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
1. 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
3. Granulomatous infiltration of the CN 5 & 7
4. 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
Through 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.
11.
12. 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……Epiphora.
14. 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 Corneal abrasions and ulcers
Corneal opacities
• Eyebrows
Thinning of eyebrows (lateral half)/ complete loss of eyebrows ie
Superciliary madarosis due to deep infiltration.
15. • 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)
16. 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
17. 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
18. • 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)
19. Diagnosis
• Based on morphological characteristics
• Lepra bacilli demonstrated from lacrimal fluid
and or conjunctival scraping is supplementary
20. Management
• Frequent washing with clean water (boiled &
then cooled)
• Local antibiotics
• Rest to the eye
• Refer if does not improve in 48 hours
21. CORNEA
• Frequently affected
• Initially asymptomatic but later severe loss of
vision
1.Earliest sign:-Beaded appearance of nerves
2.Later :- Supf 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
22. • 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.
24. • 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
25. 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
26. 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.
27.
28. Signs & Symptoms
• Deep pain & Localised erythema - Sclera
• 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
29. 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.
30. 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
31. 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
32. 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
33. 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
34. 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
35. 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
36. • 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
37. 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
38. • IOT- with acetazolamide 250 mg Qid/Timolol
• Steroid induced glaucoma if steroids > 3 wks
• Resolves 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
39. Iridocyclitis
• Less common in India compared to other
endemic nations
• Complication:- Cataract,Corneal degeneration
Occlusio pupillae& Iris atrophy,
40. Iris Atrophy
• The iris crypts flatten & the stroma thins
• Deep pigmented layer of the iris become
visible
• Full thickness iris holes in stroma
• Pupil becomes pin-point
• Patient will become 'night blind'
41.
42. 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.
43. 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/ Normal ageing process.
• Can have surgery with iol implantation
• 20% cataracts are complicated –Difficult to manage
45. 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
46. Nerve involvement
• In LL cases involvement of both 5and 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 Tuberculoid types, the involvement of both
nerves is usually U/L & depends on location of
the skin lesion.
47. 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’.
48. 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
49. 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
50. • Weakness 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
51. 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
52. • 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
53.
54. • 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
55. • 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
57. • 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.
58. 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
59. Clofazimine induced crystalline
keratopathy
• Side effect of long-standing cumulative drug
dose.
• Crystalline deposits are scattered diffusely
over the peripheral cornea in interpalpebral
region of both eye
60. History –Points to be noted
• Pain , 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
61. Eye examination
• All eye problems :-May not be due to leprosy
1. Spontaneous blinking:- Pain stimulates blinking(5th
nerve), Symmetry and completeness of blinking(7th
nerve)
2. Ask the pt to close the eyes as in sleeping and with
effort
3. Epiphora/not
4. Check out for various signs
5. Symmetry and reaction to light:- pupils
6. Tenderness on palpation:-Iridocyclitis/scleritis
7. Visual acuity measurment
8. IOP measurement
62. 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.
63. 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
64. 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
65. Self care
• Principles of eye care:
1. Protection of eyes from dryness, sun light
and dust
2. Detection of signs of irritation and injury in
early stages
3. Detection of signs of involvement of ocular
tissue in early stages
66. “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:
• Wash 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
67. • 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
68. 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.
