Eye in leprosy Anand

• 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

• Initial stages:-ocular lesions may be visually asymptomatic

• This explains the importance of routine eye care in leprosy

• 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

Objectives

• Modes of infection

• Parts of the eye involved

• Complications

• History & Examination of the eye

• Management

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.

• 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

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

• Corneal invasion via myelinated corneal nerves

• Iris & ciliary body via blood stream

• Conjunctiva & sclera from bloodstream/extension of ciliary body lesions

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.

Blepharocalasis

Sx:-Plastic repair & Brow lift

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)

• TrichiasisIn turning of eye lashes rubbing against bulbar conjunctiva & Cornea Corneal abrasions and ulcers

Corneal opacities

• EyebrowsThinning of eyebrows (lateral half)/ complete loss of eyebrows ieSuperciliary madarosis due to deep infiltration.

• 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)

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

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

• 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 conjtissue involvement)

Diagnosis

• Based on morphological characteristics

• Lepra bacilli demonstrated from lacrimal fluid and or conjunctival scraping is supplementary

Management

• Frequent washing with clean water (boiled & then cooled)

• Local antibiotics

• Rest to the eye

• Refer if does not improve in 48 hours

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

• 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.

SPK Pannus Interstitial Keratitis

• Exposure Keratitis: Absence of blinking & lagophthalmospredisposes 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

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 lepromatousspectrum where there is associated iridocyclitis

• Localised erythema and tenderness of sclera

• Nodules upto 5 mm in diameter at the limbus

Episcleritis

• Episcleritis: Benign inflammation of the Tenon‟scapsule 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.

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

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 ciliarybody causes atrophy and shrinkage of the globe known as pthisis bulbi.

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

Acute Diffuse Plastic Iridocyclitis

• Precipitated by dapsone therapy as a part of accompaniment of ENL

• Acute in onset,pain,redness,photophobia,andfailing vision.

• CCC and a nonreacting ,small fixed pupil are the diagnostic signs

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

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

Iris & ciliary body

• Silent:-No redness & minimum ocular discomfort“Blindness” if diagnosis is missed

• Iris pearls-Small,round,white & shiny lepromataon 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

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,Tearingpain

Eyelid swelling

• 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

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

• 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

Iridocyclitis

• Less common in India compared to other endemic nations

• Complication:- Cataract,Corneal degeneration Occlusio pupillae& Iris atrophy,

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'

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.

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

Post segment

• Chorid,retina -nodular lesions similar to iris pearls

• Very rare in very advanced cases

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

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.

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’.

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

Lagophthalmos

• Facial nerve damage• Lagophthalmos….B/L

in LL and UL in TT• Lower eyelid affected

due to the involvement of facial nerve –Zygomaticbranch

• In LL….infiltration of nerve & muscle

• 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

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

• 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

• 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

• 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

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

• 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.

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

Clofazimine induced crystalline keratopathy

• Side effect of long-standing cumulative drug dose.

• Crystalline deposits are scattered diffusely over the peripheral cornea in interpalpebralregion of both eye

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

Eye examination

• All eye problems :-May not be due to leprosy1. 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

effort3. Epiphora/not4. Check out for various signs5. Symmetry and reaction to light:- pupils6. Tenderness on palpation:-Iridocyclitis/scleritis7. Visual acuity measurment8. IOP measurement

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.

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

PST(Potentially sight threatening lesions)

Risk groups are :-Elderly >50 yrsLong H/o Leprosy & disabilityInitial Monotherapy treatmentMB>PBWomen>Men

Coined in pre-MDT era by Dr.LambaCorneal hypoaesthesiaLagophthalmos With/without corneal exposure leading to keratitisComplicated cataractRecurrent uveitis & Dry eye syndrome

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

“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

• 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

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.