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Prevention of Blindness in Leprosy and the Role of the Vision 2020 Programme

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Eye (2005) 19, 1099–1105 & 2005 Nature Publishing Group All rights reserved 0950-222X/05 $30.00 www.nature.com/eye 1 2 Prevention of M Hogeweg and JEE Keunen CAMBRIDGE OPHTHALMOLOGICAL SYMPOSIUM blindness in leprosy and the role of the Vision 2020 Programme Abstract Introduction Leprosy control programmes are highly The World Health Organization (WHO) aims at successful. As a result, leprosy control will eliminating leprosy as a public health problem be more and more integrated into the by 2005. This goal has been arbitrarily defined general health services. The existing vertical, as ‘a prevalence rate of active leprosy cases, in specialized control programmes will be need of anti-M leprae treatment, of less than dismantled. Eye complications in leprosy 1/10 000 in any country’. Great progress in have decreased. This is a result of earlier leprosy control has been made over the past 20 diagnosis and highly effective multidrug years. Before the introduction of the multiple treatment (MDT) of leprosy, combined with drug treatment (MDT, a fixed duration timely treatment of secondary nerve damage combination therapy of dapsone, rifampicin, by steroids. Most ocular morbidity is now and clofazimine) in 1982, more than 12 million found among elderly and disabled leprosy leprosy patients were on the treatment registers. patients who were diagnosed before effective In 2003, only 513 798 new patients were detected MDT treatment became available. Many of for treatment worldwide.1 The great majority of these patients live in leprosy settlements. these patients were found in India, Brazil, Age-related cataract has become the leading Indonesia, Nepal, and Mozambique. Leprosy cause of blindness in leprosy. The second has been eliminated from 108 countries out of cause of blindness is corneal opacification, 122, where leprosy was considered a public mainly as a result of neglected exposure health problem in 1985. This impressive keratitis and corneal anaesthesia. The miotic decrease in the number of patients is primarily pupils in late multibacillary leprosy, in attributed to the shortening of treatment combination with small central lens opacities, duration with MDT (6–12 months, as compared 1Department of may also lead to blindness. The Vision 2020 to the often lifelong treatment with dapsone Opthalmology, Leiden Initiative prioritises cataract surgery. before MDT was introduced) and the updating University Medical Centre, Leiden, The Netherlands Leprosy patients should be actively included. of the registers. The global number of new cases Disabled leprosy patients can also benefit detected annually has remained rather stable 2Nijmegen University from screening programmes for refractive since the introduction of MDT, around 500 000– Medical Centre, Nijmegen, errors and the provision of spectacles and 600 000 new cases per year. Compared to the The Netherlands low vision aids. Determining the most many millions of people with HIV/Aids, TB, feasible surgical methods for lagophthalmos and malaria, the current number of patients Correspondence: surgery remains a challenge. For all health with active leprosy is low. However, not JEE Keunen, Institute of Ophthalmology, Nijmegen and eye care staff, training in leprosy and included in the prevalence and case-detection University Medical Centre, its eye complications is needed, as well statistics are the more than 12 million patients PO Box 9101, 6500 HB as a change in attitude towards leprosy released from treatment, who do not form a risk Nijmegen, The Netherlands patients. Staff must be prepared to of spreading the infection any longer. An Tel: þ 31 42 3613138; welcome them in the general health unknown but considerable proportion of the Fax: þ 31 24 3540522. E-mail: j.keunen@ services. patients are left with the ravages of end-stage ohk.umcn.nl Eye (2005) 19, 1099–1105. doi:10.1038/sj.eye.6701984 leprosy: severely damaged hands, feet, and alsoFwhich is often not realizedFeyes. These Received: 28 April 2005 Keywords: leprosy; blindness; Vision 2020 complications occur in particular in the elderly Accepted: 2 May 2005 Prevention of blindness in leprosy M Hogeweg and JEE Keunen 1100 patients with a long history of disease, who were already blindness (VAo0.05) in 238 new MB patient at baseline.4 diagnosed with leprosy before the introduction of MDT, This is comparable to the general estimated prevalence of and who initially were treated with dapsone blindness in India. Four recent larger studies on elderly monotherapy. These patients often live in leprosy patients with long histories of leprosy, mostly living in settlements, leprosaria, of beggar colonies, in abject leprosy settlements, all indicate that blindness in such poverty. Stigma against patients with visible deformities patients is much higher, even today.5–8 If blindness is still high in many places. For them accessing the among the general population above 50 years in general health services can be quite difficult. developing countries is roughly taken as 5% (VAo0.1), Nowadays, leprosy not being a major public health these data show that blindness among leprosy patients is problem anymore, the vertical leprosy programmes at least 50% higher in a country like S Korea, with well- under the Ministries of Health are gradually being developed health services, free for leprosy patients, and dismantled and antileprosy treatment will be fully two to three times higher in leprosy settlements in integrated within the general health services. General Nigeria and China. In China alone, there may be as many health services, including eye care services, will become as 40 000 blind, among the approximately 300 000 fully responsible. However, whether the Prevention of currently living patients who have suffered from leprosy. Blindness (PBL) programmes and the eye care services Two recent and comparable smaller studies from are fully prepared for their new task, remains to be seen. Pakistan9 (n ¼ 143) and Nepal10 (n ¼ 58) report 11% and This paper summarizes the current causes of blindness in 9% of blindness, respectively. leprosy and will discuss the opportunities the Vision Risk of death in blind leprosy patients is 4.8-fold in 2020 Initiative offers, to preserve eye sight in leprosy. excess of nonblind same age peers.11 Point prevalence surveys tend to underestimate blindness, as many blind patients may have prematurely died. Blindness and eye complications in leprosy In S Korea5 23/114 (14.7%) of treated leprosy patients, Although leprosy control has been a public health who had initially been free of complications, developed success over the past decades, leprosy patients still suffer new and potentially blinding eye lesions over an 11-year from avoidable blindness. Blindness for leprosy patients period. Blindness in the better eye visual acuity is really a disaster. They completely depend on eye sight (VAo0.1) developed in 15/263 (5.7%) of the surviving to protect their often anaesthetic limbs from injuries and patients. burns. An estimated 200 000–300 000 leprosy patients are Many patients are incurably blind. It is important to blind. Of all causes of blindness 0.5–1% are directly identify those blind patients who can still be treated, for related to leprosy, and another 1–2% due to co-morbidity instance by cataract extraction. with general eye diseases, in particular age-related cataract.2 Eye complication in leprosy mainly occur in Cataract multibacillary (MB) patients. Even more so since the definition of MB disease has been widened: many Cataract is the leading cause of blindness among leprosy patients formerly classified as paucibacillary (PB) patients and can be responsible for as many as 40–50% of borderline tuberculoid patients (BT) now are included in all cases (Figure 1). This includes those who have the MB group. When considering eye complications and completed MDT. The majority of cataracts is assumed to blindness in leprosy, it is important to distinguish be simple age-related, but it has been shown repeatedly between the preMDT, now mainly elderly cohort of that cataract is more common in MB than in PB patients. patients with a long history of disease and the generally Some cataracts may be due to long-term steroid use in younger patients, with a shorter history of disease. The severe or recurrent leprosy immune reactions. The role of latter have been treated with MDT only, and show chronic uveitis in unclear, but may triple the risk of considerably less ocular complications. Prevalence of cataract.12 reported eye complications and blindness in leprosy also The quoted studies all illustrate the high prevalence of strongly depends on the method of examination, the kind cataract as a cause of blindness or severe visual of complications included and the definition of blindness impairment. With increased life expectancy, also for used. leprosy patients, numbers of cataract blind can be Some examples of studies published since 2000 are expected to further increase. summarized in Table 1. The LOSOL study on eye disease In the 11 years follow-up study in S Korea, cataract in 691 MB leprosy patients at baseline shows an age- caused 87% of the incident blindness. Cataract surgical adjusted prevalence of blindness of 2.8% (VAo0.1).3 The coverage (defined as the number of patients who had figure for India was 1.6%, the Philippines 1.3%, and cataract surgery in one or both eyes, divided by the total Ethiopia 5.5%. The Indian Cohort study reported 0.84% number of patients with cataract and after cataract Eye Prevention of blindness in leprosy M Hogeweg
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