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Be on the lookout for Lyme disease this summer
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Practitioners who encounter unexplained ocular inflammation and multisystem involvement should consider a diagnosis of Lyme disease, especially because the infection can present in a variety of ways and mimic many illnesses.
According to J. James Thimons, OD, a Primary Care Optometry News Editorial Board member, “It can look like any other disease and can affect almost any tissue of the eye, starting with the lids and working its way back to the optic nerve. It can create superficial inflammatory disease of the cornea. You can have neurotrophic disease that produces tissue loss.
“Most commonly you’re going to see inflammatory responses such as iritis, uveitis, retinitis or optic neuritis,” he continued. Dr. Thimons practices in Connecticut; Lyme disease was first discovered in Lyme, Conn.
Peaking during the months of May and June, cases are most commonly seen in the northeastern, mid-Atlantic and north-central states and among those 5 to 14 years old and 45 to 54 years old, according to the Centers for Disease Control and Prevention.
Symptoms, history findings that alert practitioners
Lyme disease is caused by the spirochete Borrelia burgdorferi and is transmitted to humans by the bite of infected Ixodes dammini or deer ticks, according to the CDC. It is the most common vector-borne disease in the United States, with about 20,000 new cases reported every year, according to the CDC’s Web site.
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Patients in the first stage may have flu-like symptoms, including malaise, fever and joint pain. The first physical manifestation of Lyme disease often is a pathopneumonic skin lesion called an erythema migrans, a rash that presents like a bull’s-eye. It can range from an inch or two in diameter to covering the afflicted patient’s entire back.
“Statistics show that about one-third of the patients don’t show a skin lesion as an initial presentation,” Dr. Thimons told PCON. “It is in those patients that it is much harder to pull the pieces together.” If the rash is not detected, the disease goes into a dormant phase and then moves onto an inflammatory process.
Ocular symptoms usually appear in the early disseminated phase of the disease, or stage 2.
Ocular findings may include blurred vision, diplopia, ocular pain or follicular or conjunctivitis, according to Gary E. Oliver, OD, FAAO, an associate clinical professor at the State University of New York State College of Optometry and director of Optometry at Woodhull Medical Center in Brooklyn, N.Y. “Some patients complain of floating black spots,” Dr. Oliver told PCON in an interview.
According to a case report in the American Journal of Neuroradiology, ocular findings associated with Lyme disease may also include conjunctivitis and periorbital edema. There also have been isolated reports of Lyme disease causing blepharospasm, iridocyclitis, panophthalmitis, optic neuritis and orbital myositis, the report said.
Bell’s palsy, conjunctivitis
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Image: Adams G |
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If a patient comes in with Bell’s palsy, a temporary paralysis of a facial nerve, Lyme has to be considered, Dr. Thimons said. Bell’s palsy usually manifests in the second stage of the disease.
“In Connecticut the literature indicates that up to 90% of the Bell’s palsy patients are actually active Lyme infections,” Dr. Thimons said.
Gerald Adams, OD, who practices in Westby, Wis., another Lyme disease hotbed, told PCON he has seen erythema migrans rashes stemming from tick bites behind the ear or near the scalp. If the rash extends to the eye it will cause a follicular conjunctivitis, especially in the lower cul-de-sac.
“That is kind of unusual.” Dr. Adams admitted. “For every one of those I’ve seen, I’ve seen at least a dozen Bell’s palsy cases.”
Stage 3, or the tertiary phase, then becomes cortical, and patients may start to develop cognitive and neurologic damage secondary to the disease.
Diagnostic tests
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Image: CDC/Gathany J |
To define the level of presentation, it is imperative to conduct a comprehensive evaluation of the entire ocular system, including visual fields, dilated fundus evaluation and color testing, if necessary, Dr. Thimons said.
“By defining the tissue level of involvement you can, in large part, define the disease,” Dr. Thimons explained. “Only certain diseases have the ability to give you panuveitis.”
To confirm a clinical diagnosis, Dr. Thimons said he orders an inflammatory profile based on the patient’s age, gender and systemic involvement. “You would start off with a complete blood count and then white cell differential,” he said. “The rest of the basic panel includes ESR, CRP and a Lyme titer, which looks for antibodies in the blood. In addition, I will tailor the remainder of the laboratory evaluation based on the patient’s age, sex, race and clinical presentation.”
Dr. Adams said he first uses non-fasting serum antibody testing by EIA or ELISA, enzyme-linked immunosorbent assay, though they are not always the most reliable indicators of the disease. “You can’t test for the bacteria itself, so false negatives can be a problem,” he said. “Some people never form antibodies to the bacteria, so they will always test negative. It is not uncommon for some people to take up to a month to form antibodies.”
If, however, the titer comes back positive, a Western blot/Immunoblot should be considered.
Jerome Sherman, OD, FAAO, a PCON Editorial Board member, said in an interview that PCR, or polymerase chain reaction test may be helpful to confirm the diagnosis in questionable cases. “It identifies the DNA fragments of the spirochete,” he said.
Referring to an infectious disease specialist
Lyme disease is a serious condition that should be treated as such, Dr. Sherman stressed. “From an eye point of view we have to take it seriously,” he said. “It can cause all sorts of damage in all kinds of places in the eye, including optic neuropathy, which has led to blindness in undiagnosed children.”
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Dr. Sherman said in the vast majority of Lyme disease, patients should be referred to an infectious disease specialist.
“The patient needs treatment sooner rather than later,” Dr. Oliver agreed. “You need to get the patient into the hands of a physician who is skilled at treating Lyme disease.”
Regulations and requirements are in place for reporting infectious diseases to the public health system for tracking purposes, Dr. Thimons said, adding that he refers the patient to his or her regular physician.
“The patient’s physician becomes the managing clinician,” he said. “What I am doing is simply related to the ophthalmic complications that may be presenting. It’s not the role of the community eye care clinician to manage Lyme disease systemically as an infectious disease.”
Counsel prevention
Dr. Sherman said rather than just diagnosing patients with Lyme disease, practitioners should counsel them to be cautious of ticks, especially in areas that are hard hit by the disease-carrying arthropods.
“You want to question people who spend a lot of time outside in wooded areas. Prevention is the best way to avoid the disease,” he advised. “Tell them to wear light colors, long sleeves, long pants and socks that go all the way up.”
Parents also should do a careful examination of children each night, especially if they have been playing in or near wooded areas, he said.
Dr. Sherman also recommends that patients use DEET to repel ticks.
Treatment protocols
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Image: Adams G |
Oral antibiotics are the first line of defense against Lyme disease, the practitioners agreed.
“It’s a systemic disease, so you have to treat the problem itself in order to resolve the ocular issues,” Dr. Oliver said. The initial treatment is typically 100 mg of doxycycline twice daily for a minimum of two to three weeks, provided there is no neurological involvement. Some patients require 4 to 6 weeks of treatment. Later stages may require intravenous antibiotic therapy.
If a patient does not see improvement with the doxycycline, practitioners might try a course of oral amoxicillin 500 mg three times daily for 3 weeks or Zithromax (azithromycin, Pfizer) 500 mg/day for 7 to 10 days, Dr. Oliver said.
Dr. Adams suggested cefuroxime axetil in stages 1 and 2 if doxycycline is contraindicated.
Dr. Sherman said he also prescribes azithromycin and treats iritis cases with steroids.
Dr. Thimons said patients should be treated orally with 200 mg of doxycycline a day for 4 to 6 weeks.
“Some people add to that Zithromax or Augmentin (amoxicillin/clavulanate, SK Beecham),” he said. “There’s a little controversy about whether that is necessary, but certainly with the more current literature there seems to be a desire to be a little bigger on the first time through to be sure the organism is eradicated.”
For more information:
- J. James Thimons, OD, is a PCON Editorial Board member. He can be reached at Ophthalmic Consultants of Connecticut, 75 Kings Highway Cutoff, Fairfield, CT 06430; (203) 257-7336; fax: (203) 330-4958; e-mail: jthimons@sbcglobal.net.
- Gary E. Oliver, OD, FAAO, is an associate clinical professor at SUNY State College of Optometry, director of optometry at Woodhull Medical Center in Brooklyn, N.Y., and a private practitioner. He can be reached at (215) 796-0455; e-mail geoliver.od@att.net.
- Gerald Adams, OD, can be reached at Adams Eye Clinic, 105 South Main Street, Westby, WI 54667; (608) 634-3434; fax: (608) 634-2024.
- Jerome Sherman, OD, FAAO, is a PCON Editorial Board member. He can be reached at SUNY College of Optometry, 33 West 42nd St., New York, NY 10306; (212) 938-5862; fax: (212) 780-4980; e-mail: jsherman@sunyopt.edu. Drs. Oliver, Adams and Sherman have no direct financial interest in the products mentioned in this article, nor are they paid consultants for any companies mentioned.
References:
- Steere AC, Bartenhagen NH, Craft JE, et al. The early clinical manifestations of Lyme disease. Ann Intern Med. 1983;99:76 –82.
- Reik L, Steere AC, Bartenhagen NH, et al. Neurologic abnormalities of Lyme disease. Medicine. (Baltimore) 1979;58:281–294[Medline].
- Winward K, Smith J. Ocular disease in Caribbean patients with serologic evidence of Lyme borreliosis. J Clin Neuroophthal. 1989;9:65 –70[Medline].
- Centers for Disease Control and Prevention (CDC). Lyme disease – United States, 2001-2002. MMWR. 53(17):365-369.