How do you manage patients from endemic areas who have positive Lyme serology with ocular abnormalities that are rarely reported in Lyme disease (optic neuropathy, disc edema, etc)?

In patients from Lyme-endemic areas, I try very hard not to let a positive serology become the diagnosis. A positive two-tier Lyme test tells me the patient has been exposed to Borrelia at some point; it does not necessarily tell me that Borrelia is responsible for the ocular findings in front of me...

It is not possible to determine if B. burgdorferi is the cause of the ocular symptoms or just an incidentally positive Lyme serology from a past exposure. In the absence of another explanation, the “default” is to treat for Lyme. The treatment depends on the specifics of the presumed infection. Mild...