Post on 12-Jul-2015
LEPROSY
PART 2
Pradnya Gogate B. Optom,
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LEPROSY : OPHTHALMIC STRUCTURES INVOLVED Cornea Sclera Iris Ciliary body Lens
Ocular adnexa
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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)
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LAGOPHTHALMOS
Due todamage to the facial
nerve late result of
infiltration and secondary atrophy of the facial nerve and orbicularis muscle
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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
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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
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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
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EXPOSURE KERATITIS
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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
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TREATMENT
antibiotic eye ointment
an eye shield
An exposure ulcer is a definite indication for eyelid surgery.
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CORNEAL HYPOAESTHESIA
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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).
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TREATMENT
no cure for corneal hypoaesthesia
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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
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ACUTE IRITIS
only in MB patients evidence of ENL reaction inside the eye recur at any time
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SIGNS AND SYMPTOMS
redness, pain, photophobia, reduced visual acuity
haziness of the cornea and secondary glaucoma
unilateral or bilateral
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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
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SIGNS OF MB LEPROSY
(temporal) madarosis of eyebrows
early collapse of the nose
nodules on the ears
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TYPE 2 REACTION: ACUTE EPISCLERITIS AND SCLERITIS
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EPISCLERITIS
is a transient condition
often as a precursor of a systemic ENL reaction
resolves spontaneously and completely
Tx: topical steroids
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SCLERITIS
bilateral in combination with a
severe ENL reaction may be nodular or diffuse
and occurs with or without acute iritis
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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
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MASSIVE BACILLARY INFILTRATION: PERI-ORBITAL COMPLICATIONS
Abnormalities occur around the eye due to infiltration by bacilli and secondary atrophy
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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)
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LESIONS WITHIN THE EYE
Ocular leproma
Superficial lepromatous keratitis and iris pearls
Iris atrophy and pinpoint pupil Chronic iritis Atrophy of the ciliary body
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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 PEARLSPUNCTATE 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)
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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
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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'.
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TREATMENT
dilate the pupil with phenylephrine 2.5 - 5%
sector iridectomy
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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
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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
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LEPROSY AND CATARACT
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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
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Medical
Surgical
Social
Educational
vocational
WAYS OF APPROACH
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THANK YOU
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