Sudden onset of blurred vision in a 63-year-old man who suffered from Lyme arthritis 4 weeks back.
A 63-year-old male, known case of hypertension and hyperlipidemia, presented to the emergency department with sudden onset of blurred vision in his right eye. The patient had been diagnosed with Lyme arthritis 4 weeks before presenting with the vision complaints.
Four weeks back, the patient had positive immunoglobulin titers (IgG and IgM) on Western blot analyses of the synovial fluid
During the current presentation, a moderate but sudden decrease was noticed in his right eye’s visual acuity. The visual impairment existed at all distances. The patient denied any similar experiences before. He did not have any other associated complaints, including photopsia, floaters, trauma, eyeglasses, or previous episodes of blurred vision. There was no history or clinical evidence to suggest a vasculitic, hematologic, or hypercoagulable condition.
Examination:
On examination, there were no positive findings. The skin examination was negative for any rash or lesion. The best-corrected visual acuity (BCVA) was 20/60 in the right eye.
Fluorescein angiography of the right eye was performed, which revealed branch retinal vein occlusion (BRVO) with macular edema. The examination and angiography of the left eye were completely normal.
Treatment:
Doxycycline and prednisone were started, and the treatment showed positive results.
Ocular manifestation of Lyme disease:
Lyme disease is a multisystem disease, but the involvement of the eye is rare. The most common ocular manifestation of Lyme disease is conjunctivitis; others include iritis, keratitis, iridocyclitis, retinal vasculitis, choroiditis, optic neuropathy, and uveitis. Branch retinal vein occlusion is an extremely rare presentation of Lyme disease, with only a few cases reported to date.
Branch retinal vein occlusion
It is the blockage or obstruction of blood flow in the branch retinal vein, which then leads to fluid oozing out and causing macular edema secondary to obstruction. The reduced blood flow and the subsequent macular edema both together reduce the visual acuity. Being a rare manifestation of LD, it is usually diagnosed only after excluding other more common causes, including uncontrolled hypertension, cardiovascular disease, trauma, and other infectious and inflammatory etiologies.
Besides macular edema, the other complications of BRVO include tractional retinal detachment, neovascularisation, rubeosis iridis, etc.
Therefore it is imperative to treat the cause and manage the patient. Treatment with oral doxycycline has shown to be effective in most patients. However, intravenous antibiotics are more effective especially in cases with for neuro-ophthalmic manifestations of LD and those with failed oral regimens.
References:
Elavia N, Li S, Wang Y, Yusuf I, Weisenreider J (2020) Ocular Manifestation of Lyme Disease: A Rare Case of Branch Retinal Vein Occlusion. J Infect Dis Epidemiol 6:160. doi.org/10.23937/2474-3658/1510160
Centers for Disease Control and Prevention (2017) National Notifiable Diseases Surveillance System, 2016. Annual Tables of Infectious Disease Data. Atlanta, GA.
