Surgical management in ocular leprosy

PA Lamba; Renuka Srinivasan; Jolly Rohatgi

Users Online: 2153

ORIGINAL ARTICLE

Year : 1987 | Volume : 35 | Issue : 3 | Page : 153-157

Surgical management in ocular leprosy

PA Lamba, Renuka Srinivasan, Jolly Rohatgi
Deptt of Ophthalmology, Lady Hardinge Medical College, New Delhi-110 001, India

Correspondence Address:
P A Lamba
Deptt of Ophthalmology, Lady Hardinge Medical College, New Delhi-110 001
India

Source of Support: None, Conflict of Interest: None

Check

PMID: 3507412

Abstract

160 Patients of leprosy with or without visual disability were submitted to various surgical procedures as prophylatic or curative measures The various procedures undertaken included cataract surgery, ectropion correction, trabeculectomy tarsorrhaphy and keratoplasty. The utility of repositioning of pupil achieved by xenon arc photocoagulation for cases of centrally situated corneal opacity has been introduced with encouraging results Such a procedure is of particularly benefit in patients who are poor risk for keratoplasty. Surgery in leprosy offers a new hope to patients with advanced ocular complications due to this crippling disease.

How to cite this article:
Lamba P A, Srinivasan R, Rohatgi J. Surgical management in ocular leprosy. Indian J Ophthalmol 1987;35:153-7

How to cite this URL:
Lamba P A, Srinivasan R, Rohatgi J. Surgical management in ocular leprosy. Indian J Ophthalmol [serial online] 1987 [cited 2021 Apr 18];35:153-7. Available from: https://www.ijo.in/text.asp?1987/35/3/153/26192

Click here to view

The main causes of visual disability in leprosy are the effects of corneal and lens opacities, uveitis or a combined effect of all of them Surgical management of ocular leprosy has in most instances been restricted to extraocular surgery viz tarsorrhaphy, ectropion correction etc. Cataract contributes greatly to the morbidity of lepromatous leprosy^[1] and its effect is compounded by an extreme miosis The other possible deterrents to intraocular surgery have been the presence of uveitis with bound down pupil, risk of possible exacerbation of iritis, and the presence of corneal involvement Cataract extraction has been attempted in cases of leprosy by various workers with fairly gratifying results^[2],[3],[4]- Xenon arc photocoagulation was utilised for repositioning of the pupil for achieving visual improvement in cases of subluxation of lens by one of us ^[5] The use of this technique was extended to cases of leprosy with corneal opacity in the present study. The experiences of surgical management of ocular leprosy are detailed hereunder.

Material and Methods

In this study 626 eyes of leprosy patients were examined with a view to evaluate the role of surgery in the management of ocular disability. 160 patients likely to benefit from surgery were selected. The aims of surgical intervention were preventive, cosmetic and for visual rehabilitation

The commonly encountered ocular lesions were corneal anaesthesia 40.5%, corneal opacities 19%, lagophthalmos 12.2%, uveitis 7.75% and lens opacities 7.8%. [Table - 2] gives the surgical procedures performed in cases of leprosy.

Observations and Results Cataract Surgery

50 eyes of 49 cases were subjected to cataract surgery. Of these 32 had mature and 18 had immature cataract Associated uveitis was present in 7 cases and 5 cases had varying grades of corneal opacities In 6 cases there was impaired corneal sensation and one patient had secondary glaucoma Iris tissue excised during complete iridectomy was submitted for histopathological examination

[Table - 3] gives the results of cataract extraction and it is observed that in 86% of cases it was possible to take out the lens intracapsularly. In majority of patients there was no reactivation of iridocyclitis on account of intracapsular extraction combined with the use of prophylactic steroid therapy. The visual results were quite encouraging. In 30 cases the vision improved to6/ 18, while in 8 patients the vision improved upto 6/60. Lack of visual improvement was observed to be due to coloboma of iris and choroid (1 case), extensive corneal opacities with healed uveitis (1 case) and the presence of secondary glaucoma (1 case).

Iris tissue submitted for histopathology did no demonstrate lepra bacillus and also did not show evidence of active inflammation. Dilator pupillae muscle was seen to be atrophic [Figure - 1].

Ectropion Correction

Of the 10 cases with ectropion, one patient underwent temporalis muscle transfer and the remaining 9 patients had ectropion correction by the Kuhnt - Szymanowsky procedure In all the cases results were highly satisfactory with complete correction of ectropion and relief of epiphora [Figure - 2].

Temporalis muscle transfer was considered only in extreme stages of lagophthalmos In earlier stages ectropion correction with lateral canthal tarsorrhaphy gave good functional results

Photocoagulation

Iris photocoagulation was done using Xenon arc photocoagulation to reposition the pupil (12) against the clear part of the cornea in cases of corneal opacity for achieving visual improvement Selective sectorial dilatation of pupil was done in 16 cases [Figure - 3] illustrates sectorial mydriasis to a position up and in, towards to clear cornea The visual improvement was almost immediate and gratifying. It was undertaken as an out-patient procedure. [Figure - 4] shows the new pupil formed at down and out position in a case of adherent leucoma using xenon arc. Photomydriasis was achieved in 7 cases with chronic iridocyclitis having a bound down pupil which failed to dilate with usual medical measures

Trabeculectomy

Trabeculectomy was done in 3 cases, of which two were in advanced stage of glaucoma One case also had associated old sclerokeratouveitis and ciliary staphyloma. Following the filtering surgery, the intraocular pressure in all patients was adequately controlled. In one patient there was evidence of improvement of vision following the surgery on account of reduction of corneal oedema. The ciliary staphyloma also flattened out following the control of pressure.

Keratoplasty

Two cases underwent penetrating keratoplasty. In one case the graft had become opaque during the period of follow up (6 months). The other patient with full thickness graft showed a slight haze in the graft after 2 months when he was lost to follow up [Figure - 5].

Tarsorrhaphy

Lateral tarsorrhaphy was done in 53 cases of leprosy who came with lagophthalmos of varying grades In 19 patients of tuberculoid leprosy without lagophthalmos, but showing reduced break up time of tear film, this procedure was done using tarsorrhaphy lid clamp^[6]sub as a prophylatic measure to prevent the occurrence of neurotropic or exposure keratitis These cases were reviewed at periodic intervals No case to the best of our knowledge has developed corneal changes so far (3 years follow-up). For patients with mild degree of lagophthalmos this procedure improved the state of corneal health and the opacity in the lower part of the cornea appeared fainter over a period of time

Discussion

Involvement of the eyes is one of the most serious complications that can occur in leprosy and if neglected may eventually lead to blindness Early detection of ocular affection is often difficult unless regular ophthalmic surveys are conducted as most of the lesions have an insidious onset and pass un-noticed until gross and often irreversible visual damage has occurred^[7] Medical treatment in such conditions is often of little help in restoring vision. This is particularly exemplified in cases of chronic uveitis and corneal opacities The affections are often bilateral with marked rigidity of pupils and lenticular opacities Many such patients are often lost to follow up owing to sheer desperation. Surgical treatment in these cases is deferred by most surgeons This is probably due to high risk nature of these cases owing to the systemic disease and also to the unpredictable nature of the outcome of surgery owing to risk of exacerbation of uveitis This study has revealed encouraging results after both intra and extra ocular surgery in these cases

Contrary to previous reports^[1],[4] cataract in this study was mostly of the senile type uncomplicated by uveitis. The results of lens extraction in these cases were comparable to those of cataract surgery on non leprous patients Our observations differ from those of Ffytche^[3] who performed cataract extraction in 81 patients with ocular leprosy and reported a high frequency of complications Earlier surgeons have also commented on the friability of the iris (8-11). We were able to perform intra capsular extraction with peripheral iridectomy in most cases Only a small number of cases with poorly dilating pupils or with uveitis required complete iridectomy. Histopathological study of the iris in such cases showed evidence of dilator muscle atrophy. Another important observation was that in cases with old uveitis, intraocular surgery under cover of systemic steroids was withstood very well by all patients and in no case was there an exacerbation of uveitis.

Cases of paralytic ectropion were adequately corrected by Kuhnt-Szymanowsky technique Patients were relieved of epiphora. Earlier reports have cited poor results of standard technique of ectropion correction in these patients The temporalis sling procedure has been particularly advocated in leprosy patients with ectropion We feel that this needs to be tried only if the Kuhnt's method is unsuccessful

The relatively newer concept of photo coreoplasty.^[12]seems to have an important role in the management of ocular leprosy. It offers a useful alternative to keratoplasty in patients with corneal blindness when opacities are situated centrally. Mydriatics often fail to dilate the pupils and keratoplasty is rendered hazardous owing to corneal anaesthesia and associated chronic uveitis. Such eyes get useful vision after segmental dilatation of the pupil in the region of clear cornea by photo-coagulation. We used the Xenon Arc photocoagulation for this purpose. Xenon Arc besides being a relatively safe and non invasive procedures is of particular benefit in patients who are poor risks for keratoplasty, in centres where keratoplasty is not feasible and also when treatment on larger scale is contemplated

Cases of glaucoma in leprosy are uncommonly encountered. Of the 3 cases, 2 were already in the absolute stage and surgery was useful in bringing down the intraocular tension and thus alleviating the pain. The 3rd case which was also quite advanced with sclero-uveitis and staphyloma did surprisingly well after surgery.

Tarsorrhaphy was performed in two types of cases - those with lagophthalmos or corneal hypoasthesia with or without exposure changes Although not so effective in relieving epiphora, it is a very effective and simple procedure in preventing exposure changes of the cornea or allaying its progress if it is already occurred. It was also tried in some cases with no lagophthalmos but with early comeal hypoasthesia with a hope that this might prevent the occurrence of sight threatening corneal changes None of the patients have so far shown evidence of corneal changes.

To sum up, surgery in leprosy offers anew hope to patients with advanced ocular complications due to this crippling disease. [Table - 4] summarizes the steps which need be taken for early diagnosis, prevention and management of ocular disability in leprosy.

References

1.	Malla CK, Brandt F, Anten JGF, 1981. Brit J. Ophthalmol, 65/4: 226-230.
2.	Kerr Muir MG, 1984 with XII International Leprosy Congress, New Delhi, 1984. Ffytche TJ, 1981. Brit J. OphthalmoL 65: 243-58.
3.	Roy IS, Samanta SK 1984 Ind J. L epr, 56: 239.
4.	Lamba PA4 Santosh Kumar D, Arora, 1985.
5.	Brit J. Ophthalmol, 69: 291-293.
6.	Lamba PA,, 1983. Brit J. Ophthalmol, 67: 61-62.
7.	Lamba PA, Santhosh Kumar D, 1984. Ind J. Ophthalmol, 32: 61-63.
8.	Woods DJ, 1925. Brit J. Ophthalmol, 9:1-14.
9.	Prendergast JJ, 1940. Arch. OphthalmoL 23:112-137.
10.	Harley RD, 1946. Amer. J. Ophthalmol. 29: 295-316.
11.	Ebenezer R, 1963. Proc All India OphthaL Soc, 19:183-188.
12.	Lamba PA Santhoshkumar D, 1984. Ind J. L.epr, 56/1 A-9.