Ocular Lyme borreliosis

Retinitis Pigmentosa Masquerades: Case Series and Review of the Literature

Retinitis pigmentosa (RP) displays a broad range of phenotypic variations, often overlapping with acquired retinal diseases. Timely recognition and differentiation of RP masquerades is paramount due to the treatable nature of many such conditions. This review seeks to present examples of pseudo-RP cases and provide a comprehensive overview of RP masquerades. We first present two pseudo-RP cases, including comprehensive clinical histories and multimodal retinal imaging, to highlight the important role of accurate diagnoses that subsequently steered effective intervention. Subsequently, we conduct an in-depth review of RP masquerades to provide valuable insights into their key distinguishing features and management considerations. The recent approval of ocular gene therapy and the development of investigational gene-based treatments have brought genetic testing to the forefront for RP patients. However, it is important to note that genetic testing currently lacks utility as a screening tool for inherited retinal diseases (IRDs), including RP. The integrity of a precise clinical assessment remains indispensable for the diagnosis of both RP and RP masquerade conditions, thereby facilitating prompt intervention and appropriate management strategies.

Neuropsychiatric Lyme Disease and Vagus Nerve Stimulation

Lyme disease, the most common tick-borne disease in the United States, is caused by infection with the spirochete Borrelia burgdorferi. While most patients with acute Lyme disease recover completely if treated with antibiotics shortly after the onset of infection, approximately 10-30% experience post-treatment symptoms and 5-10% have residual symptoms with functional impairment (post-treatment Lyme disease syndrome or PTLDS). These patients typically experience pain, cognitive problems, and/or fatigue. This narrative review provides a broad overview of Lyme disease, focusing on neuropsychiatric manifestations and persistent symptoms. While the etiology of persistent symptoms remains incompletely understood, potential explanations include persistent infection, altered neural activation, and immune dysregulation. Widely recognized is that new treatment options are needed for people who have symptoms that persist despite prior antibiotic therapy. After a brief discussion of treatment approaches, the article focuses on vagus nerve stimulation (VNS), a neuromodulation approach that is FDA-approved for depression, epilepsy, and headache syndromes and has been reported to be helpful for other diseases characterized by inflammation and neural dysregulation. Transcutaneous VNS stimulates the external branch of the vagus nerve, is minimally invasive, and is well-tolerated in other conditions with few side effects. If well-controlled double-blinded studies demonstrate that transcutaneous auricular VNS helps patients with chronic syndromes such as persistent symptoms after Lyme disease, taVNS will be a welcome addition to the treatment options for these patients.

Characteristics of Lyme optic neuritis: a case report of Lyme associated bilateral optic neuritis and systematic review of the literature

Optic Neuritis is rare in Lyme borreliosis. The current knowledge of optic nerve involvement in Lyme borreliosis relies solely on case reports. The aim of this systematic review was to characterize and investigate the associated factors of optic neuritis in Lyme borreliosis. We further presented a very rare case of isolated bilateral optic neuritis in a Lyme seropositive patient.

Classification Criteria for Multiple Sclerosis-Associated Intermediate Uveitis

PURPOSE

The purpose of this study was to determine classification criteria for multiple sclerosis-associated intermediate uveitis.

DESIGN

Machine learning of cases with multiple sclerosis-associated intermediate uveitis and 4 other intermediate uveitides.

METHODS

Cases of intermediate uveitides were collected in an informatics-designed preliminary database, and a final database was constructed of cases achieving supermajority agreement on the diagnosis, using formal consensus techniques. Cases were split into a training set and a validation set. Machine learning using multinomial logistic regression was used in the training set to determine a parsimonious set of criteria that minimized the misclassification rate among the intermediate uveitides. The resulting criteria were evaluated in the validation set.

RESULTS

A total of 589 cases of intermediate uveitides, including 112 cases of multiple sclerosis-associated intermediate uveitis, were evaluated by machine learning. The overall accuracy for intermediate uveitides was 99.8% in the training set and 99.3% in the validation set (95% confidence interval: 96.1-99.9). Key criteria for multiple sclerosis-associated intermediate uveitis included unilateral or bilateral intermediate uveitis and multiple sclerosis diagnosed by the McDonald criteria. Key exclusions included syphilis and sarcoidosis. The misclassification rates for multiple sclerosis-associated intermediate uveitis were 0 % in the training set and 0% in the validation set.

CONCLUSIONS

The criteria for multiple sclerosis-associated intermediate uveitis had a low misclassification rate and appeared to perform sufficiently well enough for use in clinical and translational research.

Classification Criteria for Intermediate Uveitis, Non-Pars Planitis Type

PURPOSE

To determine classification criteria for intermediate uveitis, non-pars planitis type (IU-NPP, also known as undifferentiated intermediate uveitis).

DESIGN

Machine learning of cases with IU-NPP and 4 other intermediate uveitides.

METHODS

Cases of intermediate uveitides were collected in an informatics-designed preliminary database, and a final database was constructed of cases achieving supermajority agreement on the diagnosis, using formal consensus techniques. Cases were split into a training set and a validation set. Machine learning using multinomial logistic regression was used on the training set to determine a parsimonious set of criteria that minimized the misclassification rate among the intermediate uveitides. The resulting criteria were evaluated on the validation set.

RESULTS

Five hundred eighty-nine of cases of intermediate uveitides, including 114 cases of IU-NPP, were evaluated by machine learning. The overall accuracy for intermediate uveitides was 99.8% in the training set and 99.3% in the validation set (95% confidence interval 96.1, 99.9). Key criteria for IU-NPP included unilateral or bilateral intermediate uveitis with neither snowballs in the vitreous humor nor snowbanks on the pars plana. Other key exclusions included multiple sclerosis, sarcoidosis, and syphilis. The misclassification rates for IU-NPP were 0% in the training set and 0% in the validation set.

CONCLUSIONS

The criteria for IU-NPP had a low misclassification rate and seemed to perform well enough for use in clinical and translational research.

Case 292: Lyme Neuroborreliosis

History A 24-year-old right-handed woman presented to a neuro-ophthalmology clinic in Massachusetts in the summer with acute binocular diplopia when looking down and to the left, which started about 1 month earlier. Her medical history was notable for Raynaud syndrome, recurrent streptococcal pharyngitis, and an allergy to amoxicillin. Three days prior to developing diplopia, she presented to an outside emergency department due to fever, chills, and back pain. She received ciprofloxacin for presumed urinary tract infection based on urinalysis, which demonstrated few bacteria and was negative for leukocyte esterase, nitrites, and white blood cells. She then presented again to an outside emergency department for diplopia evaluation. Initial MRI and MR angiography of the brain at that time did not demonstrate any relevant findings, and the patient was referred to our department for neuro-ophthalmic evaluation, where she was seen 4 weeks later. Neuro-ophthalmic examination revealed 20/20 visual acuity in both eyes, and a right hypertropia in left gaze, downgaze and right head tilt, with right eye excyclotorsion. There were no ocular signs of myasthenia gravis or thyroid eye disease, nor did the patient report ocular or systemic symptoms. She denied recent travel. High-spatial-resolution MRI of the brain and orbit were performed.

Classification Criteria For Pars Planitis

PURPOSE

To determine classification criteria for pars planitis.

DESIGN

Machine learning of cases with pars planitis and 4 other intermediate uveitides.

METHODS

Cases of intermediate uveitides were collected in an informatics-designed preliminary database, and a final database was constructed of cases achieving supermajority agreement on the diagnosis, using formal consensus techniques. Cases were split into a training set and a validation set. Machine learning using multinomial logistic regression was used on the training set to determine a parsimonious set of criteria that minimized the misclassification rate among the intermediate uveitides. The resulting criteria were evaluated on the validation set.

RESULTS

Five hundred eighty-nine cases of intermediate uveitides, including 226 cases of pars planitis, were evaluated by machine learning. The overall accuracy for intermediate uveitides was 99.8% in the training set and 99.3% in the validation set (95% confidence interval 96.1, 99.9). Key criteria for pars planitis included unilateral or bilateral intermediate uveitis with either 1) snowballs in the vitreous or 2) snowbanks on the pars plana. Key exclusions included: 1) multiple sclerosis, 2) sarcoidosis, and 3) syphilis. The misclassification rates for pars planitis were 0% in the training set and 1.7% in the validation set, respectively.

CONCLUSIONS

The criteria for pars planitis had a low misclassification rate and appeared to perform sufficiently well for use in clinical and translational research.

Spirochetal uveitis: Spectrum of clinical manifestations, diagnostic and therapeutic approach, final outcome and epidemiological data

PURPOSE

Analysis of cases with spirochetal uveitis related to spirochetes in a tertiary referral academic center.

METHODS

Retrospective study of patients diagnosed with uveitis attributed to Treponema pallidum, Leptospira spp. and Borrelia burgdorferi from June 1991 until December 2019.

RESULTS

A total of 57 cases of spirochetal uveitis (22 patients with T. pallidum, 26 with Leptospira spp., and 9 with B. burgdorferi) that consisted 1% of the overall number of uveitics were recorded. All these cases presented with a wide spectrum of clinical presentations (anterior uveitis, posterior uveitis, panuveitis, vasculitis, papillitis, and in some rare cases concomitant posterior scleritis). The treatment included mainly penicillin or doxycycline, while corticosteroids were administered systematically in some cases with Borrelia or Leptospira infection. The final visual outcome was favorable (> 6/10 in Snellen visual acuity) in approximately 76% of our patients.

CONCLUSION

Despite being rare, spirochetal uveitis can be detrimental for the vision and must always be included in the differential diagnosis.

The Significance of Serum Anti-Borrelia Antibodies in the Diagnostic Work-Up of Uveitis

Purpose.

To assess the utility of testing uveitis patients for anti-Borrelia antibodies in an area endemic for Lyme borreliosis.

Methods.

We examined 161 uveitis patients for serum antibodies to Borrelia burgdorferi by Lyme ELISA. Antibodies were determined in patients with uveitis of unknown etiology and non-selectively from patients with an established diagnosis.

Results.

Concentrations of antibodies to B. burgdorferi were elevated in 26 uveitis patients (16.1%), with elevated IgG in 11 of them (6.8%). In four of these patients Lyme borreliosis was a highly suggestive cause of uveitis because of a history of tick bites, systemic symptoms, response to antibiotic therapy, and/or a positive polymerase chain reaction result. Other causes of uveitis were ruled out. All these patients had vitritis.

Conclusions.

Non-selective testing of uveitis patients for Lyme antibodies is not reasonable even in endemic areas. We recommend using the Borrelia antibody test only in cases of uveitis of unknown cause, especially in patients with vitritis or other symptoms of Lyme borreliosis.

Intraocular inflammation: its causes and investigations

Intraocular inflammation, or uveitis, incorporates a diverse group of infectious and immune-mediated disorders. In addition, some conditions masquerade as uveitis. However, classifying uveitis according to anatomic location in adult and pediatric populations, and appreciating the effect of immune status and regional differences, refines the list of potential causes. In this way, a select few investigations can be performed, rather than a nondirected battery of tests.

Thieme Atlas of Anatomy: Head and Neuroanatomy

BACKGROUND

Establishing a causal relationship between optic neuritis and Lyme disease (LD) has been hampered by technical limitations in serologic diagnosis of LD. Even so, there is a general impression that optic neuritis is a common manifestation of LD.

METHODS

Retrospective case analysis of Lyme serology in 440 patients with optic neuritis examined between 1993 and 2003 in a single neuro-ophthalmic practice at Stony Brook University Medical Center, Suffolk County, New York, a region hyper-endemic for LD.

RESULTS

Lyme enzyme-linked immunosorbent assay (ELISA) was positive in 28 (6.4%) patients with optic neuritis, three of whom had syphilis with cross-reactive antibodies. Among the remaining 25 ELISA-positive patients, optic neuritis could be confidently attributed to LD in only one case, a patient with papillitis. The other 24 cases had reactive Lyme serologies related to a history of LD years earlier, asymptomatic exposure, false-positive results, or non-specific humoral expansion. The ELISA in these 24 cases were weakly positive and the Western blots were negative by Centers for Disease Control criteria. There were no significant clinical differences between the 25 seropositive optic neuritis cases and 50 seronegative optic neuritis cases.

CONCLUSIONS

Based on these cases and a review of the literature, there is insufficient evidence for a causal link between LD and retrobulbar optic neuritis or neuroretinitis. There is sufficient evidence to establish a causal link between LD and papillitis and posterior uveitis.

Optic neuropathy in children with Lyme disease

Involvement of the optic nerve, either because of inflammation or increased intracranial pressure, is a rare manifestation of Lyme disease. Of the 4 children reported here with optic nerve abnormalities, 2 had decreased vision months after disease onset attributable to optic neuritis, and 1 had headache and diplopia early in the infection because of increased intracranial pressure associated with Lyme meningitis. In these 3 children, optic nerve involvement responded well to intravenous ceftriaxone therapy. The fourth child had headache and visual loss attributable to increased intracranial pressure and perhaps also to optic neuritis. Despite treatment with ceftriaxone and steroids, he had persistent increased intracranial pressure leading to permanent bilateral blindness. Clinicians should be aware that neuro-ophthalmologic involvement of Lyme disease may have significant consequences. If increased intracranial pressure persists despite antibiotic therapy, measures must be taken quickly to reduce the pressure.

[Dilated cardiomyopathy and panuveitis as presenting symptoms of Lyme disease. General review of one case]

INTRODUCTION

The clinical expression of Lyme disease is highly variable. If a patient presents clinical findings consistent with a systemic Lyme borreliosis, this disease must be considered in an endemic area because of its favorable outcome with adequate treatment.

EXEGESIS

The authors report and discuss the case of a patient with an unusual history of dilated cardiomyopathy and supraventricular fibrillation followed by bilateral panuveitis. Enzyme-linked immunosorbent assay and Western blot were positive for Borrelia burgdorferi antigens. The diagnosis of Lyme disease was made after other infectious, inflammatory and autoimmune disorders were excluded by clinical, instrumental and biological investigations. The treatment by ceftriaxone and amoxicillin resolved the ophthalmologic manifestations and improved the cardiac condition.

CONCLUSION

This report underlines the possibility of an unusual presentation of Lyme disease. Ophthalmologic and cardiac involvement should be known by clinicians.

The expanding clinical spectrum of ocular lyme borreliosis

OBJECTIVE

To delineate the clinical manifestations of ocular Lyme borreliosis, while concentrating on new symptoms and findings and the phase of appearance of ophthalmologic disorders.

DESIGN

Observational case series.

PARTICIPANTS

Ten patients with Lyme borreliosis-associated ophthalmologic findings previously reported from the Helsinki University Central Hospital in addition to 10 new cases that have since been diagnosed. INTERVENTION/TESTING: The patients underwent medical and ophthalmologic evaluation. The diagnosis of Lyme borreliosis was based on medical history, clinical ocular and systemic findings, determinations of antibodies to Borrelia burgdorferi by enzyme-linked immunosorbent assay and immunoblot analysis, the detection of DNA of B. burgdorferi by polymerase chain reaction, and exclusion of other infectious and inflammatory causes.

MAIN OUTCOME MEASURES

Ocular complaints, presenting ophthalmologic findings, and the stage of Lyme borreliosis were recorded.

RESULTS

Four patients presented with a neuro-ophthalmologic disorder, five had external ocular inflammation, 10 patients had uveitis, and one had branch retinal vein occlusion. One patient developed episcleritis and one patient developed abducens palsy within 2 months of the infection incident. In the remaining 14 patients in whom the time of infection was traced, the ocular manifestations appeared in the late stage of Lyme borreliosis. Two patients with a neuro-ophthalmologic disorder and one with external ocular inflammation experienced severe photophobia, whereas the main reported symptom of the patients with uveitis was decreased visual acuity. Four patients with external ocular disease and one with a neuro-ophthalmologic disorder experienced severe periodic ocular or facial pain. Retinal vasculitis developed in seven patients with uveitis.

CONCLUSIONS

Lyme borreliosis can cause a variety of ocular manifestations, which develop mainly in the late stage of the disease. Photophobia and severe periodic ocular pain can be characteristic symptoms of Lyme borreliosis. In the differential diagnosis of retinal vasculitis, Lyme borreliosis should be taken into account, especially in endemic areas.

Ocular manifestations in children and adolescents with Lyme arthritis

BACKGROUND

Lyme arthritis is the most frequent late manifestation of Lyme borreliosis and has been associated with ocular inflammation.

METHODS

A group of 153 children and adolescents with arthritis, 84 of whom had Lyme arthritis and 69 other causes of arthritis, were followed prospectively for 22-73 (median 44) months in the course of a national study.

RESULTS

Three of 84 patients with Lyme arthritis had ocular inflammation (4%), including keratitis, anterior uveitis, and uveitis intermedia. All three had symptoms of decreased visual acuity. Whereas anterior uveitis disappeared without sequelae, a corneal scar and a permanent loss of visual acuity in the patients with keratitis and intermediate uveitis remained. Systematic examination of all patients revealed no further ocular involvement. Of 69 patients with other causes of arthritis who were followed in parallel as a control group, four of 15 patients with early onset pauciarticular juvenile rheumatoid arthritis had chronic anterior uveitis and two of 12 patients with juvenile spondyloarthropathy had acute anterior uveitis.

CONCLUSIONS

Ocular involvement with keratitis, anterior uveitis, and intermediate uveitis may occur in children and adolescents with Lyme arthritis. Visual loss appears to be symptomatic, making regular ocular screening of such patients unnecessary.

The etiology of uveitis: the role of infections with special reference to Lyme borreliosis

PURPOSE

To assess the distribution of different uveitis entities and to evaluate their associations with infections, especially Lyme borreliosis.

METHODS

During a one-year period 160 consecutive uveitis patients were evaluated in a university clinic. Selected tests were performed depending on the medical history of the patient and the clinical picture of the ocular inflammation.

RESULTS

Uveitis was classified into selected entities for 74.4% of the patients. A direct infection was suggested to be linked with uveitis in 23 patients (14.4%). Lyme borreliosis, toxoplasmosis, and herpetic infections were the most frequently seen, in seven patients (4.3%) each. All patients with Lyme uveitis had manifestations of the posterior segment of the eye, such as vitritis, retinal vasculitis, neuroretinitis, chorioretinitis, or optic neuropathy.

CONCLUSION

Infections are an important cause of uveitis in a university clinic. Lyme borreliosis is a newly recognised uveitis entity which should be kept in mind in the differential diagnosis of intermediate or posterior uveitis in areas endemic for Lyme borreliosis.

Chiasmal optic neuritis in Lyme disease

PURPOSE

To report Lyme disease as the cause of chiasmal optic neuritis in a 10-year-old girl.

METHODS

The patient underwent ophthalmologic, laboratory, and imaging examinations.

RESULTS

The patient's history and clinical course were consistent with Lyme disease. Laboratory studies disclosed increased serum Lyme immunoglobulin G titer, which improved after antibiotic treatment.

CONCLUSION

Lyme disease should be considered in the differential diagnosis of chiasmal optic neuritis.

Detection of antibodies to Borrelia species among patients with confirmed sarcoidosis in a region where Lyme disease is nonendemic

BACKGROUND

Lyme disease is a multisystemic disorder caused by the spirochete Borrelia burgdorferi, while sarcoidosis is a multisystemic granulomatous disease of unknown etiology. The purpose of this study was to evaluate the relationship between Lyme disease and sarcoidosis.

METHODS

We examined the seroprevalence of antibody to Borellia species in patients with sarcoidosis. We performed the enzyme-linked immunosorbent assay, using three Japanese Borrelia species in addition to B. burgdorferi, and dotblot analysis using purified Borrelia-specific proteins in 38 patients with histopathologically confirmed sarcoidosis and 80 healthy controls.

RESULTS

Two patients (5.3%) were positive for antibodies to Borrelia species according to one or both assays, and one (1.2%) healthy control was positive. In both patients it was suspected that Borrelia infection had developed prior to the development of sarcoidosis.

CONCLUSION

Borrelia species were thought not to be responsible for the development of sarcoidosis in a nonendemic region in Japan. Since clinical manifestations of Lyme disease share certain similarities with those seen in sarcoidosis, ophthalmologists should be aware of the need to differentiate between the two diseases and the need for prompt treatment in each case.

Diagnosis and clinical characteristics of ocular Lyme borreliosis

PURPOSE

To establish a diagnosis, in a group of patients we studied the characteristics of ocular Lyme borreliosis.

METHODS

During a two-year period, 236 patients with prolonged external ocular inflammation, uveitis, retinitis, optic neuritis, or unexplained neuro-ophthalmic symptoms were examined for Lyme borreliosis. Antibodies to Borrelia burgdorferi were measured by indirect ELISA and western blot. Cerebrospinal fluid was also analyzed by polymerase chain reaction.

RESULTS

Ocular Lyme borreliosis was diagnosed in ten patients on the basis of medical history, clinical findings, and serologic test results. Results of ELISA disclosed that five patients were seropositive, two patients showed borderline reactivity, and three patients were seronegative. Four of the five patients with borderline or negative results by ELISA had a positive result by western blot analysis. In one seropositive patient, polymerase chain reaction verified a gene of B. burgdorferi endoflagellin from the vitreous and cerebrospinal fluid specimen. In five of the six patients with known onset of the Borrelia infection, the ocular disorder appeared as a late manifestation. Abnormalities of the posterior segment of the eye, such as vitreitis, retinal vasculitis, neuroretinitis, choroiditis, and optic neuropathy were seen in six patients. Bilateral paralytic mydriasis, interstitial keratitis, episcleritis, and anterior uveitis were seen in one patient each.

CONCLUSIONS

Late-phase ocular Lyme borreliosis is probably underdiagnosed because of weak seropositivity or seronegativity in ELISA assays. Ocular borrelial manifestations show characteristics resembling those seen in syphilis.

Vogt-Koyanagi-Harada syndrome

The Vogt-Koyanagi-Harada syndrome (VKH) is a bilateral, diffuse granulomatous uveitis associated with poliosis, vitiligo, alopecia, and central nervous system and auditory signs. These manifestations are variable and race dependent. This inflammatory syndrome is probably the result of an autoimmune mechanism, influenced by genetic factors, and appears to be directed against melanocytes. On histopathologic examination typical cases show nonnecrotizing diffuse granulomatous panuveitis with initial sparing and late involvement of the choriocapillaris and formation of Dalen-Fuchs' nodules. Fluorescein angiography, lumbar puncture, and echography are useful adjuncts in the diagnosis and management of VKH syndrome. Patients with this syndrome are treated generally with high dose systemic corticosteroids or, when necessary, with cyclosporine or cytotoxic agents. The prognosis of patients with VKH syndrome is fair, with nearly 60% of patients retaining vision of 20/30 or better. The complications of VKH syndrome that lead to visual loss include cataracts in about 25% of patients, glaucoma in 33%, and subretinal neovascular membranes (SRNVMs) in about 10%; the latter, however, are an important cause of late visual loss. These complications usually require medical and/or surgical intervention, including photocoagulation. The major risk factor for the development of cataracts, SRNVMs, and, to some extent, glaucoma, is chronic recurrent intraocular inflammation that may be resistant to corticosteroid therapy. It appears that initial treatment with high dose corticosteroids, combined with prolonged corticosteroid therapy at appropriate dosage, may minimize these complications and may improve visual prognosis.

Palsies of the trochlear nerve: diagnosis and localization--recent concepts

In this review, the anatomy of the trochlear nerve, the diagnosis of palsies of the trochlear nerve, and the localization of lesions of the trochlear nerve are discussed. Paresis of the superior oblique muscle is often not evident on duction testing; therefore, subjective diplopia testing with use of a Maddox rod is often necessary. The torsional component of the deviation may be evaluated by double Maddox rod testing. Palsies of the trochlear nerve must be distinguished from other causes of vertical diplopia, such as oculomotor palsy, skew deviation, myasthenia gravis, and Graves' ophthalmopathy. Trauma is the most common cause of isolated, unilateral or bilateral, acquired palsies of the trochlear nerve when a cause can be determined. The localization of lesions of the trochlear nerve to the nucleus or fascicles (or both), subarachnoid space, cavernous sinus and superior orbital fissure, or orbit depends on the associated damage to neighboring neurologic structures. Myokymia of the superior oblique muscle is usually idiopathic and benign but may rarely be an isolated manifestation of tectal disease.

Secondary retinitis pigmentosa and cerebral demyelination in Lyme borreliosis

A 15-year-old girl developed retinitis pigmentosa-like fundus changes in the left eye and optic neuropathy in the right eye as well as cerebral demyelination as a result of late Lyme borreliosis (LB). The diagnosis was confirmed by polymerase chain reaction, which detected a Borrelia burgdorferi specific segment of a gene coding for 41 kD endoflagellin, both in the vitreous and the cerebrospinal fluid. The diagnosis was delayed because testing for Borrelia antibodies in serum and cerebrospinal fluid yielded negative results. However, later on, another laboratory reported the antibodies of the patient's pretreatment serum to be positive for LB.

Intermediate uveitis and Lyme borreliosis

A case of chronic intermediate uveitis and associated classic snowbanking (pars planitis) with severe cystoid macular oedema probably due to Lyme borreliosis is reported. Despite a disease duration of 10 years the patient's ocular symptoms and visual acuity responded promptly to intravenous ceftriaxone treatment. This case demonstrates that periodic reevaluation of patients with intermediate uveitis is necessary to obtain a specific diagnosis which may include Lyme borreliosis.

Uveitis and systemic disease

A prospective study was conducted of 865 patients with uveitis to determine the frequency of associated systemic diseases and to assess the value of limited laboratory screening of these patients. All patients underwent a standard diagnostic protocol followed--when indicated--by special tests and procedures performed in order of likelihood ('tailored approach'). For 628 patients (73%) a specific diagnosis was established based on history, ophthalmologic examination, and laboratory and radiographic studies. A definite association with systemic disease was determined for 220 patients (26%). A relationship with a subclinical systemic disorder could be presumed in 201 cases (23%) and a well-established clinical uveitis entity without a recognisable systemic disorder was present in 207 cases (24%). For 237 patients (27%) a diagnosis could not be determined. The most frequently observed systemic diseases were sarcoidosis (7%) and HLA-B27-associated seronegative spondylarthropathies (6%). Presumed or definite toxoplasmosis was encountered in 10% of cases. HLA-B27-associated acute anterior uveitis was the most common clinical entity (17%). In the majority of cases the presence of a systemic disease was not suspected prior to eye involvement and was only recognised after the subsequent diagnostic procedures.

Detection of antibodies against Borrelia burgdorferi in patients with uveitis

We determined the antibody response against Borrelia burgdorferi strains isolated from Japanese Ixodes ovatus and Ixodes persulcatus ticks by enzyme-linked immunosorbent assay and indirect immunofluorescence assay of serum specimens from 127 patients with uveitis. We examined samples of serum from Japanese patients with unclassified uveitis, iridocyclitis caused by herpes zoster virus, Behçet's disease, Vogt-Koyanagi-Harada syndrome, sarcoidosis, or other conditions (sympathetic ophthalmia, Posner-Schlossman syndrome and acute anterior uveitis with ankylosing spondylitis). Serum from healthy individuals and patients with Lyme disease served as negative and positive control samples, respectively. Significantly higher antibody titers were demonstrated in patients with uveitis than in control subjects. Of 29 patients with unclassified uveitis, nine (31) had significantly increased antibody titers against B. burgdorferi strain H014 by ELISA testing. Five patients also showed higher IgG and IgM responses than in three control subjects with Lyme disease. All positive controls showed joint problems characteristic of rheumatoid arthritis. One of three patients had uveitis. The patients were diagnosed as having Lyme disease on the basis of their history and serologic tests. A positive antibody response was recognized in several patients with Behçet's disease, Vogt-Koyanagi-Harada syndrome, sarcoidosis, and other conditions (acute anterior uveitis with ankylosing spondylitis), but not in control subjects.

Lyme disease: neurologic and ophthalmic manifestations

Lyme disease is tick-borne infection which produces early and late manifestations in many organ systems. Prominent symptoms and signs occur in skin, heart, joints and nervous system. Many ocular and neuro-ophthalmic abnormalities recently have been attributed to Lyme disease, but some cases have not been well established as direct sequelae. This review of the contemporary state of knowledge about Lyme disease was undertaken so that more rigorous criteria can be applied in future diagnosis.