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Ocular manifestations of
leprosy
Dr. Pragnya Rao
PG – II year
Dept of Ophthalmology
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Introduction
Chronic granulomatous inflammation caused by the acid-fast bacillus Mycobacterium leprae
(discovered by Gerhard Hernick Armauer Hansen in Norway in 1873)
One of the oldest recorded infections affecting humanity (2000 BC)
Primarily affects superficial tissues
– Skin
– Peripheral nerves
Global Disease burden : 181,941 cases at the end of 2011
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Why to detect ocular leprosy ??
10 – 15% of patients with ocular leprosy end up in blindness
Prevalence of blindness due to leprosy - 4.7% in India
Early stages asymptomatic
Early detection & appropriate treatment is essential
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Modes of ocular involvement
Direct invasion of ocular tissue by bacilli
Lepra reaction
Involvement of nerves
– Trigeminal nerve : ↓corneal sensations
– Facial nerve : weakness of orbicularis oculi
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External structures
Eyebrows & Eyelashes:
Superciliary madarosis
loss of eyebrows (lateral half)
Ciliary madarosis
– Loss of eye lashes
Trichiasis
– In turning of eye lashes
– Rub against bulbar conjunctiva & Cornea.
– corneal abrasions and ulcers
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Eyelids
Thickening of lid margins : Tylosis
– diffuse infiltration of skin & eyelid structures
– loss of elasticity of skin
– heavy drooping of upper eyelid
Entropion: In-turning of eyelid margins
Ectropion: Outward turning of Lid margin
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Eyelid changes (contd..)
Macule/nodule on the eyelids
Atrophy of the tarsal plate & pre-tarsal muscles
Infiltration and atrophy of meibomian glands: dryness of eyes
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Lacrimal apparatus
Dacryocystitis:
– Blockage of Naso-lacrimal duct
– Due to bacillary infiltration in nasal mucosa /ulceration/ scarring
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Conjunctiva
Lepromatous nodule may appear on conjunctiva
Occurs with type II Lepra reaction – Erythema Nodosum Leprosum
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Cornea
Corneal inflammation
Involvement of nerves
1) Corneal beads
2)Neurotrophic keratitis
Neuroparalytic keratitis
Bacillary infiltration /Lepra Reaction
1) Superficial punctate keratitis
2) Interstitial Keratitis
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Secondary to Bacillary infiltration/Lepra reaction
Superficial punctate keratitis:
Mild irritation and watering
Miliary leproma : Punctate greyish superficial spots(aggregated bacilli)
Pannus formation
(Superficial vascularisation)
Treatment:
- Topical antibiotic drops
- Lubricants
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Interstitial keratitis:
Stromal infiltration extending from limbus to central cornea
Deep vascularization
Vision is severely affected
Cornea is thickened due to excessive
infiltration
Treatment :
- Topical steroids
- Cycloplegics
- Lubricants
- Keratoplasty in late stages
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Paresis / Paralysis of Facial nerve
Lower eyelid ectropion:
Involvement of Zygomatic and Temporal branch of Facial nerve
weakness of Orbicularis oculi
Lagophthalmos (paralytic)
Incomplete closure of eyelids
Causes exposure keratitis
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Neuroparalytic ulcer :
Occurs due to Lagophthalmos following VII nerve involvement
Symptoms:
– Dry eye symptoms
Signs:
– Epithelial punctate lesions & epithelial defect
– Inferior 1/3rd of cornea involved initially
– Stromal melting & Secondary infections
Treatment:
– Lubricating eyedrops
– Taping of eyelids
– Bandage contact lens
– Tarsorrhaphy
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Ocular lesions due to involvement of the nerves
Paresis of Trigeminal Nerve
Corneal beads -1st detectable sign
Neurotrophic keratitis:
Reduced / loss of corneal sensation
- Abnormal epithelial turnover &
- Reduced reflex tearing
Clinical features:
Red eye, Foreign body sensation , Blurred vision
Marked conjunctival congestion
Corneal edema
Epithelial defect/ulcer with rolled up edges
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Treatment -Lubricating eyedrops
-Bandage contact lens
-Tarsorrhaphy
Superficial punctate keratitis
Frank epithelial defect & ulcer
Stromal melting & Perforation
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Sclera
Episcleritis:
Benign inflammation of sub conjunctival ,Tenon’s & episcleral tissue overlying Sclera
Mild pain, redness, lacrimation and ocular discomfort
Hard, yellow nodule commonly on upper outer quadrant
Treatment :
– Lubricants
– Mild topical steroids (fluorometholone)
– Oral NSAIDs
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Scleritis
Inflammation of the sclera
Associated with iridocyclitis
Severe deep circum-orbital pain radiating back to temple
Deep red, tender scleral patch scleral thinning Ciliary Staphyloma
Globe perforation
Treatment : - Oral NSAIDs & steroids
- Topical steroids &Lubricant drops
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Iris & Ciliary body
Acute / Chronic inflammation can involve any part
of Uvea
Acute Iridocyclitis:
Part of ENL reaction (Type 2 lepra reaction)
Symptoms:
– Pain, photophobia, redness, Lacrimation,
– Blurring of vision
Signs:
– Circumcorneal congestion
– Corneal edema, fine keratic precipitates
– AC cells & flare
– Miotic , sluggishly reacting pupil
– Iris Pearls: Chalk particle like glistening lesions near pupillary margin
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Chronic Iridocyclitis:
Direct invasion of anterior uvea by bacilli
Symptoms: Dull pain in the eye
Signs:
– Mutton fat Keratic precipitates
– Iris pearls, Iris atrophy & nodules
– Pupil: miotic, non-reactive, irregular
– Posterior synechiae
– Complicated cataract
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Lens – Cataract
Common in cases of multi-bacillary leprosy with chronic uveitis
Occurs due to
Intraocular invasion by bacilli
Iridocyclitis
Steroids ( systemic/local)
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Intraocular pressure
IOP may be raised due to
Steroid induced (when used to treat lepra reactions)
Sequelae to repeated iridocyclitis – Secondary Glaucoma
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Posterior segment
1 in 20 cases of ocular leprosy
Believed to spread from ciliary body
Retinal Pearls
Discrete, circular, waxy
Occasionally pedunculated nodules
similar to iris pearls
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Chorioretinitis
- White, waxy, highly refractile deposits at ora serrata
- Retinal scarring & retinal vessels sheathing and fibrosis
Endophthalmitis
Panophthalmitis
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In a Nutshell..
Ocular leprosy is a severly incapacitating condition
Most of the cases of ocular leprosy are secondary to Lepra reactions
Ocular leprosy treatment includes MDT + Specific measures
About 20 % of leprosy patients on MDT develop ocular complications
– 11 % of them are vision threatening
Ophthalmological monitoring is required following initiation of MDT
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Thank you