The Neuro-Optometric Rehabilitation Association International is an interdisciplinary group of professionals dedicated to providing patients who have physical or cognitive disabilities as a result of an acquired brain injury with a complete ocular health evaluation and optimum visual rehabilitation education and services to improve their quality of life.

BLOG: Dealing with the visual consequences of Lyme disease

William V. Padula, OD, SFNAP, FAAO, FNORA
William V. Padula

by William V. Padula, OD, SFNAP, FAAO, FNORA

The CDC estimates that more than 300,000 new cases of Lyme disease occur every year in the U.S. – and that number is likely understated.

According to a recently released analysis from Quest Diagnostics, Lyme disease can be found in all 50 states and Washington, D.C.

Lyme disease is the best known of more than a dozen tickborne illnesses in which tiny bacteria called spirochetes are injected into the body with the tick saliva. If not treated, these spirochetes multiply and spread, eventually reaching the brain, where they can cause a range of neurological effects.

Lyme disease is difficult to diagnose, in part because it is a great mimicker of other conditions. Additionally, many people never realize they’ve been bitten by a tick unless they see the “bull’s eye” rash that is characteristic of Lyme. Blood tests for Lyme often produce a false negative result, because the spirochetes spend much of their time dormant in tissue, only prompting the immune system to produce detectable antibodies when they enter the bloodstream.

Visual system damage

Humans have two visual processing systems. One is a conscious process that we use to deliberately look at something, identify it and process its meaning. The second is a spatial visual process that is part of the more primitive, subconscious brain. It processes peripheral visual information that is matched up in the brain with information coming in from the sensorimotor system (ie, muscles and joints) to get an understanding of postural alignment and balance and to begin the process of mapping out spatial relationships. All of this occurs before and supports the higher, conscious visual process.

When the spatial process becomes compromised from Lyme disease (or, for that matter, from a concussion or stroke), it leaves the higher visual process isolated. Organizing eye movements and processing information takes much more work, and the individual starts to have symptoms, such as headaches, eye strain, visual fatigue, difficulty focusing or balance problems. These symptoms may motivate a patient to see an optometrist or ophthalmologist, but the most common diagnosis is convergence insufficiency, with a recommendation for vision therapy.

Unfortunately, this only addresses a symptom and can worsen the real cause of the visual compromise. Traditional vision therapy, in which the patient works on following a target, pushes the patient to create muscle power that they haven’t actually lost and further stresses a focusing system that continues to be hindered by the lack of support from the spatial processing system.

Effective techniques

It is important for the patient to be comanaged by a physician who specializes in Lyme disease. The doctor will look for co-infections and begin a regimen of treatment that can take some time. As a neuro-optometric rehabilitation specialist, I work with the patient separately to address the visual spatial processing issues and stabilize the base of support.

We help the patient organize saccades in a very gentle manner at first, with movement of the body and weight transfer. We can also prescribe yoked prisms to rebalance the spatial process. A few weeks of wearing these specialized prism lenses can often dramatically improve convergence and tracking and is often necessary for any other vision rehabilitation efforts to be successful.

Three tips to help your patients

Recognize that Lyme disease could be the underlying cause of sudden-onset visual processing problems such as double vision, convergence insufficiency or tracking issues.

Ask patients about time spent in the woods, hiking, or in tall grass, which can be tipoffs to a recent tick bite.

Learn more about Lyme disease and vision on the NORA website and attend the Neuro-Optometric Rehabilitation Association’s advanced clinical skills symposium on the “Consequences of Lyme-related disease in visual Processing at the NORA annual conference, Sept. 20 to 23 in St. Louis. Click here to register.


Kuehn BM. JAMA. 2013 Sep 18;310(11):1110. doi:10.1001/jama.2013.278331.

Quest Diagnostics. Health trends: Lyme disease. Posted July 2018. Accessed August 23, 2018.

For more information:

William V. Padula, OD, SFNAP, FAAO, FNORA, who practices in Guilford, Conn., was the founding chairman of the Low Vision Section for the American Optometric Association and the founding president of NORA.

Disclosure: Padula reports no relevant financial disclosures.