Leprosy - Part 2 - a presentation at

LEPROSY

PART 2

Pradnya Gogate B. Optom,

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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 todamage 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 spontaneously and completely

Tx: 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 lepromatous keratitis and iris pearls

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 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)


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


Medical

Surgical

Social

Educational

vocational

WAYS OF APPROACH


THANK YOU


Leprosy - Part 2 - a presentation at

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