Ocular Manifestations of Leprosy - EYE

Ocular Manifestations of Leprosy - EYE

1. OCULAR MANIFESTATIONS OF LEPROSY Dr Kalpita Gumaste Dept of Ophthalmology KIMS , Hubli

2. INTRODUCTION The stigma of leprosy continues to persist globally as a significant deterrent to patients seeking good eye care. Apart from learning to recognize the early signs and symptoms of ocular complications in leprosy patients ,a key component for the training of health care workers in this field is gaining a sense of responsibility to facilitate early eye care access to ophthalmologists and physicians for their patients. OCULAR COMPLICATIONS occur before and during MDT and they can continue to occur even after MDT completion in bacteriologically cured patients

3. FACE Bells palsy : sudden, U/L, LMN type with complete paralysis and complete recovery in 70%patients without any treatment Facial palsy due to leprosy : usually gradual , can be B/L and almost never complete (only some parts involved ) Hypopigmented, hypaesthesic skin patches

4. Eyebrows Loss of eyebrows- superciliary madarosis Loss of eyelashes-ciliary madarosis LL> TT , one of the earliest and most characteristic sign of leprosy The condition usually starts laterally, affecting the outer two thirds of the eyebrow, and moving medially and symmetrically (lateral is cooler) Destroys hair roots

5. ECTROPION: The eversion of the eyelid margins is termed ectropion . It is common in the lower lid of patients presenting with lagophthalmos. The lower lid falls away from the globe and makes the tear film unstable and causes tearing. exposed cornea dry eye Treatmen t: lubricating eyedrops and surgical correction ENTROPION: The inversion of the eyelid margin rubbing of lashes against the cornea resulting in superficial abrasions, which cause pain only if corneal sensation is intact The integrity of the corneal surface is threatened, entropion requires corrective surgery. Misdirected lashes abrading the cornea require epilation. Not For Cosmetic Purpose

6. LAGOPHTHALMOS Lagophthalmos is the inability to close the eyelids normally . The lower lid is usually the most affected. The risk factors for lagophthalmos in leprosy are: a) Skin patch over the zygomatic area (depigmented, anesthetic, or erythematous) b) Initial months of MDT(type 1 lepra reaction) c) Borderline forms of leprosy d) Grade 2 deformities in hands and feet Can occur before during and after MDT Lagophthalmos is not a cosmetic deformity , along with decreased corneal sensation, can lead dry eye exposure keratitis ulceration and opacification of cornea. A decreased blink rate is usually evident in these patients. Lagophthalmos can also occur as a result of Bell’s palsy (distinguished)

7. Orbicularis oculi muscle strength Measurement of lagophthalmos

8. TREATMENT Blinking exercises : strengthens spared muscle fibers orbicularis oculi Tear substitutes : lubricating eyedrops and long-acting lubricant ointment at night. The exposed ocular surface drying( to keep cornea moist and protected ) Protecting the exposed cornea: To reduce fluid evaporation from the ocular surface. 1. Wear goggles during the day. 2. Cover the eyes at night with a clean piece of cloth, cross taping or using shield

9. Surgery may be required for Lagophthalmos if it becomes established >6 months duration(late) or if corneal complications develop Tarsorrhaphy Recession of the upper eyelid retractors ( levator and Müller’s muscles) Temporalis muscle transfer A temporary tarsorrhaphy may be performed as shown in (A) and (B). A permanent lateral tarsorrhaphy (C)

10. Chronic dacryocystitis (inflammation and obstruction of the nasolacrimal duct) Orbicularis Oculi weakness impairs the lacrimal drainage pump mechanism. This impairment predisposes the eye to infection , which poses a threat by harboring infectious bacteria that can repeatedly infect a corneal ulcer and prevent healing. REGURGITATION TEST The patency of the nasolacrimal duct should be checked by syringing, if it is blocked, surgery is required DACROCYSTITIS

11. REDUCED CORNEAL SENSATION Hallmark of leprosy Reduced corneal sensation typically occurs in lepromatous leprosy.

12. CORNEAL ULCER In leprosy ,Cornea extremely vulnerable to injury due to reduced sensations and secondary infection in exposure keratitis (lower half), resulting in opacification of the cornea. Not caused by M. leprae In both cases, risk factors include lagophthalmos , impaired corneal sensation, nasolacrimal infection and infected ulcers on the hand.

13. Etiology : bacterial and fungal( vegetative matter) Clinical features Management Corneal ulcers are medical emergencies and need immediate and rigorous treatment . Corneal scrapings should be taken carefully from the edge of the ulce r and sent for microbiological testing. Correcting of risk factors BACTERIAL : Topical broad-spectrum antibiotic drops (fluoroquinolones) cycloplegics e/d ,e/o and oral NSAIDs FUNGAL : topical broad spectrum antifungal (natamycin e/d) and oral ketaconazole Complications No steroids

14. Scleritis Inflammation of sclera in LL Scleritis presents as a deep red painful and tender eye (nodular, patchy or necrotising) It requires aggressive treatment with steroid drops , and oral NSAIDS If left untreated or repeated episodes thinning of the sclera staphyloma A Inflammation of episcleral tissue in LL (independent > type 2 reaction) Nodular or localized patch with mild soreness/persist without discomfort Clears without treatment more often, topical steroids and oral NSAIDs Episcleritis

15. Uveitis / Iridocyclitis Uveitis or iridocyclitis , an inflammation of the iris and ciliary body, One of the most common causes of blindness in MB leprosy patients. Leprosy is one of the imp causes of infectious iridocyclitis The iris and ciliary body ,cooler than core body temperature. favorable sites for the growth of leprosy bacilli, Inducing a host respons , leading to a GRANULOMATOUS UVEITIS (more often without ENL reactions ) Histopathological evidence shows that Mycobacterium leprae can reside in the eye long after MDT. Furthermore, sub-clinical iridocyclitis is common

16. Acute Iridocyclitis borderline lepromatous leprosy, Chronic lepromatous leprosy. Paucibacillary leprosy and tuberculoid leprosy rarely account for iridocyclitis . ACUTE symptoms :decreased vision, pain photophobia and watering. Signs : Circumcorneal congestion Sluggishly reacting small pupils. Cells and flare in AC (hypopyon in severe) Mutton fat keratic precipitates and IOP Koeppe’s nodules and iris pearls CHRONIC L ow-grade iridocyclitis, ciliary Body atrophy may change the Aqueous dynamics, causing low Intraocular pressure

17. If left untreated or inadequately treated long-lasting sequelae Peripheral anterior synechiae (or adhesions) and posterior synechiae Both of these conditions may increase the intraocular pressure, causing secondary glaucoma. Iris atrophy and polycoria Secondary cataract Chronic iridocyclitis may follow episodes of acute iridocyclitis . It can also occur as a sub-clinical inflammation TREATMENT Topical Cycloplegics Topical Steroids Oral/sub- conjunctival steroid Ocular hypotensive medication Oral NSAIDs Immunosuppressive drugs

18. CATARACT A cataract is the most common cause of visual impairment and blindness in leprosy patients. Most often, it is age-related; less often, it may be due to prolonged steroid inflammation or chronic iridocyclitis, which is mostly sub-clinical. Surgical treatment

19. Glaucoma Glaucoma may occur due to treatment with steroids or due to uveitis.(secondary) Intraocular pressure should be monitored by an ophthalmologist in patients with iridocyclitis or on prolonged steroid therapy. This monitoring is important to prevent irreversible loss of vision

20. OCULAR DEFORMITY CLASSIFICATION IN LEPROSY

21. Conclusion: Most of the blindness and impaired vision resulting from leprosy is preventable. It is important to remember that patients, especially those who are cured bacteriologically, remain at risk of leprosy-related ocular complications before, during, and after MDT. It is also important to realize that visual disability and blindness are still strongly associated with stigma, ignorance, lower socioeconomic status, and neglect. Therefore, it is the responsibility of the care givers in leprosy, including health workers, physicians, and ophthalmologists to work together with patients to help lower all barriers to accessible eye care.

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