Is leprosy blindness avoidable? The effect of disease type, duration, and treatment on eye damage from leprosy in Uganda.

AIMS: The study was designed to measure the prevalence, range, and severity of eye involvement in leprosy patients; to relate this to disease type, duration, and treatment to identify risk factors; and to provide practical guidelines for programme managers and field staff on the prevention of blindness. METHODS: The visual outcome was assessed in a population based sample of patients in Kasese District, Uganda followed for up to two decades, and related to disease features and treatment. A total of 678 patients responded to an invitation out of 2715 registered since 1973. RESULTS: Low vision was present in 4.4% of people and blindness in 1.3%, with 1.5% and 0.6% respectively being due to leprosy. Some 12.4% of patients had iritis, of whom 33% had visual loss in one or both eyes, 3.7% of patients had lagophthalmos, and 11.7% had lens opacity. For multi-bacillary (PB) cases, the adjusted odds ratios were: for iritis 4.6 (95% CI 2.6-8.2), for lagophthalmos 1.4 (0.6-3.2), and for lens opacity 1.7 (1.0-3.0). Potentially sight threatening (PST) lesions were present in 16.8% of patients (95% CI 14.0-19.6). CONCLUSION: Levels of eye involvement in this study are low compared with many surveys. Visual loss is uncommon and is more often caused by other diseases; in the present era of multidrug therapy (MDT) it is very unlikely to be caused by leprosy. It is more common with advancing age. PST lesions, especially iritis, may occur in both PB and MB cases, even if the diagnosis of leprosy is made early and MDT started immediately; they may occur also after completion of MDT. But eye complications need not proceed to loss of sight if treated promptly, and blindness can be avoided. Training of front line staff is therefore crucial.

A comparison of anterior and posterior chamber lenses after cataract extraction in rural Africa: a within patient randomised trial.

BACKGROUND: Extracapsular cataract extraction (ECCE) with a posterior chamber intraocular lens (PC IOL) is the preferred method of cataract surgery in developed countries. However, intracapsular cataract extraction (ICCE) with an anterior chamber lens (AC IOL) may be appropriate in rural Africa. A randomised controlled trial was carried out to compare these surgical strategies. METHODS: Participants over 50 years requiring bilateral cataract surgery were recruited from outreach clinics in rural north and east Uganda. One eye was randomly allocated to AC IOL or PC IOL, the other eye being allocated to the second strategy. The main outcome measure was WHO distance visual acuity (VA) category after a minimum of 1 year. Secondary outcomes were numbers and causes of complications and refractive corrections. RESULTS: Of the 110 participants recruited, 98 (89%) were assessed at least 1 year after the operation (median follow up 17.5 months). Nine eyes randomised to PC IOL were converted to AC IOL; one eye randomised to AC IOL inadvertently received PC IOL. There was no difference in VA between 95 pairs of eyes for which data for both eyes were available (uncorrected VA, p = 0.26; corrected VA, p = 0.59). 80 (82%, 95% CI 73 to 89) and 82 (84%, 95% CI 75 to 90) eyes randomised to AC IOL and PC IOL respectively had corrected VA of 6/18 or better. 16 (16%, 95% CI 10 to 25) and eight (8%, 95% CI 4 to 15) eyes respectively had secondary procedures or other complications. CONCLUSIONS: Where both strategies are available, ECCE with PC IOL should be first choice because of fewer complications. Where ECCE with PC IOL is not immediately feasible, ICCE with AC IOL is an acceptable interim technique.

Carcinoma of the conjunctiva and HIV infection in Uganda and Malawi.

AIM: To investigate the association of human immunodeficiency virus (HIV) infection and carcinoma of the conjunctiva in Africa, and the role of human papilloma virus type 16 (HPV-16). METHODS: Patients in Uganda and Malawi presenting to eye clinics with lesions suspicious of carcinoma were studied. Pathological confirmation of eye lesions was sought. HIV testing of patients who were biopsied and, in Uganda, of matched case control subjects was carried out as was testing of a sample of fixed biopsies for HPV-16 by polymerase chain reaction (PCR). The HIV-1 serology, histopathology of conjunctival biopsies (conjunctival intraepithelial neoplasia (CIN), invasive carcinoma, other lesions), and prevalence of HPV-16 infection were determined. RESULTS: Of Ugandan patients, 27/38 (71%) with carcinoma (27 invasive carcinoma, 11, CIN) were HIV positive compared with 12/76 (16%) of controls (odds ratio 13, 95% confidence interval 5-38). The calculated population aetiological fraction of carcinoma associated with HIV was 66%. Of 32 Malawian patients (20 invasive carcinoma, 12 CIN), 25/29 tested (86%) were HIV positive. HPV-16 infection was found in 7/20 (35%) of carcinoma samples, 0/9 pingueculae, and 2/6 conjunctivitis samples. CONCLUSIONS: HIV infection is strongly associated with an apparent increase in the incidence of conjunctival carcinoma in Africa. While ultraviolet light is probably the prime risk factor and HPV-16 is implicated in a proportion of cases, the interactions of ultraviolet light, HIV, HPVs, and other factors are unclear in the pathogenesis of carcinoma. The disease represents another model of multifactorial epithelial carcinogenesis.

PIP: During January-December 1994 at seven countrywide eye clinics and during September-October 1994 at New Mulago Hospital in Kampala, Uganda, biopsies were taken of suspicious conjunctival lesions and blood samples were drawn for HIV testing from all patients presenting. During October 1993 to March 1994 at the eye department of Queen Elizabeth Central Hospital in Malawi, biopsies were taken of suspicious conjunctival lesions from all patients. 38 patients in Uganda and 32 patients in Malawi had carcinoma of the conjunctiva. HIV-infected patients in Uganda were more likely to have carcinoma of the conjunctiva than HIV-negative patients (71.1% vs. 15.8%; odds ratio [OR] = 13.1). 2 of the 27 HIV-positive cases in Uganda had AIDS. The population etiological fraction of carcinoma associated with HIV infection stood at 66% for the Ugandan population. 86% of the tested Malawian patients (78.1% of all Malawian patients) had HIV infection. Almost 50% of HIV-infected Malawians had AIDS. Human papillomavirus-16 (HPV-16) was detected in 35% of invasive carcinoma cases but not in pingueculae and inflamed conjunctiva lesion cases. The researchers hypothesized that ultraviolet light, HIV, HPV-16, and other agents contribute to a complex carcinogenic process.

The 22nd Kellersberger Memorial Lecture, 1997. Preventing loss of sight from leprosy.

Multidrug treatment of leprosy is being dramatically successful in sterilising the infection. However complications are still occurring, spoiling the result in some patients by residual damage, including to the eye. Prevention of this damage is imperative. It is stressed that eye complications will only lead to loss of sight if they are neglected. The lesions caused by leprosy in the eye are briefly described. The dangerous lesions are lagophthalmos causing corneal exposure, and iritis causing pupil block glaucoma. Frequency of the lesions were very common in the past, but seem to be becoming much less so, though good epidemiological studies are sparse. Cataract, mostly not caused by leprosy, is the commonest cause of loss of vision. Prediction of complications would facilitate prompt treatment, but despite some clues, prediction is at present inadequate and all cases must be watched. The management of complications is discussed: studies of the indications and outcome of surgery for lagophthalmos, and of intraocular lens implantation for cataract are priorities. If knowledge is to be put into practice to prevent blindness, training of front line staff and organisation of the service is central. Experience of these practical aspects in Uganda in recent years is described.

Corneo-conjunctival carcinoma in Uganda.

AIMS: Since 1990, the incidence of conjunctival neoplasia has more than tripled in Uganda. It is known to be associated with exposure to solar ultraviolet radiation and to infection with the human immunodeficiency virus-1 (HIV). However, little is known about the most effective treatments. In this study, we report surgical outcomes among people with corneo-conjunctival squamous neoplasia in Uganda and investigate the role of HIV infection and other factors in the aetiology of the tumour. METHODS: Country-wide enrolment of participants; removal and histology of suspect lesions; HIV counselling and testing; home visiting of participants to determine outcomes. RESULTS: In 67 months between 1995 and 2001, 476 participants were enrolled (262 female, 214 male, median age 32 years). A total of 463 (97%) had eye-conserving removal of the lesion and 13 had other surgery. For 414, the histology was squamous neoplasia (184 invasive carcinoma, 230 intraepithelial). The prevalence of HIV infection in cases was 64%. In all, 96% were followed up for a median period of 32 months (range 0-81) after eye-conserving surgery during which time 13 (3.2%) had a recurrence. CONCLUSIONS: Surgery resulted in a low recurrence rate during the follow-up period and had minimal complications. The prevalence of HIV among cases was higher than expected on the basis of data from the general population, although about a third of cases were HIV-negative and had normal CD4 counts. No new cofactors were identified.

Evaluating the role of human papillomaviruses in conjunctival neoplasia.

Mucosal, cutaneous and Epidermodysplasia verruciformis (EV)-related human papillomaviruses (HPVs) were searched by broad-spectrum PCR in 86 conjunctival neoplasia biopsies and 63 conjunctival non-neoplastic control tissue from Ugandan subjects. Seven different EV-related HPV types, including a putative new HPV, and two mucosal HPVs were detected in 25% (14 out of 56) of HIV-positive, in 10% (three out of 30) of HIV-negative conjunctival neoplasia samples, and rarely (0-1.6%) in control subjects. The absence of high-risk HPVs and the low detection frequency of EV-related HPV types in more advanced tumour stages (10%) raise doubts about their role in conjunctival carcinomas.

Childhood blindness and low vision in Uganda.

PURPOSE: To examine the causes and outcome of subnormal vision starting in childhood in Uganda, to aid in planning for its avoidance and for rehabilitation. METHODS: All those seen having subnormal vision with onset from birth to 15 years (total 1135) (schools 1983-97; community 1988-97) were included in the study. Clinical examination was performed and a World Health Organisation (WHO) form completed, with analysis by its computer program. Main outcome measures were visual acuity, signs of eye pathology, outcome of treatment and refraction and low vision assessment. RESULTS: By WHO category 14.8% had visual impairment, 6.5% severe visual impairment, 63.2% were blind and 15.2% were too young to test. The acuities and causes were similar in school and community groups, excepting cortical visual impairment and multiple impairment, which are much commoner in the community. Cataract was the largest cause of visual impairment (30.7%) and surgical outcome was unsatisfactory. Visual loss following corneal ulceration was the second commonest cause of subnormal vision (22.0%). CONCLUSIONS: Cataract and corneal damage cause half of all subnormal vision, which is avoidable for both. Cataract surgery needs to be upgraded. To prevent corneal visual loss, primary health care should continue to be expanded, especially measles immunisation and nutrition care; rubella immunisation should be added. Special education needs to be greatly expanded. Public perceptions need changing if results are to be improved and help offered to more than the present minority.

Diphtheria-tetanus-pertussis immunization by intradermal jet injection.

An intradermal jet injector was used to administer combined diphtheria, tetanus, and pertussis (D.T.P.) vaccines to infants aged 2 to 12 months. A second dose was given one month after the first and a third six months after the second. Each dose was considerably smaller than the standard intramuscular dose. Blood samples taken one month after the third dose showed a satisfactory diphtheria and tetanus antitoxin response in all but a few cases. The antibody response to the pertussis component was not examined. Reactions were insignificant. Intradermal jet injection is proposed as a cheap, extremely rapid, and effective technique for D.T.P. immunization, especially suitable for use in remote areas where trained staff and facilities are few and many children require immunization.