Atlas Of Ophthalmology – Disorders of the eye caused by borrelia (Lyme) infection
http://www.atlasophthalmology.com/atlas/folder.jsf;jsessionid=D9BF090D9E915450E921BA96B35EA6B4?node=4882&locale=cn
_____________________________________________________________________________________________
Optician Online : Lyme disease
This article is best viewed in a PDF Format.
View PDF: http://www.opticianonline.net/assets/getAsset.aspx?ItemID=2495
Lyme disease is caused by infection with Borrelia spirochaetes (B burgdorferi, B afzelii and B garinii). The organisms are transmitted through the bite of ticks of the Ixodes ricinus complex in the US, Europe and Asia. After an incubation period of several days, the spirochaetes disseminate haematogenously to multiple organs.
SYMPTOMS
A history of environmental exposure (such as camping in an endemic area) is significant. Flu-like symptoms often accompany the rash. Common symptoms of systemic disease include headache, fatigue, chills and arthralgias. Neck stiffness or photophobia may reflect meningitis. Common ocular symptoms include blurred or double vision, pain and photophobia.
SIGNS
Lyme disease is renowned for its protean clinical manifestations. Its progression is described in three stages, although all may co-exist.
● Stage 1: A pathognomonic, localised skin rash (Erythema migrans) develops. Erythema migrans consists of single large erythematous skin lesion, often with a pale or indurated centre (‘bull’s-eye’), that may expand over several days. Conjunctivitis or periorbital oedema may occur
● Stage 2 reflects organ dissemination: The skin, joints, heart, and central nervous system are most commonly involved. Possible ocular signs are listed below
● Stage 3: Appears in 60 per cent of untreated patients after months to years, typically with a large joint oligoarticular arthritis. Chronic encephalopathy and neuropathy are observed occasionally. On ocular examination, a red eye may reflect conjunctivitis or episcleritis. Reduced acuity, impaired colour vision, and relative afferent pupillary defect vision occur with optic neuritis. Keratitis produces corneal clouding and vascularisation. There may be anterior or posterior uveitis: Iritis may manifest ciliary injection and aqueous cells or flare posterior uveitis or retinitis may show vitreous flare, opacities or discolouration, elevation of the retina with retinal detachment, and disc swelling with optic neuritis.
SIGNIFICANCE
Potentially life and vision-threatening. Optic neuritis may cause blindness, particularly in children.
http://www.opticianonline.net/Articles/2007/06/08/18673/Lyme+disease.html
_____________________________________________________________________________________________
[Ocular manifestations of Lyme disease]
Med Mal Infect. 2007 Jul-Aug;37(7-8):518-22. Epub 2007 Mar 21.
[Article in French]
Bodaghi B.
Service d’ophtalmologie, université Paris-VI, CHU de la Pitié-Salpêtrière, 47-83, boulevard de l’Hôpital, 75651 Paris cedex 13, France. bahram.bodaghi@psl.ap-hop-paris.fr
Abstract
Despite the wide spectrum of clinical entities, eye involvement remains a rare event in patients with Lyme borreliosis. Most of ocular manifestations occur during the late phase of the disease. The infection needs to be considered along with more conventional causes of ocular inflammation, particularly in regions where Lyme disease is common. The pathogenesis of this condition remains controversial. Direct ocular infection and a delayed hypersensitivity mechanism may be involved at different disease stages. Uveitis and optic neuritis are the most common ocular complications. Serological testing lacks sensitivity and specificity. In atypical cases, ocular fluids sampling and analysis may be proposed. PCR seems to be an interesting diagnostic tool, allowing genotypic analysis. In the majority of cases, therapeutic strategy should be based on the association of antibiotics and corticosteroids. A new course of antibiotics may be prescribed to patients with chronic or relapsing inflammation due to bacterial persistence in ocular tissues.
PMID: 17376626 [PubMed - indexed for MEDLINE]
http://www.ncbi.nlm.nih.gov/pubmed/17376626
_____________________________________________________________________________________________
Ocular Signs of Lyme Disease
Lyme disease is a tick-borne disease that can cause symptoms in many body systems, including the eyes, well after the initial tick bite occurs. Ocular problems are uncommon side effects of Lyme disease that can occur in the early or late phase of the disease and can take many different forms. Treating Lyme disease with antibiotics along with treating specific eye complications is essential to prevent recurrent eye problems.
Conjunctivitis
Conjunctivitis, or redness and discharge due to inflammation of the conjunctiva, can occur in the early phase of Lyme disease. The conjunctiva, or lining of the eyeball and lower eyelid, looks pinkish, with tiny reddened blood vessels visible. Pus may be present, according to the Illinois Eye and Ear Infirmary. This type of conjuncitvitis is not contagious and clears up on its own.
Uveitis
An inflammation of the uvea, the middle part of the eye, is called uveitis. The uvea is made up of the iris, the colored part of the eye; the ciliary body, which makes the fluid that fills the eye; and the choroid, the layer beneath the retina. According to Allen Ho, M.D., Lyme disease can cause intermediate uveitis, also known as pars planitis, which affects the area behind the iris. According to the Merck Manual, pars planitis is often painless; the main symptoms are increased floaters–dark dots or lines that move around–and vision loss. The main treatment used for uveitis is steroid eye drops, which reduce inflammation. Treatment can take several months, because steroids need to be slowly reduced or a rebound effects will occur. Drops that dilate the pupil may be used to keep the iris from sticking to the lens, which can happen if the iris becomes scarred, according to Dr. Ho. This can cause permanent vision loss.
Optic Neuritis
The optic nerve carries impulses from the retina to the brain. Optic neuritis is an inflammation of the fibers that cover the optic nerve. According to the Mayo Clinic, Lyme disease can cause optic neuritis. Symptoms of the disease are pain in the eye, inability to see color and vision loss.Steroids are given both intravenously and as eye drops to treat optic nerve neuritis, according to the Mayo Clinic.
Keratitis
Keratitis, or inflammation of the cornea, can be a sign of Lyme disease, according to the Merck Manual. Keratitis may cause pain in the eye, light sensitivity, tearing and blurred vision. The eye may appear opacified, or covered with a white haze. Prednisone, a steroid, is given as eye drops, or by mouth for two to six months in deeper infections.
Retinal Vasculitis
Inflammation of the blood vessels of the retina, also known as retinal vascultis, can occur as a complication of Lyme disease, according to K. Durrani, M.D. The most common symptoms of retinal vasculitis are painless, gradual vision loss. According to Durrani, treatment depends on the presentation of the disease but usually includes high-dose steroids and may include ocular injection of steroids. Laser may be used if many small hemorrhages occur in the eye.
Branch Retinal Vein Occlusion
Lyme disease is occasionally associated with Branch Retinal Vein Occlusion (BRVO), a blockage in the veins of the retina. BRVO can cause vision loss in the area where the blockage is located, according to VitreoRetinal Surgery. There’s no pain associated with a BRVO, but vision loss occurs if the blockage causes swelling in the macula. Treatment is laser if the blockage is away from the macula, or intravitreal injection of steroids if swelling occurs in the macula.
http://www.livestrong.com/article/71899-ocular-signs-lyme-disease/
_____________________________________________________________________________________________
Retina. 1996;16(6):505- 9.
Long-term follow-up of chronic Lyme neuroretinitis.
Karma A, Stenborg T, Summanen P, Immonen I, Mikkilä H, Seppälä I.
Department of Ophthalmology, University of Helsinki, Finland.
Abstract
PURPOSE: The authors report sequential fluorescein angiographic and color photographic findings of the fundi and response to treatment in a patient with chronic Lyme neuroretinitis.
RESULTS: The diagnosis of Lyme neuroretinitis was based on the history of erythema migrans and positive Lyme enzyme-linked immunosorbent assay tests from cerebrospinal fluid and vitreous and by the exclusion of other infectious and systemic diseases and uveitis entities. Fluorescein angiography results disclosed bilateral chronic neuroretinal edema with areas of cystoid, patchy, and diffuse hyperfluorescence peripapillary and in the macular areas. The hyperfluorescent lesions enlarged despite a 9-month period of antibiotic therapy.
CONCLUSION: Lyme borreliosis may cause neuroretinitis with unusual angiographic findings. Chronic Lyme neuroretinitis may be unresponsive to antibiotic therapy.
PMID: 9002133 [PubMed - indexed for MEDLINE]
http://www.ncbi.nlm.nih.gov/pubmed/9002133
____________ _________ _________ _________ _________ _________ _
Int Ophthalmol Clin. 2001 Winter;41(1) :83-102.
Neuroretinitis.
Ray S, Gragoudas E.
Harvard Medical School, Massachusetts Eye and Ear Infirmary, 243 Charles Street, Boston, MA 02114, USA.
Abstract
Despite the growing list of agents that can present as neuroretinitis, nearly one-half remain idiopathic. However, many of the candidate etiologies are treatable conditions, and accurate diagnosis can result in visual rehabilitation. A complete workup in patients presenting with acute neuroretinitis should include a thorough history and general medical evaluation. Exposure history should be thoroughly explored, including recent travel, unpasteurized and uncooked foods, sexual experience, and animal contacts. A detailed physical examination should be performed to note hidden rashes and inoculation sites and should include routine measurements of blood pressure and heart rate. Laboratory tests should be tailored to the history and may include complete blood count; erythrocyte sedimentation rate; bacterial, fungal, and viral blood cultures; antinuclear antibody test; angiotensin- converting enzyme; anti-double- stranded DNA; and C3. Serological evaluation should look for syphilis, Lyme disease, histoplasmosis, brucellosis, chlamydia, HIV, toxoplasmosis, Epstein-Barr virus, viral hepatitis B and C, and tuberculin skin test. Neuroretinitis is a clinical entity in which there is inflammation of the retinal architecture and optic nerve. There are numerous entities that can cause a picture of neuroretinitis ranging from vascular to infectious to autoimmune. With regards to the infectious etiologies, it is interesting to note that many of these organisms are obligate intracellular pathogens. The microorganisms B. henselae, T. gondii, R. typhi, T. pallidum, Mycobacterium tuberculosis, Histoplasma capsulatum, and various viruses, such as HIV, mumps, and HSV, are known intracellular agents. Other major infectious agents, such as B. burgdorferi and Leptospirosis spp. are known to remain sequestered within the circulatory system. It is possible that in this way these agents are able to breach the delicate blood-brain barrier. The implication of such findings on the treatment and management of neuroretinitis remains to be explored. Interestingly, the vast majority of infected patients do not develop neuroretinitis or demonstrate CNS involvement. Detailed examination of this variability may provide further insight into the pathogenic properties of these infectious agents, host tissue susceptibility, and mechanisms of blood-retina barrier integrity. A detailed retinal examination can provide an unobstructed view of the CNS. Careful inspection of this delicate interface may reveal subtle findings critical for accurate and rapid diagnosis of underlying systemic pathology. The varied visual and neurological symptoms of neuroretinitis attest to the fact that this is a disease of both the retina and contiguous neuronal elements. Such involvement significantly elevates the risk to the patient and emphasizes the need for early detection and prompt treatment.
PMID: 11198149 [PubMed - indexed for MEDLINE]
http://www.ncbi.nlm.nih.gov/pubmed/11198149
_____________________________________________________________________________________________
Ocular Immunology & Uevitis Foundation:
LYME DISEASE
Lijing Yao, MD
http://www.uveitis.org/medical/articles/case/lyme.html
Ocular manifestations of Lyme disease may occur at any stage but are more common in the last two stages. The most common ocular finding in stage I is conjunctivitis.
During the second and third stages, ocular involvement includes anterior, intermediate, and posterior uveitis, endophthalmitis, keratitis (stromal opacities, punctuate superficial keratitis or peripheral ulcerative keratitis), and conjunctivitis.
Neuroophthalmic features can also occur, including involvement of third, sixth, and seventh cranial nerves (Bell’s palsy, most common), optic nerve (optic neuritis and perineuritis, papilledema, ischemic optic neuropathy, optic nerve atrophy).
Other possible ocular involvement includes retinal hemorrhages, exudative retinal detachments, cystoid macular edema, blepharitis, scleritis and episcleritis.
The most commonly reported ocular syndromes in stage II are conjunctivitis and uveitis. Bilateral interstitial keratitis has been described as a characteristic feature in the late stage of Lyme disease.
_____________________________________________________________________________________________
Ophthalmic problems with Lyme:
DEFINITION
• Lyme disease is characterized by dermatological, neurological, cardiac,
rheumatic, and ophthalmic manifestations that result from tick-borne
transmission of the spirochete Borrelia burgdorferi.
KEY FEATURES
• Three chronological stages:
1.Primary or initial phase—rash at the site of tick bite (erythema chronicum
migrans) and flu-like symptoms.
2. Secondary or dissemination stage—further dermatological, cardiac, and
neurological manifestations.
3. Tertiary or late stage—arthritis, meningoencephalitis, cranial neuropathy,
peripheral neuropathy, carditis.
ASSOCIATED FEATURES
• Conjunctivitis, most common manifestation in stage 1.
• Cranial nerve palsies, optic nerve inflammation can occur in stage 2.
• Corneal, uveal, and retinal inflammation can occur in stage 3.
Loads more info in article 
_____________________________________________________________________________________________
Lyme Disease & the eye
http://www.uic.edu/com/eye/LearningAboutVision/EyeFacts/LymeDisease.shtml
