Q: Ive heard of several patients who have received a delayed diagnosis of Lyme disease. Is there anything that the optometrist can look for to help speed up the diagnosis?

Lyme disease presents in myriad ways, says optometrist Sandra Bozich, of Los Altos, Calif. Ocular symptoms include diplopia, follicular conjunctivitis, uveitis, episcleritis and optic neuritis, among others.

A common symptom in some patients are black spots that float in the visual field, but theyre very different from floaters, she says. Theyre more like large black polka dots.

More rarely, patients may develop pseudotumor cerebri or cranial nerve palsies.

Those are just the eye-related manifestations, Dr. Bozich says, and they typically dont show up until the later stages of the diseaseperhaps weeks or months after the characteristic bulls-eye rash has disappeared. (Up to one-third of Lyme disease patients may never have or notice such a rash.)

Systemic symptoms include headaches, joint aches and swelling, fatigue, and a host of other symptoms that appear to be conditions such as multiple sclerosis, fibromyalgia, chronic fatigue syndrome, temporomandibular joint dysfunction or cranial nerve palsy, says infectious disease specialist Wesley P. Kozinn, M.D., of Easton, Pa.

Some patients are diagnosed by astute orthopedic specialists who drain and culture fluid from a knee or other affected joint that has been swollen for no reason.

Dr. Kozinn sees patients with Lyme disease year-round. In the summer, when ticks are biting, patients present with the rash and perhaps a flu-like syndrome. In the fall, they present with more numerous complications. And, in the winter monthswhen primary-care doctors may not be thinking of Lymepatients who have remained undiagnosed may present with debilitating neurological and joint complications. This is when optometrists can be instrumental in solving the puzzle, Dr. Kozinn says.

To accelerate the diagnosis, always ask the full battery of questions in your review of symptoms. Whenever a patient presents with unexplained, non-specific symptomsespecially problems that involve multiple organ systemsconsider the possibility of Lyme disease, Dr. Bozich says.

The Sites and Symptoms of Lyme Disease

Skin: Rash at site of tick bite, rashes on other parts of the body, circular or bulls-eye rash, raised rash.

General:  Unexplained weight loss or gain, extreme fatigue, swollen glands, high- or low-grade fever, continual infection (sinus, kidney, bladder or eye), migrating pain and inflammation.

Head, face and neck: Unexplained hair loss, mild or severe headache, twitching of facial or other muscles, Bells palsy, tingling (nose, cheek or face), stiff or painful neck, jaw pain or stiffness, sore throat.

Eyes and vision: Diplopia, blurred vision, floating spots in vision (unlike vitreous floaters), ocular pain, periorbital edema, photo-phobia, conjunctivitis, keratitis, episcleritis or scleritis, cranial nerve palsies, photopsia, optic neuritis, retinitis, uveitis.

Ears and hearing: Decreased hearing in one or both ears, buzzing or ringing in one or both ears, pain in the ears.

Digestive system: Diarrhea, constipation, irritable bladder, nausea and vomiting, abdominal pain.

Musculoskeletal: Joint pain or swelling, stiffness (joints, back or neck), muscle pain or cramps.

Respiratory and circulatory: Shortness of breath, chest pain and rib soreness, night sweats and chills, heart palpitations, heart block-age.

Neurological: Tremors/shaking, burning or stabbing sensations anywhere in the body, weakness or paralysis, pressure in head, numbness and tingling, poor balance, dizziness, difficulty walking, increased motion sickness, lightheadedness.

Psychological: Mood swings, unusual depression, disorientation, insomnia or too much sleep, restlessness.

Mental capability: Memory loss, confusion, slurring or stammering speech, loss of concentration.

Also, know whether your practice is in an epidemiological hot spot for Lyme, Dr. Kozinn says. (To find out, go to www.cdc.gov/ncidod/dvbid/lyme/epi.htm.) The way I figure it out most of the time is that I know where the patient lives, he says.

Even if you practice outside of Lyme-endemic areasFlorida, for exampledont automatically rule out Lyme disease, Dr. Kozinn adds. Be sure to ask about the patients travel history. You may find out that a Floridian spent part of last summer in New England. 

Q: If I suspect undiagnosed Lyme disease, how do I get a more definitive diagnosis for the patient?

You could order serologic testing for the patient, Dr. Kozinn says. Regardless, youll want to refer the patient to a doctor who has an interest or specialty in Lyme disease. And that may not necessarily be an infectious disease specialist, he adds. Just because a doctor is an infectious disease specialist does not make him or her an expert in Lyme disease, Dr. Kozinn says. Above all, the patient needs a sharp diagnostician.

First, call the patients primary-care physician and gauge that doctors interest in pursuing a diagnosis of Lyme disease, Dr. Bozich says. If the doctor wants to obtain blood work or other testing, the patient is in good hands. If the doctor seems skeptical or disinterested, however, then you probably want to send the patient directly to a Lyme disease specialist.

Patients diagnosed with Lyme disease are usually put on a course of antibiotic therapy. More symptomatic patients are put on intravenous antibiotics, Dr. Kozinn says, either at home or during a hospital stay.

Dr. Bozich continues to follow the patient until the ocular symptoms are resolved. She also asks the Lyme specialist to keep her informed of the patients overall condition.

Patients who are diagnosed and treated appropriately do very well, Dr. Kozinn says. But in a few cases, the disease permanently injures patients.

Its gratifying if you do make the diagnosis, he adds. Its a great opportunity for a practitioner such as an optometrist to help a patient who comes in with these peculiar eye symptoms and general symptoms. You can prevent blindness or other physical complications, or even save a life. 

Vol. No: 142:2Issue: 2/15/05