Bilateral Granulomatous Keratic Precipitates Following Inadequate Antibiotic Coverage for Presumed Lyme Disease

Lyme disease, caused by Borrelia burgdorferi, is a multisystem infection with diverse ocular manifestations. Although ocular involvement is uncommon, it can include conjunctivitis, keratitis, uveitis, and optic neuropathy. We describe a 61-year-old man who developed bilateral mutton-fat keratic precipitates following a tick bite and incomplete systemic antibiotic coverage. His course was complicated by premature discontinuation of doxycycline and systemic corticosteroid exposure. Ophthalmic examination revealed bilateral granulomatous keratic precipitates without anterior chamber reaction. He was prescribed systemic azithromycin and referred to an infectious disease specialist for further evaluation. At the one-month follow-up, the patient demonstrated complete resolution of keratic precipitates and anterior chamber inflammation after completing azithromycin therapy, without the need for adjunctive corticosteroid use. This case underscores the importance of considering Lyme disease in the differential diagnosis of bilateral granulomatous keratic precipitates. Diagnostic challenges included an early false-negative serologic result, premature discontinuation of antibiotics, and corticosteroid exposure without adequate antimicrobial coverage. Bilateral granulomatous keratic precipitates may represent an early ophthalmic marker of systemic Lyme disease. Prompt recognition, initiation of systemic antibiotic therapy, and referral to an infectious disease specialist are essential to prevent long-term sequelae.