Maltese Medical Journal ~ Volume IT Issue I 1990

Ocular Manifestations in Lepromatous and Tuberculoid

Milan Blagojevic, Richard Soler, George Depasquale, Mario Bonnici, Denis Schiro.

countries, but it is believed to be present themselves with the first ABSTRACT between 10 and 12 million. Among signs of disease in late adult life. these about 750,000 have visual Ocular manifestations of leprosy in impairment, even blindness. This 3. Family History - In 39% it was 100 patients examined were fact is even more tragic if one keeps proved that the patient has or has reported on; - 80% were suffering in mind that blindness is almost had another member of the from the lepromatous type of the alwa:r.s associated with other immediate family (i.e. parent, disease. disabIlities: e.g. loss of sensations, sibling, or offspring) suffering from deformities of hands, feet, face, etc. leprosy. The most frequent change was loss of (40%) which was seen From all publications it is evident 4. Classification of Patients - The mainly in lepromatous patients. The that patients suffering from the types of disease were represented and were rarely lepromatous type of leprosy are more thus: affected separately, but sclero­ prone to develop ocular kerato- iridocyclitis was found in Lepromatous (LL) 57 complications, involving primarily 80% 3%. On the other hand, the was the and the anterior segment, Borderline lepromatous (BL) 23 involved rather more often - 16% while the fundus is rarely affected Borderline (BB) 5 5% (atrophy of the iris - 4, atrophy of the Borderline tuberculoid (BT) 11 (2,3,4). 15% pupillary margin - 3, - 1, Tuberculoid (TT) 4 posterior synechiae - 6, keratic There are regional, climatic, racial precipitates - 1, and iris "pearls" - 1). and other factors which have an It is evident that the lepromatous The iritis always had an insidious influence on the type of leprosy and and borderline lepromatous types chronic evolution. The origin of the on its complications in general. We constitute the most common form of iritis is probably multifactorial: have therefore undertaken this leprosy encountered in Malta, with survey to examine 100 leprosy a prevalence of 80%. a) neuroparalytic due to patients and find out the prevalence involvement of the autonomic nerves of ocular manifestations as well as 5. Treatment. All patients examined supplying the iris muscles, primarily the relation of these to the type of had been treated with multiple drug dilator; leprosy - lepromatous or tuberculoid. therapy, consisting of "Isoprodian ­ b) direct effect of Mycobacterium RMP" (a fixed combination of leprae on the iris tissue; and ME'IHODS AND MATERIAL Rifampicin 60Omg., Prothionomide c) immune or auto-immune 35Omg., Isoniazide 35Omg., Dapsone mechanisms. In the period February to August 100mg. daily for 6 days a week) for 1987 we have performed the a period of approximately 20 months, The posterior was rarely ophthalmological examination of following a previous variable period . affected (2%). No case of primary 100 leprosy, who were currently of dapsone monotherapy - in some was detected, but under the care of the Leprosy cases up to 15 years and over. At the secondary glaucoma due to Eradication Programme. time of examination the vast sclerokerato-iridocyclitis was found majority had been released from in 2 cases. seems to occur Ophthalmological examination treatment more than 10 years more frequently in leprosy patients included the condition of the external previously and since then had been (20%) than in the general population. part of the eye, examination of the kept under strict post-treatment anterior segment with slit lamp, control. The anterior segment was mostly fundoscopy, tonometry, and visual affected (21%), and all these cases acuity. Dapsone in a daily dose of lOOrng. belonged to the lepromatous (16) or borderline lepromatous (5) type. 1. Sex- Males were represented by M Blagojevic, MD Dr Se. 62% and females by 38%. R Soler, MD FRCS. INTRODUCTION M Bonnici, MD. and 2. Age Distribution - The m~ority Although leprosy has completely D Schiro,MD. of the patients - 75% - are older than Department of , disappeared from many countries, 50 years due to the facts that: the number of patients suffering St. Luke's Hospital, from this chronic, disfiguring a) the incidence of new cases has G Depasquale MD. condition, is still rather high world declined drastically in the last two wide. The exact number of leprosy Dept of decades, and Boffa Hospital patients is not available from all b) a considerable number of patients Maltese Medical Journal 39 Volume IT Issue I 1990

does not usually cause any serious complicated with secondary while sphincter muscle was only side effects. However, a massive glaucoma (fig.3,4). atrophic in 7%. This was seen always dose of 7.5gm taken in a suicidal in while, on attempt has produced bilateral ·5. Iris. Involvement of the iris was the other hand, both muscles were retinal necrosis, haemolytic anemia, encoWltered relatively often - 16% normal in tuberculoid and borderline methaemoglobinaemia, and acute of all cases (12 cases in the LL group leprosy. Because of the atrophy of renal failure (5). and 4 cass in BL). In these cases the iris muscle, particularly the different changes could be noticed dilator, mydriatics have a very poor 6. SeQuelae. A number of patients in the iris: atrophy of iris stroma effect in lepromatous iritis. showed stigmata of the disease. (4%) (Fig.5), atrophy of the iris "Leonine facies" was seen in 3 margin (3%), miosis (1%). Besides We believe that the neuroparalytic patients while a considerable these, one could find posterior factors play a very important but number had abnormalities relating synechiae (6%), keratic precipitates not the only role in the pathogenesis to their upper and/or lower limbs. (1%), and iris "pearls" (1%). of chronic iritis. A second important These included: anesthesia (14%), role belongs to the direct effect of muscle . atrophy (4%), trophic In all cases the eyes were white, the Hansen bacilli on the iris tissue. ulceration (6%), and deformity (7%). quiet and no signs of active iris This is sometimes manifested in the inflammation could be detected. The form of iris "pearls" which consist of OCULAR MANIFESTATIONS involvement of the iris had the tightly packed li· bacilli within features of the chronic iritis or mononuclear cells~ey are located The ocular changes observed in the insidious anterior seen in in the middle or deeper layers of the 100 patients examined were leprosy. The most striking iris, usually between the collarette recorded according to the type of appearance in this chronic form of and ciliary margin, but can also be leprosy, and the findings are iritis is the atrophy of iris stroma free in the anterior chamber. represented in Table 1. From the and/or iris margin (total 7%). The data the following observations are atrophy is very intensive, involving The above mentioned alterations of evident: large areas of the iris and sometimes the iris muscles and iris tissue may having an appearance similar to generate some autoantigen, which 1. Eyebrows. The most frequent essential iris atrophy, with the can trigger immWle or auto-immWle changes are fOWld on the eyebrows presence of holes in the iris reactions. To prove this and . In 40% we could ("Fenestrae iridis"). Inverse immunological mechanism further notice hair loss ranging .from heterochromia could also be seen. investigations are necessary, rarefication to complete loss of the Pronounced iris atrophy, lack of because Wltil now there is no definite eyebrows. The lateral parts of the irritative symptoms and a very evidence concerning the immWlo­ eyebrows were frequently and chronic evolution, differentiate the biological changes in the sera and severely affected. The majority of iritis in lepromatous leprosy from aqueous humor. However, the the patients with these changes other clinical entities of chronic presence of plasma cells, as shown (31%) belonged to lepromatous (ll..) anterior uveitis. For this reason, it by Ffytche in histological specimens, group. is interesting to know which are the indicate the participation of aetiopathogenic factors that play a immunological phenomena in 2. Eyelashes. Changes were only role in the Wlderlying iritis. From leprosy uveitis. seen in the LL and BL groups. our experience and from data from Ciliary Madarosis was present in the literature, we think that there Among our patients we did not 8% while was detected in are three pathogenic factors: observe any case of acute serous 4% of cases. It should be noted that nongranulomatous iritis, which regrowth of hairs on the eyebrows a) involvement of the autonomic represents bacterial allergy, similar and eyelashes can occur after nervous system supplying the fibres to acute erythema nodosum starting anti-leprosy treatment in of sphincter and dilator muscles; those cases where the hair loss had 6. Chlorioretinal changes. The not been of long standing. b) direct effect of Mycobacterium leprae on the iris tissue; and 3. Sclera 1 case showed involvement of the sclera in the form of c) immune or auto-immune . manifestations; 4. Cornea Two cases showed the Ffytche (6) estimates that chronic sequelae of stromal in the iritis in lepromatous leprosy is not a form of corneal leucoma (Fig.2). true inflammation, but is a form of Superficial keratitis, pannus, or the neuroparalytic iritis, caused by early typical white opacities having involvement of autonomic nerve "chalk-white" appearance, fibres. Direct involvement of neuroparalytic keratitis, exposure nonmyelinated autonomic nerve keratitis, or band-shaped fibres results in damage to the iris keratopathy were not observed. muscles, particularly the dilator. Meanwhile, the cornea was very Ffytche demonstrated histologically much involved in the cases of sclero­ that the dilator muscle was absent kerato-iritis, in 3% of all patients, or very markedly atrophied in 73%, M.alteee Medical Journal 40 Volume IT Issue I 1990

8. Cataract in leprosy. Lental Table 1 - Eye changes in dilfeoart types d leprosy opacities having different size and EYE CHANGES TYPES OF L£PROSY intensity were found in 20%. This is considerably higher than what is LepromabJs Bon:lerfne Bon:lerfne Bon:lerfne TIberaJIoid TOTAL tl.bercUoid % found in the general population over (LL) (BL) (BB) (81) (T1) 40 years, where the incidence is 6%. These opacities, associated with 1.Eyebrows I small non- reacting , reduce

Rarelicalion 19} 31 4) 5 O} 1 1 } 1 1 } 2 Canpleteloss 12} 1 } 1} -} 1} 40'/. Uperation was pertormed in seven patients; 3 patients had bilateral 2.Eyelast.s and 3 patients unilateral , Madarosis 7 1 8'/. while one patient had pseudophakia - Trichiasis 3 1 4'1. with 10.1.. in the posterior chamber. 3.Episderitis 1 1"10 It is important to point out that all 4.eon- these eyes have tolerated the operative procedure and Stromal implantation of intraocular artificial Keratitis 1 1 2'10 Sdero­ very well. The visual acuity kerato-riis 2 2'/. was satisfactory, as in leprosy the posterior segment is within normal 5. Iris Involved 12 4 19'10 limits. Alrqlhy dlheslroma 4'1. REFERENCES Alrqlhy 4 dmargin 2 1 3% 1. EDITORIAL BLINDNESS IN LEPROSY. Miosis 1 1"/. Posterior BRIT J. OPHrHAlMOL 1981; 65: 221-222. syned1ias 4 2 6'10 Keratic 2 DETHLEFS R. PREVALENCE OF OCULAR prec4Jilales 1 1"/. MANIFESTATIONS OF LEPROSY IN PORT Iris"pearts" 1 1"/. MORESBY, PAPUA NEW GUINEA BRIT J. OPHrHAlMOL 1981; 65:223· 225. 6.. Chorioratina 3. MALLA OK, BRANDT F. ANTEN JGF. ChorioretinaJ 1 1 2'/. OCULAR FINDINGS IN LEPROSY PATIENTS IN AN INSTITU170N IN NEPAL (KHOKANA). BRIT J. OPHrHAlMOL 1981; 65: 226·230. 7.Glaucoma

Prinary 4. BUDEC LJ, RAOOVIC R. KULIS M. CHANGES Qaucxma 0% OF TIiE EYES AND OF TIiE UMBS IN LEPROSY Secondary (IN SERBO-CHROATE). JUGOSL OFTAIM ARH gIauooma 2 2'/. 1983: 21:273·277.

S.Cataract 21>1. 5. KENNER DJ, HOLT K AGNELLO R. CHESTER GB. PERMANENT RETINAL DAMAGE FOlLOWING MASSIVE DAPf:¥JNE OVERDOSE. posterior uvea was very rarely Hg., and that for the left eye from 11 BRIT J. OPHTHAIMOL 1980; 64:7·1·744. affected; inactive chorioretinal scars to 21 mm Hg. with a mean value of could be detected in only 2% of cases. 15.02 mm Hg. 6. FFYTCHE TJ. ROLE OF IRIS CHANGES AS Their appearance was atypical and CAUSE OF BUNDNESS IN LEPROMATOUS LEPROSY. BRIT J. OPHTHAIMOL 1981; 65: was not at all evocative of leprosy. In all the eyes having chronic iritis, 231·239. One case was in the lepromatous we found the LO.P. to be within group and the other of the borderline normal limits. However, Brand et 7. BRANDT F, MALLA OK ANTEN JGF. type. al. (7) have shown that LO.P. was INFLUENCE OF UNTREATED CHRONIC significantly lower in eyes with PLASTIC IRISOCYCUTIS ON INTRAOCULAR It PRESSURE IN LEPROUS PA11ENI'S. BRIT J. 7. Glaucoma in leprosy. is rather chronic plastic iridocyclitis than in OPHrHAlMOL 1981; 65:240-242. interesting that among these 100 unaffected eles, even in those cases leprosy patients we have not where irIdocyclitis remained 8. FFYTECHE T J. CATARACT SURGERY IN detected a single case of primary untreated. THE MANAGEMENT OF THE LATE glaucoma, even though the COMPUCATIONS OF LEPROMATOUS glaucoma survey carried out in LEPROSY IN SOUTH KOREA BRIT J. In 2 of our leprosy patients we have OPHrHAlMOL 1981; 65: 243·248. Malta in April to June 1989 has noticed secondary glaucoma (2%) in established the prevalence of the eyes affected by sclero-kerato­ glaucoma to be at least 3.29% of the iridocyclitis; this secondary general population over 40 years of glaucoma was due to the blockage of age. The LO.P. in the right eye of the iridocorneal angle and the leprosy patients we have obliteration of the intrascleral examined ranged from 12 to 20 mm drainage system. Hg., with a mean value of 15.50 mm The copyright of this article belongs to the Editorial Board of the Malta Medical Journal. The Malta Medical Journal’s rights in respect of this work are as defined by the Copyright Act (Chapter 415) of the Laws of Malta or as modified by any successive legislation.

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