|Year : 1963 | Volume
| Issue : 1 | Page : 13-16
Ocular involvement in leprosy - a case report
Department of Ophthalmology, King George's Medical College, Lucknow, India
|Date of Web Publication||28-Jan-2008|
R C Saxena
Department of Ophthalmology, King George's Medical College, Lucknow
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Saxena R C. Ocular involvement in leprosy - a case report. Indian J Ophthalmol 1963;11:13-6
Leprosy appears to be one of the oldest disorders described in the history of medicine. Armauer Hansen in 1874 was the first to demonstrate leprosy bacillus, the "Mycobacterium Leprae". The disease has been classified differently from time to time but at the Pan-American Congress in Rio de Janeiro in 1946 it was modified to Lepromatous and Tuberculoid, both being consistently structural and based upon histological findings. Also an intermediate type was inserted between these strongly contrasting types, called 'Uncharacteristic,' to describe cases without either of the two typical varieties.
It is not often realised that it also has higher percentage of ocular involvements than any other systemic disease (Mendonca de Barros, j. 1946). Predergast in 1940 recorded 91% ocular involvements in leprosy. Harley (1946) reported 90% whereas Elliott above 90% of involvements, depending upon the duration of the disease.
Among the ocular manifestations in leprosy cutaneous nodules on the lids, lagophthalmos secondary to paralysis of orbicularis oculi, superficial and interstitial keratitis, episcleral nodules and uveitis are quite common. Conjunctival nodules, scleritis and lesions in retina are rare. According to Lopez (1890) the uveal tract is affected in half the cases of leprosy. Borthen and Lie (1899) estimate its complication in 37% of tuberculoid variety and in 74% of the Lepromatous, and, indeed ciliary affections are the commonest causes of blindness in this disease.
The present paper represents a complete clinical and histological demonstration of a case of 'Tuberculoid'
Leprosy having multiple bilateral ocular manifestations.
| Case Report|| |
B. S., male, aged 50 years, Sikh, a patient of leprosy since 7 years came to the ophthalmic out-patients department of Gandhi Memorial and Associated Hospitals, Lucknow on 12-8-1961 with the complaint of gradual diminution of vision since one year and painless congestion of the left eye since 13 days. In addition to this he had marked epiphora and lagophthalmos on the same side since 1 month. Congestion and watering also developed on the right side after seven days. Besides this he had deformities of hands and feet with loss of sensations. Two years back, he had a similar attack of congestion in his left eye which persisted for 20 days.
There was no history of leprosy in the family and none of contact with another case.
The palpebral aperture on left side was wider and the left eye appeared more prominent. Patient had isolated paralysis of the left orbicularis oculi [Figure - 1] producing marked lagophthalmos. Eye-brows had dropped off on lateral aspect of both the sides [Figure - 1] and [Figure - 2] but the lashes were normal. There was slight ectropion of the left lower lid, [Figure - 2]. The bulbar area on the left side showed a small ciliary staphyloma from 3 to 5 O'clock position. The limbal blood vessels were tortuous and prominent. The conjunctiva at 2 O'clock, 6 O'clock and 7 O'clock showed episcleral nodules about 2 mm. away from the limbus. The cornea showed an old tongue-shaped deep opacity from 3 O'clock to 5 O'clock position (Old patch of sclerosing keratitis). The lower portion of the cornea, in addition to it, showed a band of exposure keratitis. Few old K. P's were also visible on the back of the cornea. The corneal sensations were markedly impaired. The anterior chamber was deep and clear. The iris was muddy, lusterless and its pattern could not be demonstrated. The pupil was small and irregular due to multiple posterior synechae and was not reacting to light. There was central sclerosis of lens and uveal pigment could be seen on its anterior capsule. Fundus was not clearly visible Patient could only count fingers at ½ meter distance and the tension was normal.
On 12-8-1961 the Right eye of the patient was normal but after one week an episcleral nodule appeared at 9 O'clock position [Figure - 3]. The fundus and tension were normal. The vision on Snellen's chart was 6/9.
Slit lamp examination of both the eyes showed beaded corneal nerves besides other findings as described above.
General examination of the patient revealed marked depigmentation of hands. Terminal phalanx and distal half of middle phalanx of right index finger were missing. The metacarpophalangeal joints were extended whereas the interphalangeal joints were flexed giving rise to the appearance of 'claw hand', more so on the left side. [Figure - 4]. There was loss of sensation in fingers and medial side of palm and dorsum. The X-rays of hands showed marked absorption of hone on the distal ends of proximal and middle phalanx of the same finger. The distal end of proximal phalanx of left index finger also showed marked absorption.
The, left little toe was very small and was riding over the adjacent toe [Figure - 5]. Again the sensations were absent in toes, on planter and dorsal aspects of feet. The distal end of metatarsal bone of left small toe was totally absorbed. Proximal and middle phalanges were missing [Figure - 5]. Few sesamoid bones however were seen in all the four limbs.
The ulner, median, lateral popliteal, and anterior tibial nerves were thickened and beaded at some places.
Lepromin test in this case was strongly positive.
The histology of the episcleral nodule revealed that the piece was lined by stratified epithelium. The underlying tissue showed collections of histiocytes, mono-nuclears, lymphocytes and few foreign body type of giant cells [Figure - 6]. Acid fast stain of the tissue did not show any presence of mycobacterium leprae.
| Treatment|| |
The patient was advised to take warm boric fomentations thrice a day, Hydrocortisone eye drops 1% four times a day, Bentrofene eye drops thrice a day (preparation of Morpholine salt of 4-carboxymethylamino-4' aminodiphenyl sulphone) and ungatropine 1% twice a day in both eyes. Besides this general treatment of sulphones was given in the following dosage:-
Diaminodiphenyl Sulphone (DDS) --- 5o mgms twice a day for six days in a week and then rest for one day. This was given for one month and then rest for one week. This order of dosage was advised for one year.
In addition to it chaulmoogra oil was given for the local use on limbs. Vitamin 'B1' and 'B12' were given parenterally. After 1 month lateral tarsorrhaphy was performed on left side.
| Discussion|| |
This patient came with multiple eye lesions on both the sides. The attack of congestion which the patient got about 2 years back in left eye is in favour of a patch of anterior scleritis which has left its imprint in the form of a small ciliary staphyloma from 3-5 O'clock position and on old patch of sclerosing keratitis with old irridocyclitis. Out of many cases seen here this is the first case where scleral involvement was noted in the tuberculoid variety.
The lagophthalmos in this case was clue to isolated involvement of left orbicularis oculi muscle. This lagophthalmos and impaired sensation of cornea were responsible for the band of exposure keratitis. The paralysis of orbicularis oculi led to slight ectropion of left lower lid which caused marked epiphora.
The episcleral nodules were typically seen on both the sides, more so on the left, near the limbus. The nodules were not tender due to impairment of the sensations. Biopsy of one of these nodules confirmed the etiology.
The presence of thickened and beaded corneal nerves was a very distinctive feature which has been described to be characteristic of leprosy by Vale in 1946.
The lenticular changes in left eye appeared to be senile.
The local and general treatment as described above was carried out for 1½ months. The episcleral nodules disappeared within 1 month. The weakness of the felt orbicularis oculi muscle also improved to some extent. Lateral tarsorrhaphy relieved the epiphora and the lagophthalmos. The general treatment of Sulphones was continued.
| Summary|| |
A case of tuberculoid type of Leprosy is reported having following ocular involvements:
1. Lagophthalmos with exposure keratitis secondary to paralysis of orbicularis oculi on left side.
2. An old patch of anterior scleritis with sclerosing keratitis and irridocyclitis in left eye.
3. Episcleral nodules on both sides.
4. Thickened and beaded corneal nerves under Slit lamp.
General features of leprosy in this case have also been discussed.
A case tuberculiod type of Leprosy having lagophthalmos, sclerosing keratitis, episcleritis and thickened corneal nerves, in a man of 50 is described. General features in this case are also described. Treatment .Kith sulphones was effcation.
| References|| |
Borthen & Lie. Die. Lepra des, Auges Leipzig. (1899).
2.. Elliott, D. C. (1951) Annals of the New York Academy of Sciences, 54, 85.
Hansen, G. H. A. (1874) Norsk, Mag, Laegevidensk.
Harley, R, D. (19.16) Ocular leprosy in Panama. Am. J. Ophthal. 29: 295.
Lopez, A. (1890), F. Aug. xxii, 318.
Mendonca de Barros, j. (1L46). The ocular complications of Leprosy. Am. J. Ophthal. 29 : 162.
Muir, E, (1948) "Manual of Leprosy" 1st. Ed., p. 27. E, & S. Livingstone Ltd. Edinburgh.
Predergast, J. J. (1940) Arch. of Ophthal. 23 : 112.
Vale, E, F (1946). Subsidiary studies to leprosy of the eyes. Imphensa Nacional. Rio de Janeiro Brazil.
[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6]