|Year : 2003 | Volume
| Issue : 2 | Page : 155-159
Ocular complications in incident relapsed borderline lepromatous and lepromatous leprosy patients in south India.
E Daniel, S Koshy, Geetha A Joseph, PS Rao
Department of Ophthalmology, Schieffelin Leprosy Research and Training Center, Karigiri, Vellore District, Tamil Nadu-632 106, India
Department of Ophthalmology, Schieffelin Leprosy Research and Training Center, Karigiri, Vellore District, Tamil Nadu-632 106
Source of Support: None, Conflict of Interest: None
Purpose: To determine the magnitude of ocular complications that present in incident cases of relapsed borderline lepromatous (BL) and lepromatous leprosy (LL) patients.
Method: From 1991 to 1997, all new BL and LL patients who had relapsed from an earlier disease, detected by active case finding in the geographically defined area of Gudiyattam taluk, were invited for ocular examination after their leprosy status was confirmed clinically and histopathologically.
Results: Sixty relapsed lepromatous patients, 45 male and 15 females, were examined. Fifty-two patients had relapsed after receiving only dapsone mono-therapy, 4 after receiving paucibacillary multi-drug therapy (PB-MDT) preceded by dapsone mono-therapy and 4 after only PB-MDT. Three (5%) patients had lagophthalmos, 1 (1.6%) patients each had ectropion and trichiasis,
32 (53%) patients had impaired corneal sensation in both eyes, 2 (3.3%) patients each had corneal opacity (associated with reduced vision), corneal nerve beading, punctate keratitis, keratic precipitates, and iris atrophy, 4 (6.6 %) patients had cataract associated with decreased vision,
1 (1.6%) patient had blocked naso-lacrimal duct and 13 (21.7%) patients had pterygium. Seven (12%) patients had a visual acuity of 6/18 or less, 4 (6.7%) patients had 6/60 or less and one patients had vision below 3/60. General ocular complications rather than leprosy-related ocular complications were responsible for reduced vision. Lagophthalmos was associated with increased duration of the disease (P=0.009), Grade II deformity (P=0.001), punctate keratitis (P<0.001) and cataract (P<0.001). Beaded corneal nerves were associated with lepromatous leprosy (P<0.001) and high mycobacterial infection (P=0.05). Patients whose initial disease was categorised as BL and LL had greater impairment of vision (P=0.037), more iris atrophy (P=0.013), increased keratic precipitates (P=0.013) and more corneal nerve beading (P=0.013), when compared with the group comprising Tuberculoid-tuberculoid (TT), Borderline-tuberculoid (BT) and Intermediate (IND).
Conclusion: This first report on ocular complications in relapsed lepromatous patients demonstrates that general and leprosy-related ocular complications occur in these patients. However, they are not in excess of those reported in other leprosy groups. Borderline and lepromatous leprosy patients tend to have had more ocular complications than patients with tuberculoid leprosy.
Keywords: Relapsed leprosy, ocular complications, multibacillary
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Daniel E, Koshy S, Joseph GA, Rao P S. Ocular complications in incident relapsed borderline lepromatous and lepromatous leprosy patients in south India. Indian J Ophthalmol 2003;51:155-9
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Daniel E, Koshy S, Joseph GA, Rao P S. Ocular complications in incident relapsed borderline lepromatous and lepromatous leprosy patients in south India. Indian J Ophthalmol [serial online] 2003 [cited 2019 Jan 17];51:155-9. Available from: http://www.ijo.in/text.asp?2003/51/2/155/14712
Complications of the eye are well recognised in leprosy. The disease itself has undergone many rapid changes in the past few decades primarily due to the impact of the newer, highly effective anti-leprosy drugs.,, These drugs, which have been used extensively over the past two decades are purported to have decreased the load of Mycobacterium leprae in infected persons, thereby decreasing dissemination of the disease and the infective load of the organism. Patients requiring lifelong treatment only a few decades ago are now cured in a short period. This has caused a sharp fall in the prevalence of leprosy although the incidence of the disease has not shown a decline in many endemic areas., It is not clear how these changes have altered the prevalence of ocular complications. The once oft-quoted sentence of Hansen, the discoverer of the leprosy bacilli, There is no disease which so frequently gives rise to disorders of the eye, as leprosy does , may not be true anymore. There have been several studies in India (a country which still has the largest number of cured as well as newly occurring leprosy cases) on the prevalence of ocular complications in leprosy but most of them have used methodologies that incorporate a wide variety of bias. One category of increasingly recognised patients, although small in number, are those who have relapsed with the disease many years after "cure" and smear negativity.,,,,,,, It is not known whether these patients have significant ocular pathology. We conducted ocular examinations on all incident cases of relapsed multi-bacillary (MB) leprosy from 1991 to 1997, all patients resident in the geographically defined area of the Gudiyattam taluk in Vellore District of Tamil Nadu. We report our findings in this paper.
| Materials and Methods|| |
The Gudiyattam taluk is a geographically defined area of 1,306 square kilometers in Vellore district, Tamil Nadu, South India with an estimated population of 650,000. This region was one of the highest endemic areas for leprosy in India with more than 2000 new cases detected annually in the 1960s. Even now the region has not reached the World Health Organisation (WHO) elimination target of less that 1 leprosy patient per 10,000 population. Until 1997, for over 35 years, the Schieffelin Leprosy Research and Training Centre (SLRTC) had a leprosy control program in this area that actively recruited patients for treatment with multi-drug-therapy (MDT). Between 1991 and 1997 all relapsed MB patients were invited to have a comprehensive ocular examination. Ocular examinations were done by an experienced ophthalmologist and results recorded on an eye examination sheet. All except five (3 male, 2 female) of the relapsed MB patients agreed to enroll in the study after due informed consent was obtained.
After the leprosy diagnosis was made in the field, patients were sent to SLRTC where they were examined and the disease documented by experienced leprologists. The leprosy data on each patient included the type of leprosy before and after relapse according to both the WHO, and the Ridley and Jopling classification. The approximate duration of the disease in years was calculated from the time of the appearance of the first symptom to the time of enrollment; the bacteriological index (BI) was measured from skin smear examination of routine and special sites both at the time of the initial disease and at the time of enrollment; the deformity status was graded according to the WHO criteria, history and the presence of reversal reactions (RR) or erythema nodosum leprosum (ENL) and the presence or absence of a face patch. The duration of the disease was counted as one year for patients with duration of one year or less. Face patch was categorised as a classical face patch or an ordinary face patch. A classical face patch was defined as any hypopigmented or erythematous patch, big or small, occurring either over the malar area of the face or over the lids. Non-classical face patch was one which occurred anywhere on the face except at the classical sites.
The ocular examination consisted of first estimating Snellen visual acuity. The other ocular pathologies included documentation of lagophthalmos, measurement of the maximum palpebral width on gentle and forceful closure of the lids (if lagophthalmos was present), the presence of orbicularis oculi muscle weakness (estimated by gently pulling down on the lower lid on forceful closure), presence of ectropion, entropion, trichiasis, patency of the naso-lacrimal duct (determined by syringing the duct) and the presence of conjunctivitis, conjunctival scarring, episcleritis or scleritis. Presence of clofazamine crystals in the cornea or conjunctiva, corneal opacities, pterygium, corneal vascularisation, corneal nerve beading, punctate keratitis and corneal ulcers were noted. Corneal sensation was estimated by asking the patient to look up and applying the tail end of a wisp of cotton on the cornea 2 mm from the limbus at the 6 o'clock position. The sensation was categorised as normal if the patient responded by retracting the head or shutting the eyelids and as impaired if the patient did not respond in this way. A Cochet and Bonnet aesthesiometer could have been used instead of the cotton wisp to quantitatively estimate the corneal sensory threshold, but since this instrument is not appropriate for field conditions, it was not used. Other ocular examinations included slitlamp biomicroscopy for keratic precipitates, flare and cells in the anterior chamber, circumcorneal congestion and the pupil shape and size, the intraocular pressure using a Goldman applanation tonometer and estimation of any lenticular opacity. The pupil cycle time (PCT) was estimated using the technique already described.
STATA 7.0 was used for the statistical analysis. Ocular complications were categorised as leprosy related ocular complications (LROC) and general ocular complications (GOC). LROC consisted of orbicularis oculi weakness, lagophthalmos, ectropion, entropion, trichiasis, episcleritis, scleritis, clofazimine crystals, impaired corneal sensation in both eyes, corneal opacity associated with decrease in visual acuity, corneal ulcer, corneal nerve beading, punctate keratitis, episcleritis, scleritis, iridocyclitis, iris atrophy and cataract with decreased vision. GOC consisted of patients with naso-lacrimal duct blockage, pterygium and age-related cataract with visual acuity of 6/18 or less. Analysis was done by persons rather than by eyes. X 2sub tests were used for analysis of categorical variable and simple regression for continuous variables. The independent effect of risk factors was evaluated with logistic regression models.
| Results|| |
A total of 60 newly detected relapsed multibacillary leprosy patients from the control area underwent ocular examination in a period extending to 7 years. Age of patients ranged from 23 to 74 years with a mean (±SD) of 43 (±12) years. The median age was 42.5 years. Forty five (75%) patients were male. [Table - 1] groups all relapsed multibacillary (Borderline Lepromatous [BL] and Lepromatous Leprosy [LL]) patients by age and gender. Fifty-two patients had relapsed after receiving only dapsone mono-therapy, 4 after receiving paucibacillary multi-drug therapy (PB-MDT) preceded by dapsone mono-therapy and 4 after only PB-MDT. The classification of initial leprosy was Tuberculoid Tuberculoid (TT) in 19 (32%) patients, Borderline Tuberculoid (BT) in 25 (42%), Indeterminate (IND) in 1 (1.67%) patient, Borderline Lepromatous (BL) in 3 (5%) and Lepromatous Leprosy (LL) in 12 (20%) patients). All the paucibacillary (TT, BT and IND) patients and 6 multibacillary (BL and LL) relapsed as borderline lepromatous leprosy (BL) while 9 patients relapsed as LL. Patients whose initial disease was categorized as BL and LL had greater impairment of vision (P=0.037), more iris atrophy (P=0.013), increased keratic precipitates (P=0.013) and more corneal nerve beading (P=0.013), when compared with the group of TT, BT and IND.
Duration of disease, calculated in years from the time of first symptom or sign of leprosy to the time of the present enrollment, ranged from 3 to 32 years with a mean (±SD) of 17.5 (±5.5) years. Duration between "Released From Treatment" (RFT) after the first disease and enrollment after relapse ranged from 8 months to 20 years with a mean (±SD) of 8.3(±4.4) years. Fifty-one (85%) patients had relapsed as borderline lepromatous leprosy and 9 (15%) patients as lepromatous leprosy. Fifty-seven (95%) had an outdoor occupation. One patient had coexisting diabetes mellitus. Average skin smear Bacterial Index (BI) for acid-fast bacilli (AFB) ranged from 0 to 4.5 with a mean (±SD) of 1.14 (±1.2) at the time of enrollment. Eight (13%) patients were smear negative. The highest BI at any one skin smear site ranged from 0 to 5 with a mean (±SD) of 2.3 (±1.5). The deformity status according to the WHO classification of all patients is shown in [Table - 2]: 6 (10%) patients had Grade II deformity in all limbs and 17 (28%) patients had no deformity in any limb.
Eight (13%) patients presented with type I reaction at examination. Seven (12%) patients had a visual acuity of 6/18 or less in one or both eyes, 4 (6.7%) patients had 6/60 or less in one or both eyes and one patient had vision below 3/60. Not a single person was blind as the patient with <3/60 vision had 6/6 vision in the other eye.
The ocular complications are listed in [Table - 3]. There were no entropion or corneal ulcers. Seventeen patients had no complications, 8 patients had only general ocular complications, 27 patients only leprosy-related ocular complications and 8 patients had both leprosy-related and general ocular complications. Leprosy related ocular complications was significantly (P= 0.049) associated with gender (80% women Vs. 51% men with leprosy related ocular problems) and leprosy related ocular complications patients had more cataract (P=0.15). General ocular complications was associated with increasing age (P=0.04) and decreased vision (P<0.001). Leprosy related ocular complications without the inclusion of impaired corneal sensation was related to increasing age (P=0.051) and lepromatous leprosy (P=0.028). Orbicularis oculi weakness and lagophthalmos were both associated with increased duration of the disease (P=0.009), Grade II deformity in all limbs (P=0.001), punctate keratitis (P<0.001) and iris atrophy (P=0.003). Only the association with Grade II deformity persisted when controlled for duration of disease. Corneal nerve beading was associated with lepromatous leprosy (P<0.001) and high BI at any one site (P=0.05). Cataract was associated with age (P<0.001), decreased vision (P<0.001), lagophthalmos and orbicularis oculi muscle weakness (P<0.001) and lepromatous leprosy (P=0.028).
| Discussion|| |
India has the largest number of leprosy patients in the world. Approximately 70% of the 10 million cured leprosy patients reside in this country. Some of these patients had been treated with dapsone monotherapy for many years and have the potential to relapse. There are reports of relapse of the disease in patients years after they were treated with dapsone despite the negative skin smear for AFB.,,,,,,, These patients, although a small percentage, form a substantial number that may increase with time. Other patients who have a tendency to relapse are those who had received MDT pauci-bacillary treatment. It has been predicted that 5% of these would relapse 10 years after completion of their PB - MDT. It is plausible that these patients who had passed through an initial phase of the disease might have significant ocular complications when they present as relapsed multibacillary patients. Our group of relapsed multibacillary patients presented with certain ocular complications [Table - 3] but did not have pathology comparable to or in excess of those reported previously in other categories of Leprosy patients.,,,,,, The incidence of ocular complications was low, probably because 80% of patients in our group had tuberculoid leprosy, which is known to lead to fewer complications than the lepromatous variety and additionally because they all had received intense anti-leprosy treatment.
In our study reduction of vision was not due to leprosy-related ocular complications. Cataract was associated with lagophthalmos, lepromatous type of leprosy and grade II deformity. It is important to realise the difficulties inherent in seeking treatment for cataract surgery in these patients. Not only do these patients have to try and get through the stigma attached to the disease because of their deformity but also find a skilled and accessible eye care center to take care of both the cataract and the attendant leprosy-related ocular complications. In many leprosy endemic areas of India the responsibility of diagnosing and treating patients has been transferred to the primary health care centers and district hospitals from vertical control area programs. This necessitates training of personnel in these areas to identify patients with multiple problems in their eyes who need cataract surgery and appropriately refer them to centers where surgery can be undertaken with minimal risk.
In this series of patients we could not find any association between face patches and lagophthalmos or orbicularis oculi muscle weakness. Neither did we find such an association between reactions and the presence of lagophthalmos. However we did find a significant association between corneal nerve beading and lepromatous leprosy and a high BI Detecting corneal nerve beading on bio-microscopic examination would suggest that the patient belongs to the lepromatous spectrum of the disease and has a high bacillary content. Women tended to have more leprosy-related ocular complications in this series than men. Such an association has not been found in other prevalence studies. It is apparent from this study that ocular complications, both leprosy related and unrelated, do occur in relapsed patients though the magnitude of such complications is small. These findings are important when seen against the background of substantial changes that have occurred in the past two decades in the care of leprosy patients. The treatment time is considerably shorter, and patients are removed from the prevalence statistics once they have been cured after adequate anti-leprosy treatment. However, we fear the stigma of the disease is likely to continue and become an impediment to access essential health care, including eye care, for these patients and it is more true for patients who are struck twice with the disease.
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[Table - 1], [Table - 2], [Table - 3]
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