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Ocular Leprosy Report

Update on Ocular Leprosy

Gordon J Johnson closed and leprosy workers are being MD FRCS FRCOphth phased out or re-deployed. Tamil Nadu is Professor and Director the first state in India in which leprosy con- International Centre for Eye Health trol has become fully integrated into the Institute of general health services; other countries are following the same pattern. Under these 11-43 Bath Street The faces of leprosy conditions there is a real danger that new London EC1V 9EL, UK Photos: Margreet Hogeweg cases will be missed, and disabilities will Numbers of People with Leprosy not be adequately dealt with. Therefore, 1. At time of diagnosis guidelines for the responsibilities and The setting in which the decision to The widespread use of Multiple Drug training of general health workers must treat will be made in India will be the Therapy (MDT) in leprosy control pro- be rapidly developed. The eye care pro- Primary Health Centre (PHC), under grammes has resulted in a great reduction gramme must also assume great responsi- the supervision of the PHC Medical in worldwide prevalence. There is a mixed bility. Officer (PHC MO). Each centre may picture from country to country, so that Some of the problems and opportunities only see 5–10 new patients a year, of there is still a high incidence of newly associated with integration of leprosy care whom only one may have lagophthal- diagnosed cases in some regions, for exam- into Primary Health Care were identified at mos. ple in northern Brazil and parts of India. At the Workshop. \ It was agreed that the eyes of all new the beginning of 2000 there were approxi- 1. A very large number of general workers patients should be examined at diagno- mately 640,000 cases registered for treat- will need training. For those already in sis – for visual acuity; for lagophthal- ment with MDT, and around 680, 000 had service, ophthalmic assistants may be mos, indicated by lid gap or corneal been newly detected in 1999.1 More than trained to do the training. For those exposure on ‘mild closure’, as in sleep; 10 million previous leprosy patients have Primary Health Care workers still in for a skin-patch around the eye or been released from treatment (RFT), and training, we must ensure that teaching cheek; and for . The visual acu- removed from registers. Many of them about eyes in leprosy is included. ity will be taken by any paramedic, and have disabilities or the potential to develop 2. General workers may not welcome yet the patient inspected by the PHC MO if disabilities. In countries such as China and more responsibilities. It will be neces- anything is found. The equipment South Korea, there are many elderly people sary to reduce the recommended tasks required is an E-chart, torch and ruler. with disabilities, some still living in lep- and technology to the minimum essen- The MO will assess vision: < 6/60 in rosy settlements or colonies. In West tials. either eye, lagophthalmos or a red eye, Bengal alone there are 64 such settlements. 3. Leprosy patients may be unwilling to and decide whether referral to an Ophthalmologist (Asia) or Ophthalmic Leprosy and the Eye accept these new workers and services. They may not have a choice; counsell- Clinical Officer (Africa) is indicated. A It is recognized that there is more blindness ing at the time of change-over may help. lid gap >5mm is referred for surgery. If in multibacillary (MB) patients with lep- 4. Organisational support will be needed the lid gap is 5mm or less and there is a rosy than in other people of the same age. at national, regional and district levels. recent history, systemic prednisolone This has been confirmed in a longitudinal In sub-Saharan Africa, prevention of should be started; if not recent, the study of leprosy (LOSOL) in India (301 blindness due to leprosy will, in prac- patient is counselled in self-care. When patients recruited over 7 years) and the tice, only survive within the general eye a skin patch is pale, the patient receives Philippines (289 patients). Severe visual care programme. The reorganisation counselling; if red and raised, steroids impairment and blindness (less than 6/60) required as a result of the Vision 2020 should be started and the patient seen was 55% higher at disease diagnosis than initiative is an ideal opportunity to think every month. in an age-standardised comparison group. how eye care in leprosy could be inte- 2. During treatment with MDT This was due to in 90%, the other grated. In some countries community (i) single skin lesion: seen at start of main causes being lagophthalmos (failure rehabilitation workers may be involved treatment only, no follow-up. to close the ) leading to corneal in long term follow-up of RFT patients. (ii) Paucibacillary (PB) leprosy, 6 months opacity, and . 5. Under these circumstances it may be treatment: seen at 3 and 6 months, at attractive for leprosy relief agencies to the same time as patient checked for Vertical Leprosy Programmes are direct some support to general eye care ulnar nerve involvement and foot Becoming Integrated programmes. ulcers. (iii) MB leprosy, 1–2 years treatment: Because of the success in reducing the Three Groups of Leprosy Patients prevalence of leprosy, governments are not patient seen at least every 6 months, or prepared to continue to allocate money pre- The 3 groups which need to be considered more frequently if required by the viously given to leprosy control pro- are : Prevention of Disability Programme. grammes. There is also political pressure in 1) At the time of diagnosis with leprosy. 3. At the time of RFT WHO and by some governments to declare 2) During the time of treatment with MDT. All patients will be educated about leprosy ‘eliminated’. In consequence, spe- 3) ‘Cured’ patients, when finished with possible eye complications, instructed cialised leprosy programmes are being MDT and released from treatment. in self-care, and told to return if any

Community Eye Health Vol 14 No. 38 2001 25 Ocular Leprosy Report

The aim is to narrow the lid gap and cover wearing aphakic spectacles when the the . There is no agreement as to the bridge of the nose has collapsed, or the best procedure, whether , or problem of handling them with deformed horizontal lid shortening, including recon- hands. Some surgeons use frequent topical structing the canthus. Temporalis muscle steroid drops or systemic steroids post- transfer is not suitable for routine use. operatively to reduce the risk of post-oper- We need to improve the type of surgery, ative inflammation. and obtain evidence as to what is the best procedure. We also need to understand Conclusions why patients are not prepared to accept this Leprosy and cataract surgery. The gradual change-over from vertical lep- Photo: Margreet Hogeweg rosy programmes to an integrated pro- adverse events occur. People with Cataract Surgery gramme for leprosy sufferers increases the lagophthalmos of 5mm or less should responsibility on the staff of the eye care be followed 6 monthly. In the past, because of small , programmes to ensure that the patients are synechiae, atrophy, and the demonstra- examined and operated on at the right time, Lagophthalmos Surgery tion of the presence of leprosy bacteria in and that general health workers are trained the iris even after a full course of MDT, in leprosy eye care. The indications for referral for surgery are Ophthalmologists have been reluctant to lagophthalmos of 5mm or more; any insert IOLs after cataract surgery. This is Reference degree of lagophthalmos if reduced corneal changing, and very good results with pos- sensation is found by the supervisor; any terior chamber IOLs were reported at this 1 Weekly Epidemiological Record. 2000; No 28, 14 July; 75:226-231 degree of lagophthalmos in a one-eye Workshop. Apart from the improved opti- or www.who.int/lep/disease/wer7528.pdf patient; and for cosmetic reasons. cal results, IOLs avoid the problem of ❏

should have, as a minimum, annual eye Recommendations care examinations and management. 9. Lagophthalmos surgery should be pro- Paul Courtright DrPH 5. We recommend that visual acuity and vided to patients who need it. Evaluation of BC Centre for Epidemiologic & lagophthalmos become the major indica- the need for lagophthalmos surgery should International Ophthalmology tors for monitoring disability and that be based on one or more of the following St. Paul’s Hospital, 1081 Burrard Street corneal hypoaesthesia, corneal opacities, conditions: Vancouver, BC, V6Z 1Y6 and uveitis (which will be recognised as • size of lid gap Canada one cause of a red eye) are removed from the leprosy disability grading scheme. • corneal exposure 1. It is critical that leprosy patients (during 6. At the end of treatment patients must be • corneal hypoaesthesia their anti-leprosy treatment and after educated regarding the risk of • visual acuity release from treatment) are integrated into and informed that they should return for • cosmetic appearance general health and eye care programmes. examination if they develop lagophthal- 2. Integration will require close collabora- There are a number of surgical procedures mos, diminished vision, red eye, or a facial tion between leprosy control and preven- being used for lagophthalmos surgery. skin patch in reaction. Explicit instructions tion of blindness programmes. At the Research is needed to determine the best need to be given to each discharged patient national, regional and local level, strong possible surgical procedures to correct the as to where to go. Patients with lagophthal- political commitment (including profes- lagophthalmos and to improve functional mos should continue to be followed up. sional organisations) is needed. Integration and cosmetic outcomes of the surgery. 7. A training component that addresses the will reinforce and complement Vision Standardised routine monitoring of out- 2020 initiatives and support leprosy control skills and activities of health workers in comes of lagophthalmos surgery is recom- activities. relation to care of eyes in leprosy should be mended. There are many barriers that pre- 3. Cataract is the leading cause of blind- introduced into national plans. Plans vent patients from accepting lagophthal- ness in leprosy affected persons and many should address the needs at different levels mos surgery which need to be clearly iden- do not have access to general eye care ser- and should include the needs of existing tified; programmes need to be developed to vices. All persons affected by leprosy health workers through supplementary increase uptake of lagophthalmos surgery. should have equal access to eye care ser- courses. Health workers currently in train- Finally, ophthalmologists and other rele- vices. Education of health workers (includ- ing should receive appropriate teaching vant surgeons need to be trained in good ing eye care staff) is required to ensure that through medical, nursing and paramedical quality lagophthalmos surgery. leprosy patients gain access to eye care curricula. In every setting with a leprosy 10. Research shows that cataract surgery facilities. control programme, a practical referral sys- with IOL implantation, even in patients 4. At the time of disease diagnosis all tem needs to be clearly defined. All referral with evidence of chronic uveitis, can pro- patients should be examined for lagoph- points (staff) need to be educated regarding vide a good quality outcome. IOL implan- thalmos (any gap), visual acuity, the red the eye care needs of leprosy patients. tation,whereavailable,shouldbepromoted eye, and presence of a facial skin patch. All 8. In settings where there are leprosy among leprosy patients who need cataract patients with lagophthalmos, decreased colonies/villages it is recommended that at surgery. The outcomes of cataract surgical vision, persistent red eye, and/or a facial least annual screening eye examinations services need to be routinely monitored. skin patch in reaction should be referred by and treatment are conducted. Furthermore, the general health worker to a higher level. patients in ‘care after cure’ programmes ✩ ✩ ✩

26 Community Eye Health Vol 14 No. 38 2001