Indian Journal of Ophthalmology

ORIGINAL ARTICLE
Year
: 2003  |  Volume : 51  |  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

Correspondence Address:
E Daniel
Department of Ophthalmology, Schieffelin Leprosy Research and Training Center, Karigiri, Vellore District, Tamil Nadu-632 106
India

Abstract

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.



How to cite this article:
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;51:155-159


How to cite this URL:
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 2020 Apr 5 ];51:155-159
Available from: http://www.ijo.in/text.asp?2003/51/2/155/14712


Full Text

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.[1],[2],[3] 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.[4],[5] 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 ,[6] 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.[7] 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.[8],[9],[10],[11],[12],[13],[14],[15] 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[2],[16] and the Ridley and Jopling[17] 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,[16] 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.[18]

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 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.

References

1WHO Study Group. Chemotherapy of leprosy. WHO Technical Report Series No 847. Geneva: World Health Organization, 1994.
2WHO Expert Committee on Leprosy. Sixth Report. WHO Technical Report Series, No 768. Geneva: World Health Organization, 1988.
3WHO Expert Committee on Leprosy. Seventh Report. WHO Technical Report Series, No 874. Geneva: World Health Organization, 1998.
4Noordeen SK. Leprosy control, elimination, and eradication. Indian J Lepr 2000;72:65-68.
5Desikan KV. Elimination of leprosy: Aspirations, achievements and prospects. Indian J Lepr 2000;72:87-96.
6Ffytche T. Blindness in leprosy - A forgotten complication . Aust NZ J Ophthalmol 1989;17:257-60.
7Courtright PD. Defining the magnitude of ocular complications from leprosy: Problems of methodology. Int J Lepr Other Mycobac Dis 1988;56:566-73.
8The Leprosy Unit, WHO. Risk of relapse in leprosy. Indian J Lepr 1995;67:13-26.
9Srinivasan H. Symposium on relapse in leprosy. Indian J Lepr 1995;67:1-2.
10Naafs B. Features of relapse in paucibacillary leprosy after multidrug therapy. Indian J Lepr 1995;67:61-7.
11Ganapati R. Relapse in leprosy. Indian J Lepr 1995;67:195-97.
12Soares DJ, Neupane K, Britton WJ. Relapse with multibacillary leprosy caused by rifampicin sensitive organisms following paucibacillary multidrug therapy. Lepr Rev 1995;66:210-13.
13Vijayakumaran P. Profile of relapses after MDT in paucibacillary leprosy and subsequent management. Indian J Lepr 1996;68:300-3.
14Edward VK. Relapse in leprosy. Indian J Lepr 1995;67:333-34.
15Ponnighaus JM, Sterne JA. Epidemiological aspects of relapses in leprosy . Indian J Lepr 1995;67:35-44.
16World Health Organization. Report of a study group:chemotherapy of leprosy for control programmmes. World Health Organization Tech Rep Ser 1982. p.675.
17Ridley DS, Jopling WH. Classification of leprosy according to immunity - A five group system. Int J Lepr Other Mycobact Dis 1966;34:255-273.
18Miller SD, Thompson HS. Edge-light pupil cycle time Br J Ophthalmol 1978;62:495-500.
19Soshamma G Suryawanshi N. Eye lesions in leprosy Lepr Rev 1989;60;33-38.
20Das R, Goswami A, Mitra AK, Roy IS. Ocular complications in leprosy. J Indian Med Assoc. 1980;74:5-8.
21Brandt F, Malla OK. Albrecht Von Graefes. Ocular findings in leprous patients. A report of a survey in Malunga/Nepal. Arch Klin Exp Ophthalmol . 1981;217:27-34.
22Lamba PA, Kumar DS. Ocular involvement from leprosy. Indian J Ophthalmol . 1984;32:61-63.
23Prasad VN, Narain M, Mukhija RD, Bist HK, Khan MM. A study of ocular complications in leprosy . Indian J Lepr . 1984;56:241-50.
24Tsai HH , Suryawanshi N. Ocular complications in patients with leprosy in Karigiri, South India. Lepr Rev . 1985;56:135-41.
25Cakiner T, Karacorlu MA. Ophthalmic findings of newly diagnosed leprosy patients in Istanbul Leprosy Hospital, Turkey. Acta Ophthalmol Scand. 1998;76:100-2.