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ARTICLES
Year : 1986  |  Volume : 34  |  Issue : 1  |  Page : 15-18

Leprotic paralytic lagophthalmos with ectropion and its surgical correction


Departments of Ophthalmology & Dermatology King George's Medical College, Lucknow, India

Correspondence Address:
Pavan Kumar
Departments of Ophthalmology & Dermatology, King George's Medical College, (Lucknow)
India
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Source of Support: None, Conflict of Interest: None


PMID: 3443493

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How to cite this article:
Kumar P, Saxena R C, Srivastava S N. Leprotic paralytic lagophthalmos with ectropion and its surgical correction. Indian J Ophthalmol 1986;34:15-8

How to cite this URL:
Kumar P, Saxena R C, Srivastava S N. Leprotic paralytic lagophthalmos with ectropion and its surgical correction. Indian J Ophthalmol [serial online] 1986 [cited 2020 Feb 19];34:15-8. Available from: http://www.ijo.in/text.asp?1986/34/1/15/26351

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Leprosy an ancient disease, has a high incidence of ocular involvement. Since mycobacterium leprae has a predilection for peripheral nerves the superficial branches of the trigeminal and facial nerves are involv­ed[1], resulting in an insensitive cornea and lagophthalmos[2]. Paralytic ectropion of lower lid is due to loss of tone of the orbiculous oculi muscle, resulting in persistent watering. So, a. double threat to the cornea exists wherein foreign bodies and the discomforts of an exposed cornea go unnoticed and the unblinking lid fails in its protective function. Thus blindness results in a patient with arrested or active leprosy, if the motor function of the lids is not restored, since little can be done to restore corneal sensa­tion. This paper presents a clinical study of VII cranial nerve involvement in leprosy, with a brief discussion about the surgical amelioration of lagophthalmos and ectropion in one of the cases with bilateral involve­ment.


  Material and methods Top


100 leprotic patients studied and were clinically classified as below

1. Lepiomatous leprosy .. 64 patients

2. Tuberculoid leprosy .. 28 patients

2. Borderline leprosy .. 8 patients

Only 7 patients with tuberculoid leprosy had leprotic paralytic ectropion. These patients of orbicularis-oculi involvement had symptoms of chronic tearing, watering, irritation and diminution of vision to differ­ent extents. [Table - 1]. All these patients were having V and VII nerve involvement.

On examination, these patients were of average built and showed bilateral ocular adenxal findings-loss of eye-lashes and eye­brows, skin nodules, paralysis of Orbicularis­oculi, anaesthetic patches on the skin, with diffuse infiltration of lids, which were stiff and immobile, lagophthalmos was present.

The cornea showed moderate to severe degrees of exposure Keratopathy, Punctate Keratitis and corneal Scarring, Vascularised corneal opacity was present in one patient.

On investigation, the lacrimal passages were fully functioning even after several years of leprotic ravaging of the surrounding tissues.

Management

All patients with Orbicularis-oculi palsy had been on Tablet Dapsone for two years or more. The progress of the active disease was halted, but the sequale to the Vth and VIlth cranial nerve involvement required surgery under general anaesthesia separately in each eye. Surgical technique for correc­tion of lagophthalmos used was the Gillie's­Musculo fasical sling, utilizing the tempora­lis muscle in a modified form as first tried by Jhonson[2] in 1962, which consists of using the lower portion of the temporalis tendon and leaving the muscle fibres untouched in their lid, so that the polarity of the muscle trans­plant is not reversed, unlike that in Gillie's Procedure, thereby the function and move­ment of the new lid motor is assured.


  Observations Top


Each operated eye of the patient was clinically examined regarding the following parameters-as shown in [Table - 2]. There was same ability of the transfer to act inde­pendently of the rest of the temporalis muscle and reflex activity in the temporalis transfer was present to some extent. Both eyes of one patient were operated, separately and successfully. So success rate was 100%. [Table - 2].


  Discussion Top


Non-operative conservative treatment has nothing to recommend to the lagophthalmos in leprosy, though medical treatment such as local Priscol injections in the neighbourhood of the facial nerve has been tried[3].

Various surgical techniques have been employed to correct such deformities and rehabilitate such unfortunate victims. Tarsorraphy of the lateral half of the eyelids had given only partial success[4]. Surgeons have associated the above described techni­que with that of Kuhnt-Szymanowski's.

In others, in addition to raising the lower lid with strips of fascia lata, a subtotal section of the L.P.S. has been done in an attempt to narrow the opening of the levator through lack of antagonism of the orbicu­laris.

Our consensus is in favour of the above simple technique, as there was no necessity of repitition or addition of the other sites and thus a commendable improvement was made regarding the patient's countenance and alleviating his discomfort.

Thus this method does not provide an ideal solution, yet it provides for a reasonab­ly efficient working device capable of pro­tecting the eyeball. It ensures gentle pres­sure of the lower eyelid on surface of the eyeball rectifying the position of the lacri­mal ducts and directing the flow of tears almost normally.


  Summary Top


In 100 cases of leprosy, 7 developed lagophthalmos, Ectropion, watering and exposure Keratitis, from involvement of VIlth and Vth cranial nerves. With the recent effort, and rehabilitation of such patient, we used the method originated by Sir Harold Gillie to restore lid function. A motor mechanism for the paralysed lid was created by using a portion of the temporal is muscle, unconsciously when the jaws moved in chewing or biting or by conscious effort, thus correcting exposure Keratitis and preventing blindness.

 
  References Top

1.
Ffytche, T.J. 1981, Brit. J. Ophthalmol. 65: 231-239.  Back to cited text no. 1
    
2.
Jhonson, A. H 1965, International J. Leprosy, 33 : 89-94.  Back to cited text no. 2
    
3.
Nema, H.V. and Mathur, J.J. 1967, Rev. 38: 159-161.  Back to cited text no. 3
    
4.
Saxena, R.C., 1963, J. All Ind. Ophthal. Soc. 11: 13-16.  Back to cited text no. 4
    


    Figures

  [Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4]
 
 
    Tables

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