|Year : 1984 | Volume
| Issue : 2 | Page : 61-63
Ocular involvement from leprosy
PA Lamba, D Santosh Kumar
Department of Ophthalmology, Jawahar Lal Institute of Postgraduate Medical Education and research, Pondicherry, India
P A Lamba
Professor of Ophthalmology, Lady Harding Medical College New Delhi 110 001
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Lamba P A, Kumar D S. Ocular involvement from leprosy. Indian J Ophthalmol 1984;32:61-3
Frequency and severity of ocular involvement in cases of leprosy is directly proportional to the duration, degree of advancement of the disease and the treatment status of the patient. On account of lengthy duration of the illness, it invariably produces ocular disabilities. Visual impairment culminating to total loss of vision is a major tragedy in the life of a patient with leprosy. This visual disability is to a large extent preventable provided the ocular involvement is diagnosed at an early stage and appropriate measures are undertaken in time.
In view of the magnitude of the severity of the ocular involvement in leprosy and wide variation in the reported incidence of ocular lesions due to inclusion of those lesions which are not potentially sight threatening lesions, whom the author has termed lesions of `academic interest' or coincidental lesions, it was felt worthwhile to undertake a study.
| Material and methods|| |
325 patients of leprosy were examined by a team of qualified ophthalmologists, to determine the early and the late signs of eye involvement, and based on the experience acquired to grade the ocular disability with rationalisation for the benefit of field workers and also to make easy comparison between the various studies.
| Observations and discussion|| |
Out of the total 650 eyes, 87.3% eyes shows signs of ocular involvement due to leprosy. The prevalence of potential sight threatening lesions (STL) was only 33.62%. [Table - 1] Similar prevalence rate of such lesions was reported by Shields et al. The lesions of academic interest (like loss of eye brows, madarosis, cataract, conjunctivitis, pterygium) formed the main bulk and gave rise to higher frequency rate of ocular involvement in leprosy.
In the present study, 18 cases had cataract which was responsible for severe blurring of vision. In 17 cases cataract was seen to be a senile change and not considered to be the direct result of leprosy. As such these cases had been excluded from the potential sight threatening lesions. Only in one case the cataract was considered to be of complicated type on account of associated leprotic iridocyclitis. Similarly there were few more cases who had ocular disease (hypopyon corneal ulcer and traumatic cataract with perforation of globe following trauma) but were not in any case related to leprosy as the cause. Inclusion of such conditions as the cases of visual disability vitiates the results of ocular involvement in leprosy. The detailed work up of these cases of cataract using bio-microscopy made it clear that incidence of complicated cataract was only 5.5 percent and in rest of them it was only a senile change. Surgical lens extraction undertaken in these cases gave full recovery of vision comparable to similar age group not afflicted with leprosy. Leprosy in most of the cases is not responsible for the etiopathogenesis of such cataracts and the report 'cataract not an infrequent complication of lepromatous cases in India needs to be critically reviewed.
The existing literature on leprosy should be reviewed and analysed with special reference to the exclusion of lesions of academic interest or other coincidental causes for visual impairment. Stress should be laid on early diagnosis of sight threatening lesions and their appropriate management.
| Grading of ocular disabilities|| |
The Classification of disabilities in leprosy has been suggested in 1960 by WHO and had been later modified in 1969 (WHO BULLS= TIN). The ocular part of the WHO classification as given in [Table - 2] has quite a few lacunae and does not serve the purpose for which it was framed.
1) A classification which does not attempt to identify the type of disability but only aims at grading the severity of disability forfeits the very purpose.
2) Conjunctivitis in leprosy is not a disability nor it is an essential stage during the development of ocular leprosy. Moreover it might be a coincidental observation not causally related to leprosy. There is not true leprous conjunctivitis.
3) It is irrational to put lagophthalmos, keratitis, iritis and blurring of vision in the same group (Grade II) while they signify different stages of the condition. The prognosis and the management also is different. The condition like lagophthalmos could be effectively managed and further damaging effects to the unprotected cornea prevented. So it is more appropriate to have keratitis and iritis in a higher grade.
4) Blurring of vision is a very vague and nonspecific disability. It could be due to many clinical conditions like refractive errors, cataract or lesions at the macula which nay be totally unrelated to leprosy. So the term should be dropped and substituted by more specific conditions like perforation of cornea or onset of secondary glaucoma with associated blurring of vision.
| Proposed classification|| |
As more and more ophthalmologists are concerning themselves with ocular lesions in leprosy it becomes essential to classify the ocular lesions on a rational basis and properly identify potentially sight threatening lesion and a disability based grading of the lesions. The proposed classification divides the leprosy related visual disability into 5 grades [Table - 2].
The lesions have been grades depending upon the severity as well as the chronological sequence to facilitate a proper assessment and management.
Grade-I : Insensitivity of cornea is sight threatening lesions (STL) but not very severe in itself. Long standing neglect can render it serious.
Grade-II : Lagophthalmos by itself is not serious but due to the exposure of cornea is capable of producing exposure keratitis. However this causes corneal lesions in much less time than Grade I lesions and hence placed in a higher grade.
Grade-III : Lesions like Keratitis, Iritis, Scleritis produce visual impairment by themselves and are understandably more serious than Grade II lesions.
The Grade IV of proposed classification clearly signifies that the disease process is progressive. It may result in blurring of vision on account of perforation of cornea due to exposure or the chronicity of plastic iridocyclitis may result in the development of sequelae and secondary glaucoma which induces a progressive blurring of vision.
Grade-V : Signifies a burnt out disease in eyes with development of unilateral or bilateral phthisis bulbi (blind eye).
| Summary|| |
The proposed classification of ocular disabilities in leprosy gives a better understanding of the progress, the prognosis and also signifies when the preventive measures are likely to be successful. Only upto Grade-III the progress of the condition could be arrested or prevented.
The potentially sight threatening lesions (STL) have been identified and classified according to their severity as well as chronological order of appearance.
| Acknowledgement|| |
The author is grateful to the Indian Council of Medical Research, New Delhi for financial support. Thanks are also due to Dr. R Arthanariswaran and Dr. (Mrs) Shoba V. Bhat for technical assistance.
| References|| |
Shields J.A., Waring G.O. and Monte L.G., 1974, Amer. J. Ophthalmol. 77:880.
Ramanujam K, Sunder RR., and Khamnei A.A. 1978, Lepr. Review 231.
World Health organisation, 1960, Technical Report Series No. 189: 1969, Classification of disabilities resulting from leprosy. Bull. Wld. Hlth. Organisation 10:609.
Choyce D.P., 1967, Brit. J. Ophthalmol 53:217.
[Table - 1], [Table - 2]
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