Ocular leproma in patients under treatment indicates persistent infection and probable dapsone resistance requiring change in the antileprotic management.

1. Dr .Dhivya.N
Dr.Divya.K
Dr.Sundar.D
PSG Institute of Medical Sciences and Research
FP No:145

2. Background
 Leprosy (Hansen's disease or Hanseniasis) is one of the systemic
diseases which can give rise to a plethora of features in the eye. The
incidence of ocular involvement in leprosy has been variously quoted as
51% to 69%.
 Though iris nodules and lepra pearls are characteristics of the ocular
manifestation of this disease,ocular leproma can manifest in patients under
treatment indicating persisting infection signifying dapsone resistance.we
report a case of ocular leproma in an adult female on multi drug therapy for
leprosy.

3. Case report
 A 38-year-old female who is a known case of boderline lepromatous
leprosy on treatment with multi bacillary -multidrug therapy(MB-MDT)
presented to us complaining of watering in the left eye (OD) for 1 year,
redness and diminution of vision for both distant and near for 1
month,bilateral headache and eye pain of 15-day duration.
 On general physical examination, she had characteristic leonine facies
with madarosis, depressed nasal bridge and broadening of the nose. She also
had dry scaly patches of the skin over the extremities and around the eyes.

4. Case report
 On ocular examination, her best corrected visual acuity was 6/12 in the
right eye(RE) and 6/36 in the left eye(LE). A nodular scleral mass lesion
was noted in the left eye, adjacent to the limbus, around 3 × 2 mm in size,
extending into the anterior chamber.
 Other findings in the same eye were the presence of circumciliary
congestion, cornea showed epithelial defect with stromal thinning and deep
vascularisation adjacent the scleral nodule with fine keratic precipitates, 2+
grade flare and cells.
 Pupils were 4mm,sluggishly reacting to reacting to light,with clear
lens and normal fundus.The intraocular pressure was low 10mmhg and 8
mmhg in RE and LE respectively.

5. Clinical photograph of the left eye showing scleral granuloma.

6. Case report
 A clinical diagnosis of the left eye granulomatous sclerouveitis with
interstitial keratitis secondary to boderline lepromatous leprosy was
made.Excision biopsy of nodular lesion was done and histopathological
reports showed conjuctival granulomatous inflammation probably due to
Hansen’s disease.Stain for acid fast bacilli(AFB) was negative.
 She was started on topical and systemic steroids and cycloplegics for the
ocular manifestations. Following treatment, her vision improved both eyes,
the nodular lesion resolving and the keratic precipitates had also reduced.
One month after starting the treatment, the patient was asymptomatic and
the eyes were quiet with the lesions reduced in size.steroids were tapered.

7. Clinical photograph of left eye showing resolution of granuloma post
treatment.

8. Case report
 After 1 month she presented with ulcers over the left hand and lip with
increasing in size of lesions and signs of facial nerve palsy. Dermatologist
opinion was sought.Possibility of dapsone resistance was suspected .She
was started on monthly once Rifampicin ,oflaxacin and minocycline(ROM)
therapy in addition to conventional MDT therapy.Patient improved
symptomatically with single dose of ROM Therapy.
 She was advised to continue the multidrug therapy along with the pulsed
ROM regimen for two years.At last follow up, patient presented with healed
lesions in both eyes and extremities.

9. Discussion
 Ocular involvement in leprosy is either due to primary infection of the
eye or secondary neural involvement. Lagophthalmos, ectropion,trichiasis,
conjunctival leproma, prominent corneal nerves, impaired corneal sensation,
exposure keratitis , corneal opacities, interstitial keratitis ,scleritis and
chronic uveitis are commonly noted clinical signs in ocular leprosy.
 Three different types of uveal involvement have been described:
(a) typical acute granulomatous iridocyclitis with keratic precipitates,
posterior synechiae and hypopyon with or without conjunctival leproma;
(b)neuroparalytic uveitis in the form of dilator muscle atrophy;and
(c) presence of iris pearls and lepra pearls with complicated cataract.
 Ocular hypotony in conjunction with hypotension has been reported in
patients under therapy for multibacillary leprosy.

10. Discussion
 Ocular features noted in our patient were sclerouveal granuloma
(leproma) with anterior uveitis in the left eye.Cornea involvement in the
form of reduced corneal sensation and interstitial keratitis with stromal
thinnning and pannus formation was present. Lagophthalmos is another
common ocular finding was also present in this case.
 Ocular leproma is a granulomatous nodule in the eye, usually near the
limbus or deep in the iris and ciliary body. Lepromas are usually yellowish
and fleshy and may resemble a conjunctival tumor. Unlike scleritis, a
leproma is completely painless.Ocular lepromas occur in MB patients
treated irregularly by dapsone monotherapy and are usually a sign of
dapsone resistance. Treatment negligence could be the cause for leproma in
our patient.

11. Discussion
 Pulsed ROM(rifampicin 600mg,ofloxacin 400mg and minocycline 100mg-
monthly)for 24 months has been advocated in mutibacillary(MB) leprosy
patients who cannot be given the MDT due to poor response or
hypersensitivityor other reasons .
 ROM as effective MDT conferring similar clinical,bacteriological,
histological improvements without increased rates of lepra reactions.
 Our patient also showed marked clinical improvement with resolution of the
granuloma on addition of ROM regimen to the conventional MDT.she was
advised to continue pulsed ROM for 2 years.

12. Conclusion
 Granulomatous ocular leproma can manifest secondary to persistent
infection during therapy signifying resistance to dapsone therapy,
irregular anti-leprotic therapy or its discontinuation. A high index of
suspicion among clinicians of dapsone resistance in patients under
treatment and prompt institution of alternate drug therapy is essential to
prevent leprosy related blindess.