Leprosy - Part 2 - a presentation at www.eyenirvaan.com

Pradnya Gogate B. Optom,

LEPROSY
PART 2

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LEPROSY : OPHTHALMIC
STRUCTURES INVOLVED






Cornea
Sclera
Iris
Ciliary body
Lens

 Ocular

adnexa

EYE COMPLICATIONS


Leprosy: Potentially Blinding Lesions
 Lagophthalmos

(whole spectrum)
 Corneal hypoaesthesia (whole spectrum)
 Acute iritis and scleritis (MB leprosy)
 Chronic iritis and iris atrophy (MB leprosy)
 Cataract (whole spectrum)


LAGOPHTHALMOS
 Due

to

 damage

to the facial

nerve
 late result of
infiltration and
secondary atrophy of
the facial nerve and
orbicularis muscle


HOW IS LAGOPHTHALMOS
ASSESSED?


Observe the Frequency and Extent of Blinking



Ask the Patient to Close the Eyes 'As in Sleep'



Ask the Patient to Close the Eyes Tightly




Treatment of Lagophthalmos is Dependent On:
 1.

Duration of the lagophthalmos
 2. Width of the eyelid gap, and exposure of the cornea
 3. Presence or absence of corneal hypoaesthesia




Duration of lagophthalmos ≤ 6
months: prednisolone 40mg/day
slowly reducing over 12 weeks



Duration of lagophthalmos > 6
months with eyelid gap < 6 mm:
Conservative treatment, e.g.
sunglasses, 'think blink‘



Duration of lagophthalmos > 6
months with eyelid gap ≥ 6 mm:
eyelid surgery


EXPOSURE KERATITIS


damage to the lower, exposed
part of the cornea, due to
dryness
 superficial punctate keratitis
 deeper corneal defect
 secondarily infected
 blindness by scarring or
perforation
 Chronic exposure may lead to
progressive scarring



TREATMENT


antibiotic eye ointment



an eye shield



An exposure ulcer is a definite indication for
eyelid surgery.


CORNEAL HYPOAESTHESIA


CAUSES OF CORNEAL
HYPOAESTHESIA
 As

a result of reversal reaction in the
trigeminal nerve (V cranial nerve).



As a result of exposure of the cornea in
lagophthalmos.

 As

a result of severe scleritis and damage to
the ciliary nerves (often bilateral).

 As

a result of bacterial infiltration and
secondary atrophy of ciliary and corneal nerves
(often bilateral).

TREATMENT



no cure for corneal hypoaesthesia


Patients should receive good health education
 protection of the eyes with glasses or sunglasses
 regular blinking exercises
 regular inspection of the eyes


Corneal hypoaesthesia may be an indication for early
eyelid surgery
in lagophthalmos


ACUTE IRITIS


only in MB patients



evidence of ENL reaction inside the eye



recur at any time


SIGNS AND SYMPTOMS
 redness,

pain,
photophobia, reduced
visual acuity

 haziness

of the cornea
and secondary
glaucoma

 unilateral

or bilateral


TREATMENT

 atropine

sulphate 1% twice daily, steroid eye
drops 6 times daily and steroid ointment at
night time

 Systemic

steroids if there is ENL reaction


SIGNS OF MB LEPROSY






(temporal) madarosis of eyebrows
early collapse of the nose
nodules on the ears


TYPE 2 REACTION: ACUTE
EPISCLERITIS AND SCLERITIS


EPISCLERITIS
 is

a transient condition

 often

as a precursor of a systemic ENL
reaction

 resolves
 Tx:

spontaneously and completely

topical steroids


SCLERITIS
bilateral
 in combination with a
severe ENL reaction
 may be nodular or diffuse
and occurs with or without
acute iritis





painful



ciliary nerves may become damaged and pain
becomes less



ciliary staphylomas



subsequent scleral translucency



thinning of the sclera



In sclerosing keratitis the whole cornea may become
opaque

TREATMENT
 Acute

scleritis is treated topically with
steroids

 Oral

non steroidal anti-inflammatory drugs
(NSAID's), such as Ibuprofen (400 mg four
times daily)

 Treatment

of the ENL reaction will require
high doses of systemic steroids and
clofazimine

MASSIVE BACILLARY INFILTRATION:
PERI-ORBITAL COMPLICATIONS

Abnormalities occur around the eye due to infiltration
by bacilli and secondary atrophy

LESIONS AROUND THE EYE


loss of eyebrows



eyelashes also become atrophic and
scanty (madarosis), and trichiasis



collapse of the nose and secondarily
blocked lacrimal sac



loose skinfold in the upper eyelids
(blepharochalasis)


LESIONS WITHIN THE EYE
 Ocular

leproma

 Superficial

pearls

 Iris

lepromatous keratitis and iris

atrophy and pinpoint pupil

 Chronic

iritis

 Atrophy

of the ciliary body

OCULAR LEPROMA


Lepromatous nodule in the eye, usually in the region
of the lateral limbus



a ring of nodules



pinkish red or yellowish and fleshy



pinkish red or yellowish and fleshy



painless



pupil may be deformed

PUNCTATE AVASCULAR LEPROUS KERATITIS
AND IRIS PEARLS
PUNCTATE LEPROUS KERATITIS
faint discrete superficial infiltrates in the upper
outer quadrant of the cornea
 consist of clumps of bacilli-laden cells
 become tiny white opacities
 finally coalesce in a diffuse haze
 bilateral and asymptomatic.


Beading of the corneal nerves (diagnostic for leprosy)


IRIS PEARLS


tiny white clumps (like grains of salt) extruding from the
surface of the iris



histology shows M. leprae



dislodge into the lower angle of the anterior chamber,
where they may be absorbed or give rise to anterior
synechiae





Iris pearls are pathognomonic for leprosy.
seen in longstanding MB leprosy

MASSIVE BACILLARY
INFILTRATION: OCULAR
ATROPHIC CHANGES


IRIS ATROPHY AND PIN-POINT PUPIL
 The

iris crypts flatten
 the stroma thins
 deep pigmented layer of the iris become visible
 full thickness iris holes appear
 prominent in the stroma of the iris dilator
muscle
 pupil becomes pin-point
 bilateral
patient will become 'night blind'.

TREATMENT


dilate the pupil with phenylephrine 2.5 - 5%



sector iridectomy


CHRONIC IRITIS


no redness



flare and cells in the anterior chamber



small keratic precipitates



greyish exudates along the pupillary margin



the pupil constricts



posterior synechiae may form


ATROPHY OF THE CILIARY
BODY


ciliary body is believed to be the port of entry of M.
leprae into the eye



loss of accommodation



intraocular pressure tends to be low i


LEPROSY AND CATARACT


Prevention of blindness due to leprosy


Early diagnosis of leprosy and timely
MDT treatment



Early recognition of reactions and
effective treatment of reactions with
systemic steroids



Regular eye examination and treatment
of any complications



Lagophthalmos surgery in all patients
with a eyelid gap of ≥ 6 mm



Lens extraction in any leprosy patients
who develop blinding cataract

WAYS OF APPROACH


Medical



Surgical



Social



Educational



vocational


THANK YOU


Leprosy - Part 2 - a presentation at www.eyenirvaan.com

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