Prevention of blindness in leprosy and the role of the Vision 2020 Programme.

Leprosy control programmes are highly successful. As a result, leprosy control will be more and more integrated into the general health services. The existing vertical, specialized control programmes will be dismantled. Eye complications in leprosy have decreased. This is a result of earlier diagnosis and highly effective multidrug treatment (MDT) of leprosy, combined with timely treatment of secondary nerve damage by steroids. Most ocular morbidity is now found among elderly and disabled leprosy patients who were diagnosed before effective MDT treatment became available. Many of these patients live in leprosy settlements. Age-related cataract has become the leading cause of blindness in leprosy. The second cause of blindness is corneal opacification, mainly as a result of neglected exposure keratitis and corneal anaesthesia. The miotic pupils in late multibacillary leprosy, in combination with small central lens opacities, may also lead to blindness. The Vision 2020 Initiative prioritises cataract surgery. Leprosy patients should be actively included. Disabled leprosy patients can also benefit from screening programmes for refractive errors and the provision of spectacles and low vision aids. Determining the most feasible surgical methods for lagophthalmos surgery remains a challenge. For all health and eye care staff, training in leprosy and its eye complications is needed, as well as a change in attitude towards leprosy patients. Staff must be prepared to welcome them in the general health services.

Strategies for improvement of management of ocular complications in leprosy.

Responsibility for eye care of leprosy-affected persons should be shared between leprosy and eye care staff. Leprosy and PHC staff should be responsible for: treatment of reversal reactions in the face, and of recent lagophthalmos, with prednisolone, conservative treatment of mild lagophthalmos, referral of patients with severe lagophthalmos and/or exposure keratitis, unless there is sufficient expertise within the programme, recognition of the acute red eye and treatment of acute conjunctivitis, referral of all other conditions of acute red eye, unless there is sufficient expertise within the programme, recognition of severe visual impairment and referral as needed, recognition of the need for reading glasses in patients aged over 40 years, in rehabilitation services, encouraging medical colleges, Control of Blindness Societies, and staff of general eye care facilities, to actively take part in the treatment of eye complications in patients affected by leprosy, and encouraging charitable organizations to provide special eye care programmes for patients affected by leprosy, in particular for those who are disabled and are living in leprosy settlements. Eye care services (a visiting ophthalmologist or paramedical ophthalmic assistant to the specialized leprosy centres for consultation is an appropriate alternative and may sometimes be even more feasible) should take the responsibility for: eyelid surgery in patients with large lid gaps (> 6 mm), or, signs of exposure keratitis, and treatment and follow-up of acute iritis, corneal ulcers, foreign bodies, and other causes of 'the acute red eye', in cooperation with the leprosy service or PHC staff. The eye care services should offer 'positive discrimination' in the treatment of cataract-blind leprosy patients, realizing the great difficulties that these patients have in avoiding injuries or taking care of injuries once they have occurred, especially in the case of limbs that have lost protective sensation.

The pattern of cataract and the postoperative outcome of cataract extraction in Ethiopian leprosy patients as compared to nonleprosy patients.

Cataract is a blinding disease occurring all over the world. One of the causes of cataract is leprosy. Sixty leprosy and 100 nonleprosy patients were assessed and underwent intracapsular cataract extraction. Leprosy patients with cataract were much younger than nonleprosy patients. The leprosy group had a significantly higher rate of complications and this was seen more in paucibacillary cases. There was a higher rate of visual disability in the leprosy group than in the nonleprosy group. Cataract was seen in younger patients in the leprosy group. This raised the possibility of leprosy being the cause of the cataract. The leprosy group consisted mostly of multibacillary cases, however unlike in other studies the rate of complications tended to be higher in the paucibacillary group. There were no preoperative findings that correlated with a low postoperative intraocular pressure.

Corneal sensitivity in patients with leprosy and in controls.

AIMS: In a quantitative prospective study the corneal sensation in patients with leprosy was compared with age matched controls. METHODS: The patients with leprosy were classified as paucibacillary and multibacillary and were divided in three groups: (1) patients without clinically detectable eye pathology; (2) patients with lagophthalmos, (3) patients with signs of iridocyclitis. The corneal sensitivity was assessed with the Cochet and Bonnet aesthesiometer. RESULTS: There was a significant decrease in corneal sensitivity in multibacillary patients without clinically detectable eye pathology and in patients with lagophthalmos or iritis when compared with controls. A significant correlation between the loss of power of the orbicularis oculi muscle and the degree of corneal sensation loss could not be established. No significant decrease in corneal sensitivity was found in paucibacillary patients without eye pathology compared with the control group. CONCLUSION: The results of this study showed that loss of corneal sensation can occur while there is no clinically detectable eye pathology, at least in multibacillary patients. Regular checkups of the corneal sensation should, therefore, be part of the routine control of leprosy patients. Health education on eye care and early warning signs should be encouraged.

Eye disease in newly diagnosed leprosy patients in eastern Nepal.

To determine the magnitude of eye lesions in newly diagnosed leprosy patients we examined their eyes. The Eastern Leprosy Control Project was supported by The Netherlands Leprosy Relief Association; we used the regional clinic in Biratnagar and 5 mobile clinics in surrounding districts as our survey area. All patients who presented at the clinics over 10 weeks, diagnosed as having untreated leprosy were included. Of the 260 examined patients 97 (37.3%, 95% confidence interval 28.3-40.3%) had an eye lesion; 12/260 patients (4.6%, 95% confidence interval 2.0-7.2%) had sight-threatening lesions (lagophthalmos, iris involvement, corneal anaesthesia), directly related to leprosy; 46 (17.7%) patients were diagnosed as having some degree of cataract; 2 patients were aphakic; 3 patients (1.2%) were blind according to the WHO definition. In this series of new and untreated leprosy patients many eye lesions found are not relevant or leprosy related. There were 9 new patients with lagophthalmos, some too longstanding to treat with steroids. We found 3 patients with iris involvement. The figures we found for eye lesions, sight-threatening lesions and blindness are low when compared to other studies. The number of patients with any grade of cataract is high. The average total of leprosy patients who were blind can be compared with the average total who are blind in the general population.

Disabilities of hands, feet and eyes in newly diagnosed leprosy patients in eastern Nepal.

The objective of the study was to determine the magnitude of hand/feet/eye disabilities in newly diagnosed leprosy patients by examining all newly diagnosed leprosy patients who presented at the Eastern Leprosy Control Project (supported by The Netherlands Leprosy Relief Association), made up of a regional clinic in Biratnagar and 5 mobile clinics in surrounding districts. The study comprised of all new and previously untreated patients who presented at the clinics over a 10-week period who were diagnosed as leprosy sufferers. Of the 260 leprosy patients examined 12 (4.6%) had sight-threatening lesions (lagophthalmos, iris involvement, corneal anaesthesia); 3 patients were blind due to cataract; 96/260 patients (37.0%, 95% confidence interval 35.0-43.0%) had 1 or more disabilities of their hands and/or feet. The most frequently found disabilities were sensory loss of the hands and feet, claw hand and plantar ulcers. According to the WHO disability grading 60% had no disabilities, 19% had grade 1 and 21% had grade 2 disability. Disability assessment is very important not only to evaluate the effectiveness of the control programme but also for the patient, whose most important worry is the stigmatizing deformities leprosy patients suffer. The earlier detection of sensory loss might reduce these secondary deformities.

Paralysis of facial muscles in leprosy patients with lagophthalmos.

The objective of the study was to determine the pattern of involvement of facial muscles in lagophthalmos. Fifty-seven patients with lagophthalmos were examined to assess the degree of paralysis of facial muscles. Eighty-one percent of the patients with lagophthalmos had involvement of at least one other muscle group. In patients with lagophthalmos with a gap at mild closure of 5 mm or more, 27 of 30 (90%) had involvement of at least one other facial muscle. In lepromatous leprosy the pattern of involvement was symmetrical and "patchy," the right and left sides being affected equally. In tuberculoid leprosy, the ipsilateral muscles were more often involved, which is the pattern of involvement of a nerve trunk. The upper and lower facial muscles were affected in the same proportion. Hence, on clinical grounds, there is little support for the often postulated statement that the superficial course of the facial nerve above the zygomatic bone is decisive for exclusive paralysis of the zygomatic branch of the facial nerve.

Progression of eye lesions in leprosy: ten-year follow-up study in The Netherlands.

Forty-eight leprosy patients in The Netherlands were re-examined 10 years after initial examination. Forty-six of these patients had received a course of multidrug therapy (MDT), according to the World Health Organization recommendation, at the time of their initial examination. Two patients had burned-out disease and had been merely under observation. Out of 40 patients, who initially did not show eye complications due to leprosy, 37 patients were essentially the same 10 years later. The eyes had changed in 3 multibacillary patients: 1 patient had developed a late type 1 reaction with facial nerve involvement and lagophthalmos; 2 patients had undergone intra-ocular surgery for cataract and acute glaucoma, respectively. Out of 8 patients with pre-existing eye involvement, 1 patient recovered and the lesions in 2 patients remained unaltered. One patient showed progression of pre-existing exposure keratitis. Four patients had undergone cataract extractions; all four patients were lepromatous, with a long history of disease and signs of iris involvement at the first examination. The main progressive lesions were cataracts in lepromatous patients.

The significance of facial patches and type I reaction for the development of facial nerve damage in leprosy. A retrospective study among 1226 paucibacillary leprosy patients.

Charts of 1226 paucibacillary leprosy patients, registered between 1982 and 1987 were reviewed for recent facial nerve damage, facial patches and the presence of Type I reaction. Twenty-six (2.1%) patients with recent lagophthalmos were identified. In a great majority (85%) patients with recent lagophthalmos showed significant patches over the malar region or around the eye, at the same side as the nerve damage together with clinical signs of Type I reaction. This combination of significant patches in certain locations and Type I reaction seems to be a pre-condition for facial nerve damage. The clinical implication is that a small group of patients may be identified, who are at risk of facial nerve damage. By examining these patients more carefully it will be possible to detect nerve damage early and to prevent permanent damage of the facial nerve by timely treatment with an appropriate steroid regimen.

Treatment of recent facial nerve damage with lagophthalmos, using a semistandardized steroid regimen.

Twenty-seven patients with borderline leprosy and facial nerve damage of less than or equal to 6 months duration (36 eyes) were treated with a semistandardized regimen of steroids (the average starting dose was 25-30 mg, duration 5-6 months) on an outpatient basis. Red and raised reactive patches were usually present in the upper malar area or around the eye(s) in patients with recent lagophthalmos. The lid gap was measured in millimetres during gentle and strong closure. After completion of the steroid course 75% of the eyes had complete closure or only a slight gap of less than or equal to 2 mm on gentle closure. Steroids were found to be beneficial and safe, in the dosage that we prescribed.