Macular Degeneration, Swelling, Edema, Vision Loss
Long-term follow-up of chronic Lyme neuroretinitis.
The authors report sequential fluorescein angiographic and
color photographic findings of the fundi and response to treatment in a
patient with chronic Lyme neuroretinitis.
A Lyme enzyme-linked immunosorbent assay with purified
41-kd flagellin as antigen was used to detect immunoglobulin G and
immunoglobulin M antibodies to Borrelia burgdorferi in serum, cerebrospinal
fluid, and vitreous. The changes were documented by fluorescein
angiography and color photography tests performed during a 5 1/2 year
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
Lyme borreliosis may cause neuroretinitis with unusual
angiographic findings. Chronic Lyme neuroretinitis may be unresponsive
to antibiotic therapy.
Graefes Arch Clin Exp Ophthalmol. 2008 Mar;246(3):457-8. doi:
10.1007/s00417-007-0740-0. Epub 2008 Jan 12
Intravitreal triamcinolone for macular edema in Lyme disease.
To describe the outcome in a patient with macular edema caused by Lyme disease treated with injection of 4 mg intravitreal triamcinolone.
The patient, 2 years after systemic Lyme disease treated with doxycycline for 4 weeks, developed macular edema with serous retinal detachment in one eye (visual acuity: 0.6). After unsuccessful therapy with intravenous ceftriaxone, indomethacin and acetazolamide, 4 mg intravitreal triamcinolone (IVTA) was injected via the pars plana.
Visual acuity improved to 1.0 and macular thickness recovered over 1 month. No changes were found in intraocular pressure. No recurrence of macular edema was seen after 2 years.
IVTA can restore visual acuity and reduce macular thickness in macular edema caused by Lyme disease. However, since borreliosis is a systemic disease, previous systemic antibiotic treatment is recommended.
Klin Monbl Augenheilkd. 1989 Aug;195(2):91-4.
[Borrelia burgdorferi infection with bilateral optic neuritis and intracerebral demyelinization lesions].
[Article in German]
In September, 1987, the authors saw a 25-year-old female patient with retinal perivasculitis, cystoid macular edema and papilledema in her right eye. The left eye was normal. Visual acuity was 0.2 (OD), 1.2 (OS). After conventional infections had been ruled out systemic methylprednisolone therapy was instituted, but the patient's condition deteriorated. In May 1988 she presented with papilledema and a "neuroretinitis"-like finding in her left eye; in her right eye advanced optic nerve atrophy; visual acuity was 0.1 (OD) and 0.07 (OS). The laboratory workup revealed an acute phase of a chronic Borrelia burgdorferi infection, with total immunoglobulins (immunofluorescence test) of 1:1280 and an IgM of 1:650 (normal ranges: total Ig up to 1.80, IgM up to 1:40). MRI showed multiple paraventricular and subcortical demyelinating lesions. However, the cranial CT scan was normal. After 14 days' treatment with doxycycline 200 mg/d, visual fields and acuity improved to sc 0.2 (OD) and sc 0.1 (OS) (July, 1988). This case of intracranial demyelinizating lesions associated with bilateral optic neuritis in a serologically determined Borrelia burgdorferi infection is the first of its kind described in the literature. http://www.ncbi.nlm.nih.gov/pubmed/2796241
Eur J Ophthalmol. 2009 Mar-Apr;19(2):307-9.
Bartonellosis causing bilateral Leber neuroretinitis: a case report.
- 1Clínica David, Unidad Oftalmológica, Morelia, Michoacan and General Hospital "Dr. Miguel Silva," SSA, Morelia, Michoacan - Mexico. email@example.com
Bartonella henselae is the causal agent of cat scratch disease and one variation in its presentation is Leber neuroretinitis. The unilateral presence of exudation as a macular star and papilledema represent its most common presentation.
Observational case report. A 7-year-old girl presented a sudden decrease of visual acuity and bilateral macularexudation (macular star) as well as choroiditis.
A complete recovery of visual acuity was seen after a 6-week follow-up. Erythromycin plus deflazacort treatment was given.
The present case represents an unusual variety of cat scratch disease. This represents a challenge in the differential diagnosis of diseases such as Lyme disease and tuberculosis among others.
PMID: 19253255 [PubMed - indexed for MEDLINE]http://www.ncbi.nlm.nih.gov/pubmed/19253255
Mayo Clin Proc. 1996 Dec;71(12):1162-6.
Optic disk edema with a macular star.
Optic disk edema with a macular star is a descriptive term encompassing a heterogeneous group of disorders. The clinical features include sudden visual loss, swelling of the optic disk, peripapillary and macular exudates that may occur in a star pattern, and cells in the vitreous. Herein we describe the clinical features, potential etiologic factors, differential diagnosis, work-up, and natural history of this entity.
Although optic disk edema with a macular star is usually idiopathic, infectious causes, especially syphilis, Lyme disease, cat-scratch disease, and toxoplasmosis, should be considered. The macular exudate likely results from primary optic nerve disease, not from inflammation of the retina; therefore, we prefer the term "idiopathic optic disk edema with a macular star" for idiopathic cases rather than "neuroretinitis."
When optic disk swelling and macular star are associated with focal or multifocal inflammatory lesions in the retina (retinitis), especially if an infectious cause is documented, the term "neuroretinitis" is appropriate. The prognosis for visual recovery is usually good, but residual visual loss may be severe in a few cases.
Patients with a recurrent type of the disease may not experience pronounced improvement in optic nerve function. The macular exudate may not develop in cases of disk edema until 2 weeks after the patient's initial assessment; thus, patients who have acute papillitis with a normal macula should be reexamined within 2 weeks for development of a macular star. The presence of a macular star militates strongly against subsequent development of multiple sclerosis.
PMID: 8945487 [PubMed - indexed for MEDLINE]
Bull Soc Belge Ophtalmol. 1995;259:205-14.
Retinal vasculitis in Lyme borreliosis.
We observed retinal vasculitis in seven patients with clinical and serologic evidence of Borrelia burgdorferi infection. Three patients presented with abrupt loss of vision due to acute retinal vasculitis. Funduscopy demonstrated engorged veins, hemorrhages, perivenous infiltrates and retinal white spots. Fluorescein angiography showed leakage from the veins, from the white spots and from the optic disc.
Moreover arterial occlusions were observed in two patients. Four patients had signs of chronic uveitis with vitritis, cystoid macular oedema and retinal vasculitis, which was associated with neovascularization and vitreous hemorrhage in one patient, and with optic neuritis in another patient. Six patients received antibiotic treatment and three patients received systemic corticosteroids.
Marked improvement in the three acute retinal vasculitis cases occurred within several weeks, the fundus changes disappeared in another few months, and no recurrences were observed.
The final visual acuity was excellent in these patients, although optic disc pallor and visual field loss persisted in one case. In the four patients with chronic uveitis visual blurring improved following antibiotic treatment and the retinal vasculitis and vitritis slowly regressed. The proliferative retinopathy of one patient required panretinal laser treatment.
PMID: 8936779 [PubMed - indexed for MEDLINE]
Eur J Ophthalmol. 1994 Oct-Dec;4(4):223-7.
Intermediate uveitis: what is the natural course of the disease and its relationship
with other systemic diseases?
This study examined the natural course of intermediate uveitis, to find
a possible correlation with systemic diseases and to identify the ocular
complications. Patients were classified according to follow-up time in
three groups: A (1-5 years) 12 pts, B (6-10 years) 10 pts, C (11-15 years
or more) 6 pts for a total of 28 patients (52 eyes).
We studied the recurrences, the complications of the disease and the
overall prognosis. Eight patients were found to be suffering from systemic
diseases: sarcoidosis 2, Adamantiades-Behcet 2, multiple sclerosis 3
and Lyme disease 1.
Cataract was found in 21 eyes (40.5%) and macular changes in 20
eyes (38.4%) but chronic cystoid macular edema persisted in only six
Group C presented more complications than group B. Group A had
the fewest. The frequency of recurrences was 1-5 for group A. 1-3 for
group B and 1-2 for group C.
Four patients received no therapy, 15 received steroids and nine
received cyclosporine and steroids. In this series intermediate uveitis
was bilateral in 85.8% of patients and related with systemic diseases
Recurrences appeared mainly during the first five years. The longer the
presence of the disease the more frequent were complications and the
final visual acuity depended mostly on the severity of the initial attack
and the number of exacerbations.
PMID: 7711475 [PubMed - indexed for MEDLINE]