Ocular Lyme disease: Narrative review and case series

Abstract

Lyme disease (LD) is a multisystem tick-borne infection with heterogeneous clinical manifestations. Ocular involvement is uncommon but may be sight-threatening and diagnostically challenging. We conducted a narrative review of the literature on ocular lyme borreliosis and a retrospective analysis of patients diagnosed at our institution over a 20-year period (2005–2025). Clinical features, diagnostic approaches, and treatment outcomes were evaluated. Eighty-six patients were included (mean age 38.0 ± 3.4 years; 62.8% male). Ocular involvement occurred at different stages of LD and affected the anterior segment (conjunctivitis, keratitis, episcleritis, and anterior uveitis), posterior segment (vitritis, retinal vasculitis, chorioretinitis, and cystoid macular edema), and neuro-ophthalmic system (optic neuritis, neuroretinitis, and cranial neuropathies). Posterior uveitis and retinal vasculitis were the most clinically significant findings. A history of tick bite was reported in less than half of the cases. Diagnosis required integration of epidemiologic exposure, clinical presentation, and laboratory testing, although serology and polymerase chain reaction showed important limitations. Most patients improved with systemic antibiotic therapy, while some developed persistent or recurrent inflammation. Ocular LD is a rare but clinically relevant condition with a broad spectrum of manifestations. A multimodal diagnostic approach and early treatment are essential to optimize the outcomes, although immune-mediated relapses may occur despite appropriate therapy.