Eye in leprosy

Eye in Leprosy

1. Eye in leprosy Anand

2. Its very difficult for a blind man to carry out his routine activities But it’s a tragic situation when one blind man could not even rely on his sensation of hands and feet for doing his daily activities Preservation of Vision is very important in Persons affected with Leprosy

3. Initial stages:-ocular lesions may be visually asymptomatic This explains the importance of routine eye care in leprosy

4. Ocular involvement in leprosy..70-75% Severe ocular symptoms-10-50 % pts Blindness - 05 % of patients. Eye ball & adnexa involved MDT doesn’t guarantee withholding of ocular complications

5. Objectives Modes of infection Parts of the eye involved Complications History & Examination of the eye Management

6. Modes of infection Direct invasion of M.leprae in eyes & surrounding tissues 2. Inflammatory lesions – - Sensitization of ocular tissue to M. leprae antigens - Formation of intravascular immune complexes Granulomatous infiltration of the CN 5 & 7 Granulomatous infiltration of contiguous structures – eyebrows, eyelids, lid glands, lacrimal drainage system Secondary infections may also play a role.

7. Direct involvement of bacilli- through blood stream . Ant compartment preferred 3 ⁰ < Post compartment M.leprae enters the eyes T hrough Bvs of the ciliary body Small autonomic nerves Invade the iris Where they hide from the effect of treatment

8. Tuberculoid spectrum Is affected only when there is an inflammatory patch over the branches of the facial nerve Usually U/L Usually M.leprae wont invade the eye/Even if there is an invasion its not clinically significant Lepromatous spectrum High risk for leprosy complications Symmetrical and slower than in tuberculoid pts

9. Corneal invasion via myelinated corneal nerves Iris & ciliary body via blood stream Conjunctiva & sclera from bloodstream/extension of ciliary body lesions

10. Eyelids Loose skinfold in the upper eyelids ( blepharochalasis ) Thickening of eyelids & shiny nodules –diffuse infiltration leads to loss of skin elasticity Thin floppy upper eyelid occurring due to atrophy of the tarsal plate & pre-tarsal muscles rendering eyelid less effective in spreading the tears and cleaning of cornea Entropion & Ectropion Macule/nodule on the eyelids Weakness of eyelid movement Lagophthalmos ….. ectropion and sagging of the medial side of the eyelid margin…… E piphora .

11. Blepharocalasis Sx :-Plastic repair & Brow lift

12. Eye lashes Loss of eyelashes is not common Scanty, small & thin/ loss of eye lashes due to atrophy of the tissue supporting hair follicles ( ciliary madarosis ) Trichiasis In turning of eye lashes rubbing against bulbar conjunctiva & Cornea C orneal abrasions and ulcers C orneal opacities Eyebrows Thinning of eyebrows (lateral half)/ complete loss of eyebrows ie Superciliary madarosis due to deep infiltration.

13. Meibomian glands: Atrophy Dryness of eye due to poor quality tears Corneal transparency and nutrition hampered Lepromatous spectrum-More dry eye Chronic Dacroadenitis will cause Keratoconunctivitis sicca (Severe dry eye)

14. Nasolacrimal Apparatus Dacyrocystitis : Bacillary infiltration in the nasal mucosa. Nasal ulceration/ scarring or nasal collapse causes stagnation of secretions In case of chronic dacryocystitis redness &/or swelling and tenderness over lacrimal sac (between eye and nose) can be noticed Sx :- Dacryocystorhinostomy Hot compresses and systemic antibiotics:-Med Rx

15. Conjunctiva Mode of Infiltratrion :- by 2 ways Direct blood borne deposits of bacilli Extension of ciliary body lepromata through the connecting vascular scleral channels near the limbus The lateral conjunctiva near the cornea in the interpalpebral fissure is the coolest part of the surface of the eye

16. Continuous exposure to dust & heat leads to chronic conjunctivitis Photophobia,lacrimation,redness and irritation…Mild chronic conjunctivitis Lepromatous nodules - Smooth ,reddish and non tender A mild conjunctival inflammation with edema & dilated blood vessels may be seen. Pterygium consisting of macrophages containing M. leprae has been reported Episcleral nodules….cardinal sign(Deep conj tissue involvement)

17. Diagnosis Based on morphological characteristics Lepra bacilli demonstrated from lacrimal fluid and or conjunctival scraping is supplementary

18. Management Frequent washing with clean water (boiled & then cooled) Local antibiotics Rest to the eye Refer if does not improve in 48 hours

19. CORNEA Frequently affected Initially asymptomatic but later severe loss of vision 1.Earliest sign :-Beaded appearance of nerves 2.Later :- S upf punctate keratitis ( Localised,discrete,milky,chalk depsoits on cornea) 3 . Pannus - extends around the entire corneal circumference 4.Interstitial keratitis finally.Which extends right around the limbus

20. Superficial punctate keratitis: on the cornea especially upper part of the cornea . Pannus :- Circum corneal in Leprosy while in upper part of cornea in Trachoma Interstitial keratitis : The granuloma may infiltrate deeper into the stroma & seriously affect vision. A grayish patch is seen extending from limbus towards the center of the cornea.

21. SPK Pannus Interstitial Keratitis

22. Exposure Keratitis: Absence of blinking & lagophthalmos predisposes eye to injuries, foreign bodies, insect bite & constant exposure of cornea to heat, dust & wind. Corneal ulcer : Constant sun exposure , injury by foreign body, trichiasis,secondary bacterial invasion forms corneal ulcer Corneal ulcer is an emergency. Do not use corticosteroids. Refer immediately” “Atropine causes photophobia; use of goggles help reduce photophobia” Corneal Opacity : Corneal ulcer may heal by scarring Perforation is uncommon until sec bact /viral infection supervenes

23. Scleritis Seldom affected alone MC assoc with RA Affected as a part of SPK,iritis,iridocyclitis Less severe form:- Episcleritis Scleritis occurs in pts with untreated lepromatous spectrum where there is associated iridocyclitis Localised erythema and tenderness of sclera Nodules upto 5 mm in diameter at the limbus

24. Episcleritis Episcleritis : Benign inflammation of the Tenon‟s capsule overlying Sclera is called Episcleritis . Hard , dirty yellow nodule, most commonly on upper outer quadrant is seen with or without any symptom . Sometimes, nodules may become inflamed causing epiphora (overflowing of tears), pain & general ocular discomfort . It is a superficial lesion and rarely has long-term complications.

25. Signs & Symptoms Deep pain & Localised erythema - S clera Repeated episodes …..scleral thinning & results in bulging of uveal tissues through the sclera Staphyloma :-Pigmented uveal tissues can be seen through the thinned out sclera Ask the patient to look down: Palpate above the upper tarsal plate through the closed eye lids to elicit tenderness in the Red eye. Tmt :-Steroid eyedrops Systemic or subconjunctival steroids

26. IRIS &CILIARY BODY Iris & ciliary body-Heavily infected via hematogenous route The sphincter muscles will undergo destruction Impairment of autonomic nerves supplying the iris and ciliary body cause early dysfunction of the pupillary muscles Fixed non reactive pupil Destruction of the tissues of the iris and ciliary body causes atrophy and shrinkage of the globe known as pthisis bulbi .

27. Nodular lepromata Multiple yellowish nodules of varying sizes seen over the iris. Occur infrequently Miliary lepromata Tiny white spots seen in the iris Due to aggregation of leprae bacilli Found immediately adjoining the papillary margin Pathognomonic of leprosy

28. Acute Diffuse Plastic Iridocyclitis Precipitated by dapsone therapy as a part of accompaniment of ENL Acute in onset,pain,redness,photophobia,and failing vision. CCC and a nonreacting ,small fixed pupil are the diagnostic signs

29. Chronic plastic iridocyclitis Insidious onset and chronicity are the hallmarks Keratotic precipitates in the back of the cornea and exudates in the ant chamber and on anterior lens capsules. May be an occlusion of the pupils Small , irregular,non reacting to light or accomodation (d/t Multiple post synechae may be formed) Finally- cataract,vitrous opacities,RD,atrophy of eyeball-phthisis bulbi

30. Iridocyclitis MCC of irreversible blindness in leprosy Aka irits /uveitis Iridocyclitis = Iritis + Ciliary body inflammation Iritis never exists in isolation Insidious onset & chronicity are the hallmarks No extensive studies on reactions occuring in eye as its difficult to get a biopsy of the eye done

31. Iris & ciliary body Silent:-No redness & minimum ocular discomfort “ Blindness” if diagnosis is missed Iris pearls - Small,round,white & shiny lepromata on or near pupillary margin(like chalk particles) It’s the first sign of pupillary invasion Early lesions-with a slit lamp & Larger lesions-even with naked eye Infiltration assumed to be blood borne Highly vascular ,Hence can get heavily infiltrated

32. Signs and symptoms Ciliary flush :-Erythema at the limbus 360 degrees around the cornea . Also seen in corneal ds. Therefore if corneal ds are ruled out then the diagnosis must be iridocyclitis Decreased vision Photophobia Ocular tenderness,Tearing pain Eyelid swelling

33. Iot can be higher or lower than the fellow eye. Slit lamp examn :- Keratic precipitates on the posterior surface of the cornea Pupil:-smaller & irregular Posterior synechiae may be seen Iris atrophy in chronic cases Eccentric pupil due to scarring and contraction of the iris stroma

34. Treatment Clofazamine -Both antibacterial & antiinflammatory Atropine:-Puts iris and CB to rest & rapid healing Elimination of ciliary muscle spasms:- Pt is more comfortable In the absence of corneal ulcers - Topical sterods (prednisolone 0.5%) applied 4-6 times/d Steroid drops during day and oint during night Dose of the steroid can be gradually tapered Oral prednisolone 60 mg/d for severe/resistant iridocyclitis Subconjunctival steroid injection also been tried

35. IOT- with acetazolamide 250 mg Qid / Timolol S teroid induced glaucoma if steroids > 3 wks R esolves spontaneously on discontinuation of steroid tmt C.S application should be gradually withdrawn Mydriatics should similarly be administered 2 or 3 times weekly for 2-3 weeks after the initial attack has subsided. If coincidental infection is suspected, give a mydriatic together with an antibiotic for the infection for 2 days before introducing topical corticosteroids Several applications daily may be needed for a prolonged period of time

36. Iridocyclitis Less common in India compared to other endemic nations Complication:- Cataract,Corneal degeneration Occlusio pupillae & Iris atrophy,

37. Iris Atrophy The iris crypts flatten & the stroma thins Deep pigmented layer of the iris become visible F ull thickness iris holes in stroma Pupil becomes pin-point Patient will become 'night blind'

38. Glaucoma Low prevalence Aqueous humor dynamics:-Altered Topical steroid drops –More chance of glaucoma Digital examination:-Extremely inaccurate Digital tonometry : For this, ask the patient to look down Placing 2 index fingers on the lid skin above the tarsal plate of upper eye lid Will do fluctuation &Compare with the other eye.

39. Cataract Cataract occurs due to intraocular invasion 3x increased risk in MBL patients As a complication of chronic iridocyclitis Steroids….. Subcapsular cataract Any other causes/ N ormal ageing process . Can have surgery with iol implantation 20% cataracts are complicated – Difficult to manage

40. Post segment Chorid,retina -nodular lesions similar to iris pearls Very rare in very advanced cases

41. Lacrimal drainage disorders Lower eyelid tone is lost Decreased blinking rate/Poor drainage Ectropion :- Eyelid & lacrimal punctum are displaced anteriorly Eyelid is not in normal contact with the eye Hence the tears wont flow into the punctum Finally epiphora occurs Rx:-Eyelid surgery can give a partial relief

42. Nerve involvement In LL cases involvement of both 5 and 7 cranial nerves is B/L but total paralysis is rare . In Borderline leprosy undergoing upgrading reactions, B/L & fairly complete involvement of the 7 nerve is seen . In T uberculoid types, the involvement of both nerves is usually U/L & depends on location of the skin lesion.

43. CN 5 (Trigeminal nerve)paresis Ophthalmic nerve:- Cornea,conjunctiva & ocular adnexa Loss of corneal sensation and affects eye blinking Normal blinking:-16-20/min Infrequent/irregular/absent blinking:-Noted Corneal sensation can be tested Absence of blinking, leads to dryness of the corneal epithelium making it prone to ulceration. This is known as ‘exposure keratitis’.

44. Facial nerve paresis Lagophthalmos / /sagging of lower eyelid ( Ectropion ): Lower eyelid ectropion : The involvement of Zygomatic and temporal branch of facial nerve causes weakness of orbicularis oculi muscles resulting in incomplete closure of the eye . Lower eyelid is affected first and shows greater degree of paralysis Involvement of marginal fibres of Orbicularis Oculi causes ectropion and inadequate drainage Leads to epiphora

45. Lagophthalmos Facial nerve damage Lagophthalmos ….B/L in LL and UL in TT Lower eyelid affected due to the involvement of facial nerve – Zygomatic branch In LL….infiltration of nerve & muscle

46. W eakness of the muscle results in widening of the palpebral fissure with out any other disability. A gap of 1.0 mm or less between the two eyelids is considered normal Paresis of strong peripheral preorbital part of the orbicularis oculi muscle is not common and this can be used in deliberate closure of eye by force

47. 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

48. Look for the gap between the two eyelids. It is considered normal if there is no gap or gap of less than 1mm is present. In leprosy this gap is due to sagging of lower eyelid in the early stages. (DD Bell‟s palsy) To assess early weakness of orbicularis oculi muscle, ask the person to close the eye tightly and try to pull the lower lid down to see whether the patient is able to keep his eyes closed against resistance Eye muscle weakness…reversible if detected early Otherwise it’s a permanent change

49. 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

50. 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

51. Surgery Static procedures:- Tarsorrhaphies ( Medial,temporal,lateral ) Dynamic Procedures:- Temporalis Muscle transfer- Pt can blink but Not spontaneously Above two are done only if the corneal sensations are intact If not:-Lid closure

52. Even after MDT , M.leprae may persist inside Iris macrophages Fibrosed nerves Even when slit skin smear shows negative result the bacteria may persist within eye 24% of patients had ongoing eye problems after completion of MDT Patients with keratitis, posterior synechia , and cataract should be subjected to the particularly active and regular follow-up The realization of the guidelines covered by the Vision 2020 Programme can contribute to the prevention of blindness in leprosy.

53. Persons with high risk of ocular lesions Skin lesion on face – PBL with/without Type I Reaction In untreated MBL of long duration – B/L involvment Present or past Type 2 reaction Present or past Type 1 reaction & lagophthalmos Present or past ocular pathology

54. Clofazimine induced crystalline keratopathy S ide effect of long-standing cumulative drug dose. Crystalline deposits are scattered diffusely over the peripheral cornea in interpalpebral region of both eye

55. History –Points to be noted P ain , blurring of vision ,photophobia Past H/O Red eye & any tmt taken for it Past H/o any surgery of the eye Must look for blinking of the eyes without the knowledge of patient

56. Eye examination All eye problems :-May not be due to leprosy Spontaneous blinking:- Pain stimulates blinking(5 th nerve), Symmetry and completeness of blinking(7 th nerve) Ask the pt to close the eyes as in sleeping and with effort Epiphora /not Check out for various signs Symmetry and reaction to light:- pupils Tenderness on palpation:- Iridocyclitis / scleritis Visual acuity measurment IOP measurement

57. Visual acuity If the person cannot read the top line of the chart, or count fingers at 6 meters, they are visually impaired and have grade 2 disability in that eye.

58. When to refer ??? Lagophthalmos with large lid gaps (> 6 mm and /or exposure keratitis). Acute red eyes Trichiasis , Ectropion , Entropion Poor Visual Acuity (VA < 6/60) or recent deterioration in vision. Cataract

59. PST(Potentially sight threatening lesions) Risk groups are :- Elderly >50 yrs Long H/o Leprosy & disability Initial Monotherapy treatment MB>PB Women>Men Coined in pre-MDT era by Dr.Lamba Corneal hypoaesthesia Lagophthalmos With/without corneal exposure leading to keratitis Complicated cataract Recurrent uveitis & Dry eye syndrome

60. Self care Principles of eye care: Protection of eyes from dryness, sun light and dust Detection of signs of irritation and injury in early stages Detection of signs of involvement of ocular tissue in early stages

61. “ Protect eyes from dryness, sun, dust and injury: Use of Sunglasses with side pieces / hat with broad rim during day Eye shields at night Never apply a bandage which may further damage the insensitive cornea Blink frequently/ “ Think-Blink” Keeping the eyes moist and clean: W ash eyes frequently with clean water/instill oil drops / sterile liquid paraffin to keep moist If normal facial muscles –to push their cheeks up or other facial muscles to close their eyes

62. If both facial muscles and lid are weak:-The person is taught to place their fingers at the outer corner of the eye and gently pull outwards and upwards until the eye closes and count till 10. Person must repeat the procedure throughout the day

63. Early detection of signs of irritation, injury and involvement of ocular tissue Daily inspection:- any redness of the eye /corneal injury/dust/ eyelashes touching the bulbar conjunctiva or cornea / foreign body / any other injury to the eye Teach person To inspect the eyes, with clean hands (Wash hands with clean water before touching the eyes). Use a mirror / take help of a friend –look for any redness Remove any spec of dirt using a clean and soft cloth, gently Epilate the eye lash touching cornea and report to eye specialist immediately To develop a habit to observe a few selected objects placed at a distance daily, for early detection of any deterioration in the vision.