a 25-year - old female presented with right eye sudden and painless blurring of vision for 4 weeks , who visited a hilly area in the himalayas , north india .
no history of headache , fever , stiff neck , malaise , nausea , redness , watering of eyes , floaters , and trauma was reported .
her visual acuity ( va ) in the right eye was 20/60 ( unaided ) and 20/20 in the left eye .
anterior chamber was normal , relative afferent pupil defect was present , and fundus examination showed signs of papillitis , superior temporal retinitis contiguous with disc , vasculitis involving large vessels near the disc [ fig . 1 ] . examination with + 78 d revealed vitreous cells in the vicinity of neuroretinitis .
fundus fluorescein angiography ( ffa ) and optical coherence tomography ( oct ) confirmed the diagnosis of neuroretinitis [ fig .
the patient was empirically started on oral steroids ( prednisone 40 mg / day [ 1 mg / kg ] ) .
fundus photograph showing papillitis , neuroretinitis , vasculitis ( a ) fundus fluorescein angiography showing active vasculitis .
( b ) optical coherence tomography showing vitritis rheumatoid factor , cytoplasmic antineutrophil cytoplasmic antibodies ( c - anca ) , perinuclear anti - neutrophil cytoplasmic antibodies ( p - anca ) ( anti - myeloperoxidase ) antibodies , antinuclear antibody , anti - double - standard antibody , angiotensin converting enzyme , human leukocyte antigen b-27 , rapid plasma reagin and fluorescent treponemal antibody test , treponema pallidum immobilization and t. pallidum hemagglutination assay for syphilis , toxoplasma titer , hiv elisa were within limits .
lyme disease antibodies , igg and igm serum were 0.3 ( < 0.90 ) and 9.1 ( < 0.90 ) . mantoux test ( 5 mm  5 mm ) , chest x - ray , magnetic resonance imaging head , and echocardiography revealed no abnormality . on follow - up examination after 1 week , her va dropped to hand movement close to face and signs of fluid retention were present .
3b ] . considering the worsening of signs , symptoms , and positive igm tire for borrelia burgdorferi , serum western blot analysis test confirmed lyme disease .
oral doxycycline 100 mg was administered twice daily for 6 weeks and prednisone was tapered over a period of 4 weeks .
fundus and oct showed settling of neurosensory detachment and reduction of intraretinal fluid [ fig .
( b ) macular optical coherence tomography showing neurosensory detachment and vitritis ( a ) fundus photograph showing resolving lesions .
( b ) optical coherence tomography showing absence of neurosensory detachment and a normal foveal contour
the infectious agent of lyme disease is b. burgdorferi , a spirochete , isolated successfully from blood , synovial fluid , spinal fluid , retina , and vitreous of the eye .
it is transmitted by the vector ixodes tick bite and occurs in three chronological stages ; primary , secondary , and tertiary table 1 . over
50% of untreated , treated initially , and on treatment , patients may develop stage 3 lyme disease . hence , long follow - up is recommended for early diagnosis of cardiac , neurological , and arthritic involvement .
the centers for disease control and prevention made lyme disease a reportable disease in 1982 .
major manifestations individual case reports with positive lyme serology have reported papillitis , anterior ischemic optic neuropathy , optic neuritis , and neuroretinitis ; false positives have been up to 10% among residents of endemic areas without any apparent signs of infection .
the current definition of lyme disease includes a patient who develops erythema migrans ( em ) within 30 days of exposure in an endemic area or endemic area exposure , without em , but with signs involving one organ system and a positive laboratory test or no history of exposure , but with em as well as involvement of two organ systems or no exposure in an endemic area , but with em and a positive serology .
our patient was diagnosed as lyme disease based on history of exposure , involvement of one organ , i.e. , eye and positive serology for b. burgdorferi .
neuroretinitis is a focal inflammation of the optic nerve and peripapillary retina or macula of either infectious or idiopathic etiology .
infectious causes are cat scratch disease , syphilis , lyme disease , toxoplasmosis , mumps , salmonellosis , tuberculosis , and histoplasmosis .
although rare in india , we need to consider lyme disease in the differential diagnosis of neuroretinitis , especially if the patient hails from a forested area .
babu and murthy and vanya et al . have reported resolution of neuroretinitis with a combination of doxycycline and corticosteroids .
long - term use of antibiotics is successful in preventing disease progression to tertiary stage .
we conclude that neuroretinitis can be the presenting and the only presentation of lyme disease , hence should be considered in the differential diagnosis of neuroretinitis .
documentation with fundus photography , ffa , and oct for response to treatment is recommended .
doxycycline and corticosteroids should be started at the earliest as it is a treatable disease .
 we present a case of neuroretinitis as presenting and the only presentation of lyme disease in a 25-year - old female who visited hilly areas in the himalayas of north india . 
 she presented with right eye sudden and painless blurring of vision . 
 her vision at presentation was 20/60 . 
 she had fundus examination ; fundus fluorescein angiography ( ffa ) and optical coherence tomography ( oct ) imaging showed classical features of neuroretinitis . 
 no other organ was involved . 
 oral steroids were prescribed and relevant investigations sent for noninfective and infective causes 
 . worsened visual acuity ( va ) to hand movement and positive igm titers for borrelia burgdorferi led to the diagnosis of lyme disease - associated neuroretinitis . 
 treatment with oral doxycycline plus oral steroids for 4 weeks revealed va of 20/20 and resolution of fundus and oct changes . 
 neuroretinitis as presenting and the only presentation of lyme disease will be discussed with serial fundus , ffa , and oct pictures . 