate, patients are administered Ceftriaxone 2 g or penicillin G, 20 million units intravenously q.d. for 2 to 3 weeks. Average follow-up schedule is 1-3 days until improvement is evident and then weekly until the condition resolves. While patient with unilateral facial weakness tend to have full recovery, patient with bilateral facial weakness have a greater chance of delayed recovery and minor residual function deficits. VI. Conclusion The great imitator can be uncovered if clinicians keep some important facts in mind, such as the location of tick endemic areas, the necessity of a detailed patient history, and understand the most common signs and symptoms associated with Lyme. In addition, understand how to differentiate between peripheral and central facial weakness in order to help pinpoint where the lesion lies. Bilateral seventh nerve facial weakness is a true rarity and should be managed in a timely manner due to increased risk of residual manifestations. Optometrist can not only play a key role in managing lagophthalmos with dry eye therapy, but also provide findings to direct differential diagnosis, lab work, and systemic treatment of the disease. Bibliography Adam T. Gerstenblith MD, Michael P. Rabinowitz MD. The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease.