Year : 1988 | Volume
: 36 | Issue : 3 | Page : 135--139
Clinico-histopathological study of the eye in leprosy
Sandeep Mithal, VK Pratap, Alka Gupta, Rajiv
Lecturer in Ophthalmology. Medical College, Meerut, India
Lecturer in Ophthalmology. Medical College, Meerut
Involvement of the eyes is one of the most serious complication that may occur in leprosy, and if neglected or left untreated may eventually give rise to blindness. 200 patients of leprosy were studied with the aim to know the extent of ocular involvement of the eye. Along with this conjunctival smear and biopsy were taken for histological and bacteriological examination. These findings were compared with the findings of smear and biopsy of skin taken for histological and bacteriological examination.
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Mithal S, Pratap V K, Gupta A, Rajiv. Clinico-histopathological study of the eye in leprosy.Indian J Ophthalmol 1988;36:135-139
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Mithal S, Pratap V K, Gupta A, Rajiv. Clinico-histopathological study of the eye in leprosy. Indian J Ophthalmol [serial online] 1988 [cited 2020 Sep 23 ];36:135-139
Available from: http://www.ijo.in/text.asp?1988/36/3/135/26128
"Blindness in the individual who has normal skin sensitivity is enough of a handicap but in one who has lost that faculty it is disatrous. Few have the resources, material, mental or spiritual to 'live with it". Estimation of leprosy sufferers in the world have always been difficult. A recent WHO report suggests that the number of leprosy sufferers is as high as 15 million in the world. In India it is about 3.2 million.
Keeping in view the importance of leprosy as a cause for serious visual impairment the present study was done with the aim to assess the extent involvement of the eye in leprosy. Along with this, a study was made to correlate the findings of histological and bacteriological examination of the skin along with histological and bacteriological examination of conjunctival biopsy and smear.
Material and Methods
This study included 200 patients of leprosy of both sexes and of different age groups. Cases were studied over a period of one year. All the patients were examined thoroughly, clinically as well as histopathologically, for skin lesions to confirm the diagnosis. The criteria for diagnosis of leprosy were those laid by Dharmendra (1967) :
1. Loss of sensation in skin patches.
2. Thickening and tenderness of cutaneous nerves.
3. Routine smear examination of skin for demonstration of M.Leprae.
Detailed external ocular examination was done with the help of a torch and the anterior segment with the help of a corneal loupe (X10) and slit lamp for finer details. Corneal sensation was tested with cotton wool wisp. Posterior segment was examined with the help of an ophthalmoscope. Vision was tested with Snellen's chart and the intraocular pressure was recorded.
Conjunctival smear was prepared and conjunctival biopsy of every leprosy patient was taken irrespective of their ocular involvement. For histological examination the section was stained with haemotoxyline and eosin and for bacteriological examination with Ziehl Neilson stain. Skin biopsy was taken from characteristic skin lesions and processed for histological and bacteriological examination.
In the end all the data was collected and analysed.
Leprosy cases were classified on the basis of clinical, histological and bacteriological findings.
Posterior segment lesions are extremely rare. There was only one case with a patch of healed choroiditis which we saw in a• case of Aphakia.
It is generally agreed that the eyes are frequently involved in a systemic disease process and leprosy as such can cause serious ocular complications.
As shown in [Table 1] maximum number of cases were of lepromatous leprosy (37.5%) followed by borderline tuberculoid (17.0%) & tuberculoid type (16.5%). Out of 200 patients studied 165 (82.5%) were males and 35 (17.5%) were females. Ebenzer (1961)  stated that incidence was less among women and children. The cause of this is the relative immobility of female patients.
The incidence of ocular involvement in this series was found to be 50.5% when all types of leprosy were considered together. Incidence was maximum in lepromatous type (76.0%), followed by border-line lepromatous (52.17%) and bordline tuberculoid (32.35%) types. In tuberculoid type it is only 18.18%. These findings can be compared to those of Borthern & Lie (1899) who found that the eye is invloved in 37.0% of tuberculoid type and in 74.0% of lepromatous type. Chance (1916)  recorded 75% ocular involvement in Norway.
The involvement of ocular adenexa was most common. Loss of eyebrows (73.26%) and Madarosis (41.38%) were the most common signs in lepromatous leprosy. Lagophthalmos was found to be 43.7% in tuberculoid type which corresponds with the findings of Ticho (1970) . Chronic conjuctivitis is quite common due to exposure and secondary bacterial infection (33.33%) (Abraham 1976) .
Early corneal manifestations were diminished corneal sensitivity (63.36%) but absolute anaesthesia is rare (Harley 1946). Beading of corneal nerves is also present. Superficial punctate keratitis was the most common corneal lesion (24.74%). Exposure keratitis was found mainly in case of lagophthalmos in tuberculoid cases (12.17%).
Involvement of the uveal tract is an important aspect of ocular leprosy because of the resultant blindness. In all the cases of leprosy anterior uveitis was found to be maximum in cases of lepromatous leprosy. Iris pearls at the pupillary margin (4.94%) and chronic granulomatous iridocyclitis (49.5%) were the common manifestations.
Involvement of the posterior segment is extremely rare. Somerset & Sen (1950)  found only 2 cases. In a few cases macular and choroidal degeneration was found which could have been due to other causes.
In the conjunctival smear AFB was seen in 59.0% of cases being maximum in lepromatous cases. On conjunctival histological examination 45.5% cases have shown varying histological patterns. 60.0% were of lepromatous type followed by tuberculoid type 54.5%. In 3 cases only, (L5%) on bacteriological examination AFB was seen in the conjunctiva. All of them were of the lepromatous type and different histological patterns were chronic inflammatory changes (69.5%), epithelial hyperplasia with chronic inflammation (19.78%), subepithelial vacuolization (12.08%) and foam cells (2.19%). On bacteriological examination of skin 160 cases (80.0%) have shown AFB out of which 92.0% were of the lepromatous type and 87.87% of the tuberculoid type.
The comparison of total number of cases of leprosy which were examined and lepromatous cases with conjunctival histological changes, conjunctival bacteriological examination and smear examination as shown in [Table 12][Table 13] is statistically significant.
On the basis of the study of 200 cases of leprosy the maximum percentage were of lepromatous leprosy (37.5%). 50.50% were cases with ocular involvement, more in males than females. Involvement of the ocular adenexa was most common. Important complications observed were loss of eyebrows, madarosis and lagophthalmos: corneal involvement due to lagophthalmos were mainly present in lepromatous leprosy. There was diminished corneal sensivity, superficial punctuate keratitis and exposure keratitis. The iris was the most commonly involved presenting as granulomatous iridocyclitis. Involvement of the posterior segment was very rare and in only one case of postoperative follow up of cataract extraction a patch of healed choroiditis was seen. 59.0% cases have shown positive AFB in the conjunctival smear. 45.5% have shown histological changes. On bacteriological examination 3 cases (1.5%) had shown AFB in the conjunctiva. In skin biopsies 80.0% cases had shown AFB on bacteriological examination. On comparison of skin histological & bacteriological findings with conjunctival smear examination and of conjunctival histological changes with bacteriological & smear examination both were satistically significant (P<.05).
It is therefore recommended that the eyes of all leprosy patients and not merely of those attending with eye complications should be examined monthly. Suspicious cases should be referred to eye clinics for more detailed examination. Treatment could then be initiated at a much earlier stage, and many more eyes can be saved. The aim should be to detect the ocular complications before the leprosy patient becomes an eye patient.
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|2||Ehenzer, R.: "Iritis in Leprosy". Proc. All Indian Ophth. Soc., 19,183-187, 1961.|
|3||Borthern, L. & Lie M.P.: "Die Lepre des Augesleipig Wilhelm Engleman", Cited by Duke Elder, Text Book of Ophthalmology, Vol.II, P.2320, 1899.|
|4||Chance, B.: Ann Ophth. 25, 432, Cited by Duke Elder in system of Ophthalmology Vol. IX, 1916.|
|5||Ticho. V. & Bensira. I.: "Ocular Leprosy in Malawai". Br. J. Ophth.54, 107-112, 1970.|
|6||Abraham. J.L.: Prevention & treatment of Eye Complications in Leprosy", Lep. In India, Vol. 48, No.8, 1976.|
|7||Harley, R.D.C.: Ocular Leprosy in Panama". Amer. J. Ophth, 29,295,1946. |
|8||Somerset. E.J.& Sen. N.A.: "Leprosy lesion of fundus Ocute". Br. J. Oph., 40, 164, 1956.|
|9||Sehgal, V.N.; Agarwal, D.P.; & Sehgal, N.: Ocular leprosy". Ind. J. Med. Res., 64, Nov. 11, P-1600-5, 1976.|