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OCULAR PROBLEMS IN NEGLECTED LEPROSY
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Do you know that every hour, 65 new cases of Leprosy (Hansen’s Disease) are being detected and, of these, four already have disability and eleven are children. In a Western society, that news is nothing less than horrendous. Approximately 25% of all leprosy patients suffer from some form of eye involvement.
In view of the W.H.O.’s resolve to place all leprosy clinics under general health programmes once that area has a leprosy prevalence rate of less than one case in 10,000 population, it is a matter of urgency that all medical person be adequately equipped to diagnose a case of Hansen’s Disease in its early stages to prevent nerve damage and, in particular, blindness.
These brief notes are designed merely to - (1) “whet the appetite”, - (2) Stimulate an awareness
of the colossal needs of leprosy sufferers and - (3) to challenge caring people to get involved with
us in working towards the eradication of the disease. Please get back to me at the email address at the bottom of the page if you wish to receive more “in depth” material.
Blindness is a serious complication of neglected leprosy. 5% of sufferers become totally blind. However, as with all other disabilities and deformities caused by leprosy, eye problems can be completely prevented. Whenever we examine a person thought to have leprosy, it is most important that we also examine the eye. Some think that we need only search for skin patches and nerve enlargement etc. but the eyeball, eyelids and eyebrows must also be carefully examined. As we have said before, M.leprae gravitate towards the COOLER parts of the body and the eye is one of those parts. That is why mainly the anterior or front part of the eye is affected , because it is the cooler part of the eye.
DAMAGE TO THE 7th NERVE - is common in leprosy and it is particularly the occipito-temporal and zygomatic branches which are affected, producing a selective paralysis of the orbicularis oculi muscle. This can happen in any type of leprosy but is especially common in association with Tuberculoid (TT), Borderline Tuberculoid (BT) lesions of the face, especially during Type One reactions and in late Lepromatous (LL) leprosy.
THE EYELIDS have a very important function - (1) to protect the eye from the entry of foreign bodies such as dust - (2) to permit sleep by shutting out the light - (3) to facilitate the secretion of tears and their passage into the lacrimal duct and - (4) to assist in lubricating the cornea by a thin film of tear. There are two main muscles that are responsible for the opening and closing of the eyelids. The eyelid is opened by the levator palpebrae muscle which is activated by the 3rd. cranial nerve. The eyelid is closed by the orbicularis oculi muscle which is activated by the 7th. cranial nerve being one the upper branches of the facial nerve. It is these branches that often are affected by leprosy, resulting in “Lagophthalmos” which is the inability of the patient to completely close the eyelids. Ectropion is the deformity which results in the lower eyelid turning out. If the patient also suffers from corneal anaesthesia, the problem is compounded, often leading to complete blindness. The insensitive, dry ( dry if the lacrimal duct is blocked due to infection) eyes, if they are to be saved, need to be constantly, mechanically lubricated with glycerine, castor-oil etc. and the patient needs to wear protective goggles. During bouts of severe reaction, relief can sometimes be given by a course of cortisone or a simple surgical procedure, known as tarsorrhaphy - partly stitching the eyelids together after “freshening” the edges.
THE EYELASHES are extremely sensitive and, if dust or other foreign particles come into contact with them, a sudden reflex action closes the eyes and prevents entry of material that could injure the eyes. If there is a sensory deficit in the nerves to the eyelashes, they cease to perform their work, placing the eye at risk. The problem is exacerbated if the eyelashes are lost.
THE EYEBROWS help to prevent sweat from the forehead running into the eyes. The forehead and eyebrow area, because of evaporating perspiration, is a cooler area to which M.leprae gravitate and, for this reason, particularly in chronically neglected cases, eyebrows may disappear because the autonomic nerve supplying the hair follicle of the eyebrows and eye-lashes is destroyed. This deformity is called Madarosis. For cosmetic reasons, a eyebrow surgical transplant operation can be performed to help the patient overcome the trauma of stigma.
THE NASOLACRIMAL APPARATUS needs to be carefully observed. A common problem among leprosy patients with eye involvement is that they suffer from excessive watering of the eyes. Dacryocystitis, which is the infection of the lacrimal sac, is commonly the result of nasal infection. When there is lagophthalmos, apply pressure over the lacrimal duct and see if the puncta exudes pus which is a sign of Dacryocystitis. The nasal mucosa, being a COOLER region, is very prone to the infiltration of M.leprae in lepromatous patients. If the duct is blocked, daily syringing of the duct and the application of antibiotic drops gives some relief.
CONJUNCTIVA is often affected in chronic sufferers but it is mainly due to exposure and secondary infection rather than infiltration by M.leprae. Antibiotics generally help control this bacterial infection. In times of acute E.N.L., erythematous nodules are seen. The conjunctiva, with the cornea, can suffer sensory deficit if the 5th. nerve is involved.
EPISCLERA AND SCLERA are among the earliest sites of ocular involvement in leprosy. Among some lepromatous patients, protruding, yellowish, gelationous nodules, which may contain many M.leprae, cause extreme suffering, compounding lagophthalmos by still further preventing the eyelids from completely closing.
CORNEA - in lepromatous leprosy, the corneal nerves can be affected. Neuroparalytic keratitis may result from partial or total sensory loss when the 5th. nerve is affected resulting in corneal anaesthesia. Corneal Ulceration may at first be superficial and only detectable if the cornea is anaesthetic, due to 5th. cranial nerve involvement. The ulcer is not painful and is only recognised because of lacrimal and conjunctival inflammation. The ulcer may heal, leaving a scar which affects the vision or else it becomes infected and penetrates to the back of the cornea. An active ulcer can be distinguished from a healed scar after infiltration of 1% Fluorescein. Inflammation debris collects in the anterior chamber with the formation of Hypopyon or a deposit of puralent fluid in the bottom of the anterior chamber.
CILIARY BODY AND IRIS also may be affected. “Iris Pearls” or very small white spots may be seen These are aggregations of M.leprae. Even after a full course of MDT, these spots may never disappear. The destruction of the Ciliary body is the main cause of occular blindness in leprosy. Iridocyclitis, where the Iris is involved with the Ciliary Body, is the most common lesion of the uveal tract. Another deformity is due to adhesions between the Iris and the Lens resulting in Anterior Synechiae and Posteria Synchiae. One of the main reasons for urgently treating Iridocyclitic conditions is the prevent synechiae. If Iridocyclitis is not treated Glaucoma may result. Acute Iridocyclitis is one of the principle manifestations of Type 2 reaction in the eye, often leading to blindness.
OCULAR LESIONS WHICH ARE SPECIFIC TO LEPROSY - (1) Cornea - Keratitis , which may be accompanied by a corneal ulcer is often seen in the Lepromatous type. (2) Sclera - Scleral lepromatous nodules (Scleritis) are often seen in Lepromatous types. (3) Conjunctiva - Conjunctival nodules are seen in Lepromatous types. (4) Iris and Ciliary Body - Iritis or Iridocyclitis (red eye) may be seen in Lepromatous type. Bacilliary Invasion :- The first signs are a beading of the cornial nerves only seen with a corneal microscope. M.leprae infiltration of the corneal surface starts with Punctate Keratitis and discrete white small opacities, usually of the upper temporal quadrant which may fuse, resulting in a general haze of Bowman’s Membrane - a thin transparent membrane in front of the cornea. This Punctate Keratitis is pathognomic of leprosy.
SURGERY IN THE CORRECTION OF EYE and FACIAL DEFORMITY - is a procedure which need never be performed if the disease is diagnosed in the early stages and Multi-Drug -Therapy initiated. Unfortunately, where the Temporal and Zygomatic branches of the Facial Nerve are involved, paralysis may result in the orbicularis and frontal muscles. This is also often associated with the trigeminal nerve. Corneal anaesthesia, paralysis of the lower eyelid and ectropion ( lid turned out) , if not corrected, can cause conjunctivitis, keratitis, corneal ulceration, perforation and complete loss of sight. Corrective surgery is of two types - (1) Tarsorrhaphy which is the narrowing of the space between the lids called the “palpebral fissure” , combined with the use of a static sling to raise the lower eyelid. (2) The diversion of fibres from a muscle not affected by leprosy, in order that the patient may open and close his/her eyes at will. This surgical procedure is called “Temporalis Transfer”, the original technique of which was pioneered by Gilles and described below by Handel Thangaraj:-
A 10cms. curved incision is made over the temporal fossa, commencing from in front of the ear to the level of the superior temporal line. The temporalis fascia is exposed and cleaned. Three parallel incisions are made about 0.5cms. apart, demarcating two strips of fascia. The lower end of the strip is cut from its attachment to the zygomatic arch.. The incisions are now carried right up to the superior temporal line and the strip is cut across at this extremity right down to the periosteum. The fascia and periosteum are lifted and the dissection is continued into the muscular attachment. The muscle is stripped along these lines towards the insertion. The two strips of fascia, along with the muscle, are dissected down until enough length is obtained. The rest of the procedure consists of passing the graft slips into the eyelids and suturing them to the medial palpebral ligament. Handel Thangaraj modified this procedure and improved upon the Gilles method but in this simple study we cannot go into minute details. Details of the Thangaraj modification can be provided upon request.
Basic to the above procedure is the fact that the muscle we can feel at our temples when we clench our teeth or smile, is not affected by leprosy, so fibres of this muscle are transferred to pull on both upper and lower lids to make them close. In the initial stages, the patient needs to consciously clench his teeth to make the lids close but, after repeated physiotherapy, opening and closing the eyelids becomes a automatic act.
RELATED SURGERY OF THE FACE :- (1) Eyebrow reconstruction where the eyebrows have been lost; (2) Reconstruction where the septal support of the nose has been lost; (3) Cosmetic removal of wrinkles of the facial skin; (3) Trimming of pendulous ear-lobes.
Eyebrow Reconstruction can have a profoundly beneficial cosmetic effect on patients who suffer stigma because the autonomic nerves supplying the hair follicles of the eyebrows have been destroyed. By taking free or pedicle grafts from the occiptal region where hair is growing and making an incision over the eyebrow to insert the graft, the patient can be made to look more or less normal with an improved sense of self esteem. One thing the patient needs to remember is that, whenever he goes for a haircut, he needs to get his eyebrow trimmed!
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