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

6. 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

7. 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

8. 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
• Treatment: 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.

9. 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)

10. Orbicularis oculi muscle strength
Measurement of lagophthalmos

11. 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

12. • 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)

13. • 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

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

15. 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.

16. • 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 ulcer 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

17. 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

18. 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

19. • 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 Low-grade iridocyclitis, ciliary
Body atrophy may change the
Aqueous dynamics, causing low
Intraocular pressure

20. If left untreated or inadequately treated long-lasting sequelae
1) Peripheral anterior synechiae (or adhesions) and posterior synechiae Both of these
conditions may increase the intraocular pressure, causing secondary glaucoma.
2) Iris atrophy and polycoria
3) Secondary cataract
4) 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

21. 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

22. 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

23. OCULAR DEFORMITY CLASSIFICATION IN LEPROSY

24. 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.

25. THANK YOU