Catastrophic ocular complications in leprosy: a case report.

Leprosy is a chronic, granulomatous infectious disease commonly affecting the skin, nerves, mucosa and eyes. The stigma associated with the disease frequently leads to delay in presentation to health professionals. Treated patients, though considered cured presumptively, many continue to live with physical disabilities and deformities. Intact visual acuity prevents humans from trauma and any reduction in visual acuity, especially in leprosy, increases the risk of getting injured by many folds. Here, we present a case of leprosy with complete loss of vision due to bilateral anterior staphyloma secondary to keratitis and his physical deformities preventing him to take care of his eyes. This paper aims to emphasize on the importance of a baseline ophthalmology consultation in all newly diagnosed leprosy patients and repeat examination at onset of any new symptoms of the eye.

Corneal blindness in Plato's cave: the acting forces to prevent and revert corneal opacity. Part I: epidemiology and new physiopathological concepts.

The burden of corneal blindness and visual deficiency can be felt worldwide. Its association with several endemic diseases such as childhood blindness, trauma, infectious keratitis (including variants caused by herpes, hanseniasis, and fungi), vitamin A deficiency, diabetes mellitus, and other dry eye syndromes reflects its poorly understood underlying mechanisms and suggests that the actual frequency of the disease is underestimated. The low effectiveness of preventive and therapeutic strategies against corneal scarring or deformity predicts a high frequency of patients with corneal blindness in the future. Corneal blindness is associated with environmental factors and socioeconomic limitations that restrain health assistance and maintain a modest efficiency of the current therapeutic strategies for resolving corneal diseases in large-scale programs. We present here a critical review of the concepts associated with corneal blindness that need to be considered when planning strategies to prevent and treat corneal blindness worldwide (to be able to leave Plato's cave, where corneal blindness is encaged.

Unsolved matters in leprosy: a descriptive review and call for further research.

Leprosy, a chronic mycobacterial infection caused by Mycobacterium leprae, is an infectious disease that has ravaged human societies throughout millennia. This ancestral pathogen causes disfiguring cutaneous lesions, peripheral nerve injury, ostearticular deformity, limb loss and dysfunction, blindness and stigma. Despite ongoing efforts in interrupting leprosy transmission, large numbers of new cases are persistently identified in many endemic areas. Moreover, at the time of diagnosis, most newly identified cases have considerable neurologic disability. Many challenges remain in our understanding of the epidemiology of leprosy including: (a) the precise mode and route of transmission; (b) the socioeconomic, environmental, and behavioral factors that promote its transmission; and

Ocular leprosy.

Ocular involvement in leprosy is estimated to be 70-75%, about 10-50% of leprosy patients suffer from severe ocular symptoms, and blindness occurs in about 5% of patients. The disease leads to many ophthalmologic symptoms and signs in the range of the eyeball itself, as well as of the bulb adnexa, ie, eyebrows, eyelids with eyelashes, and lacrimal drainage system. Especially dangerous are complications of lagophthalmos and corneal hypoanesthesia, neurotrophic or infectious keratitis, and iridocyclitis and cataract formation, which may lead to significant decrease of visual acuity or even blindness. Multidrug treatment rapidly interrupts transmission of Mycobacterium leprae by infectious patients, but even after being completed, it does not guarantee the withholding of ocular complications.

Ocular leprosy

Ocular involvement in leprosy is estimated to be 70-75%, about 10-50% of leprosy patients suffer from severe ocular symptoms, and blindness occurs in about 5% of patients. The disease leads to many ophthalmologic symptoms and signs in the range of the eyeball itself, as well as of the bulb adnexa, ie, eyebrows, eyelids with eyelashes, and lacrimal drainage system. Especially dangerous are complications of lagophthalmos and corneal hypoanesthesia, neurotrophic or infectious keratitis, and iridocyclitis and cataract formation, which may lead to significant decrease of visual acuity or even blindness. Multidrug treatment rapidly interrupts transmission of Mycobacterium leprae by infectious patients, but even after being completed, it does not guarantee the withholding of ocular complications.

Ocular leprosy

Ocular involvement in leprosy is estimated to be 70-75%, about 10-50% of leprosy patients suffer from severe ocular symptoms, and blindness occurs in about 5% of patients. The disease leads to many ophthalmologic symptoms and signs in the range of the eyeball itself, as well as of the bulb adnexa, ie, eyebrows, eyelids with eyelashes, and lacrimal drainage system. Especially dangerous are complications of lagophthalmos and corneal hypoanesthesia, neurotrophic or infectious keratitis, and iridocyclitis and cataract formation, which may lead to significant decrease of visual acuity or even blindness.Multidrug treatment rapidly interrupts transmission of Mycobacterium leprae by infectious patients, but even after being completed, it does not guarantee the withholding of ocular complications.

Recent advances in ocular leprosy.

Proper MDT soon after detection of leprosy and anti-reaction measures with newer steroids, regular supervision and monitoring of those released from treatment (RFT) reduce the incidence of ocular leprosy to a remarkable extent. Today, most eye complications are because of normal ageing process or of other phenomena in normal healthy population. Cataract and lagophthalmos are the main causes of blindness. However, in India, though the rate of cataract surgical coverage is up to the mark, the same for lagophthalmos is lagging far behind. Integration of management of ocular leprosy into community eye health care service is the talk of the day along with other health care facilities delivered to people affected with leprosy (PAL). Routine eye examinations are necessary for all PB and MB patients, as well as for the RFT persons in order to detect and treat eyes that are at high risk. All eye surgeries can be performed when needed, irrespective of deformities and bacteriological status, by latest microsurgical techniques with good outcome, and better rehabilitation measures. Reorientation training in ocular leprosy is the immediate special need for ophthalmologists, paramedical ophthalmic assistants and eye health care managers working in general hospitals in those areas that were previously "leprosy endemic zones".

Análise das principais manifestações oculares de pacientes hansenianos nas regiões Norte e Sudeste do Brasil / Analysis of the main ocular presentations in leprosy patients in Northern and Southeastern Brazil

OBJETIVO: Analisar as principais manifestações oculares encontradas em pacientes diagnosticados com Hanseníase nas regiões Norte e Sudeste do Brasil. MÉTODOS: Foram examinados 28 pacientes com diagnóstico de hanseníase, sendo 12 pacientes - Grupo I, da região Sudeste (ABC) e 16 pacientes - Grupo II, da região Norte (Amazônica) do país. O Grupo I foi observado no período de agosto de 2003 a junho de 2004 no Ambulatório de Oftalmologia da FMABC-SP e o segundo grupo na 10ª missão do Projeto Amazônia Visão 2000 realizada no mês de julho de 2004. Todos os 28 pacientes foram submetidos a exame oftalmológico completo. RESULTADOS: Em relação ao sexo notou-se em ambos os grupos predomínio do sexo masculino. Observou-se um predomínio de indivíduos de 50 a 60 anos na região amazônica e de 40 a 50 anos na região do ABC. Quanto à forma clínica da doença observaram-se na região amazônica 13 casos (81%) de hanseníase virchowiana (MHV) e 3 casos (19%) de hanseníase tuberculóide (MHT). Na região do ABC 6 pacientes (50%) foram diagnosticados com hanseníase dimorfa (MHD), 5 (41%) hanseníase virchowiana e apenas 1 (9%) hanseníase tuberculóide. Não foram encontradas formas de hanseníase indeterminada (MHI) nas 2 regiões investigadas, sugerindo que em ambas, o diagnóstico foi tardio. CONCLUSÕES: Neste estudo verificou-se um predomínio das alterações oculares com maior gravidade nos pacientes examinados na região amazônica. Encontraram-se alterações oculares principalmente nas formas clínicas mais graves da doença.

OBJECTIVE: To analyse the main ocular presentations observed in leprosy diagnosed patients in Northern and Southeastern in Brasil regions. METHODS: Twenty-eight diagnosed leprosy patients were examined divided in two groups. Group I, compound by 12 patients at southeastern (ABC) and group II, compound by 16 patients at northern region (Amazon). Group I was examined from August 2003 to June 2004 at SP, in FMABC ophthalmology outpatient service and the second group was examined during the10th Mission of 2000 Vision Amazon Project that was carried out on July 2004. The twenty-eight patients were submitted to complete ophthalmological trial. RESULTS: It was noted predominance of male in both groups. It was noted the predominance of 50 to 60 years old individuals in Amazonian region and individuals aged 40 to 50 years old in ABC region. Concerning the clinical form of the disease, it was noted that, in Amazon region, there were 13 cases (81%) of Lepromatous leprosy and 3 cases (19%) of Tuberculoid leprosy. At ABC region there were 6 patients (50%) diagnosed with borderline leprosy, 5 (41%) lepromatous leprosy and only one (9%) with tuberculoid leprosy. There weren't forms of indeterminated leprosy in both investigated regions, what suggests a late diagnosis. CONCLUSION: It was verified a predominance of the most severe ocular changings among the examined patients at Amazonian region. It was observed ocular changings, mainly in most severe clinical forms of the disease.

Patterns of ocular morbidity and blindness in leprosy--a three centre study in Eastern India.

BACKGROUND: Eye disease and visual impairment due to leprosy are not uncommon, but their prevalence and the risk factors for such pathology have yet to be fully characterized. METHODS: An observational study of leprosy-affected individuals in the community, in three districts in Eastern India was performed to determine the prevalence of ocular morbidity and blindness. The subjects were chosen by stratified random sampling, according to stage of treatment, or stage of post-treatment surveillance. Each subject underwent ophthalmic examination according to a standard pro-forma. RESULTS: Thirty-three out of 1137 (2.9%) subjects were blind according to the WHO classification, and 232/1137 (20.7%) had moderate visual impairment. The prevalence of blindness and visual impairment was greatest in one centre, Jhalda. Multivariate Logistic Regression analysis showed that longer duration of disease, more advanced treatment stage and older age were independently associated with blindness. One hundred and forty-one cases (28%) in Muzaffarpur, 95 cases (63%) in Saldoha and 378 cases (78%) in Jhalda had active or treated multibacillary leprosy. DISCUSSION: The prevalence of blindness in leprosy varies in different population groups, with differing patterns of leprosy-related ocular morbidity, blindness and disease type evident even in different areas of the same region. Leprosy screening and surveillance programmes should include ocular examination as part of routine screening, particularly in individuals with a history of multi-bacillary disease. Individuals with known sight- threatening pathology should undergo continued active follow up. Local epidemiological studies would enable appropriate programme planning and efficient allocation of resources.

Lid surgery in patients affected with leprosy in North-Eastern Nigeria: are their needs being met?

Corneal blindness is second only to cataract as a cause of blindness in leprosy patients. Eyelid surgery provided by trained paramedical staff can often prevent blindness in these patients. We sought to determine the extent to which paramedic personnel are meeting the eyelid surgical needs of these patients and to investigate the barriers that may be preventing them from seeking surgery. A total of eight leprosy settlements in north-eastern Nigeria were selected for this study. In these villages, 480 residents who were 30 years of age or older who had been diagnosed as having leprosy had their eyes examined for the presence of lagophthalmos, entropion/trichiasis and evidence of surgery for either of these conditions. Patients who had not been operated on for either of these conditions were questioned to determine their reasons for not seeking surgery. One hundred and sixteen (12.1 %) eyes were in need of surgery while 5.1 % of eyes had been operated upon. The surgical coverage for eyelid surgery was 30%; lagophthalmos had a better surgical coverage of 44.4% compared to entropion/trichiasis, which had 24.7% coverage. Lack of awareness about the treatment available was the most common reason given for not seeking surgery. This study shows that despite the presence of trained paramedical staff in the community, the eyelid surgical needs of these patients are not being met primarily because the level of awareness about the availability of effective treatment still remains low. In addition, the readiness of eye-care staff to visit these settlements was disappointing. Extra efforts will have to be made.

Ocular leprosy in Nigeria: a survey of an Eku leprosorium.

To determine the ocular morbidity, visual disability and potential for blindness in leprosy patients recently released from treatment. In-patients from Eku leprosy settlement were interviewed and examined for ocular disease from leprosy and other causes. They were examined using the Snellen's chart, pentorch, Kowa portable slit-lamp, direct ophthalmoscope and the pulsair non-contact tonometer. The patients were also refracted. In all, 60 inpatients who were recently released from treatment, comprising 39 men (65%) and 21 women (35%), were examined. Fifty-eight patients (96.67%) had ocular symptoms, the most common being blurred vision in 23 patients (38.33%). Nine patients (15%) were blind. Cataract was the most common cause of blindness occurring in three of the nine patients (33.33%). The most common types of ocular lesions were madarosis (31.67%), lagophthalmos (16.67%) and cataract (16.67%). Potentially blinding conditions due to leprosy were seen in 42 patients (70%). The incidence of ocular involvement, blindness and potentially blinding conditions are high in leprosy patients recently released from treatment. Regular ophthalmic evaluation and integration into Vision 2020 programmes are recommended.

Cataract surgical coverage and barriers to uptake of cataract surgery in leprosy villages of north eastern Nigeria.

AIMS: To determine the coverage, outcome, and barriers to uptake of cataract surgery in leprosy villages of north eastern Nigeria. METHODS: People 30 years and above resident in eight leprosy villages were examined. Cataract blind people were questioned about the reasons they had not been treated. Subjects who had received an operation for cataract were examined to determine the outcome and, where applicable, the causes of poor outcome. RESULTS: 480 people were examined. Cataract was the commonest cause of blindness. The cataract surgical coverage (people) was 39.2% for orthodox surgery and 29.7% for couching. After surgery, visual acuity > or =3/60 had been restored to 82.1% of eyes that had had orthodox surgery, but only 58.6% of eyes that had been couched. Cost was the commonest reason given for not seeking treatment for cataract. CONCLUSIONS: Cataract is the major cause of blindness in this population but cataract surgical needs are currently not being met. There is a need for better collaboration between leprosy control and ophthalmic services, improved education of people affected by leprosy, a commitment to improving orthodox cataract surgery outcomes, and consideration of a possible role for traditional healers as sources of referral for orthodox surgical services.

Prevalence and causes of blindness and low vision in leprosy villages of north eastern Nigeria.

AIMS: To determine the prevalence and spectrum of ocular pathology, and the prevalence and causes of blindness and low vision in leprosy villages of north eastern Nigeria. METHODS: People affected by leprosy, aged 30 years and above, resident in eight leprosy villages were invited to participate. Ocular examination was undertaken of each consenting individual. RESULTS: 480 people were examined. 456 (48%) of 960 eyes had at least one ocular lesion, but only 37% of all lesions were leprosy related and potentially sight threatening. The prevalence of blindness (VA<3/60 with available correction) was 10.4%. An additional 7.5% of subjects were severely visually impaired (3/60< or =VA<6/60). Cataract was the commonest cause of blindness. Other major causes were non-trachomatous corneal opacity and trachoma. CONCLUSIONS: Blindness and low vision are highly prevalent among leprosy patients in this setting. Only a third of the burden of ocular pathology is related to the direct effects of leprosy. Efforts to reduce the backlog of cataract and trichiasis, to improve early detection and management of lagophthalmos, and to provide refractive services are urgently required.

Factors associated with sight threatening lesions of leprosy in patients on multidrug therapy.

One hundred and six consecutive patients (old and newly diagnosed) attending the leprosy clinic at Guru Teg Bahadur Hospital, Delhi, underwent a detailed ophthalmic examination to identify factors associated with the prevalence of sight threatening lesions of leprosy so as to delineate a sub-group of patients who should continue under active ophthalmic surveillance to prevent blindness. All of them were receiving multidrug therapy as recommended by WHO. Demographic data, systemic parameters and ophthalmic lesions attributable to the disease were endorsed on to a proforma. The data were analysed by chi-square test, discriminant analysis and multivariate regression analysis to isolate factors that could be associated with sight threatening lesions of leprosy. In 106 leprosy patients 212 eyes were examined; sight threatening lesions were found in 37 eyes (17.4%). The comea was involved most commonly (78.3%). The lesions were still present in 15.8% of patients who had completed multidrug therapy. Leprosy related visual impairment was seen in 2.3% eyes and blindness in 0.9% eyes. Factors significantly associated with sight threatening lesions included female gender, multibacillary leprosy, increasing duration of leprosy, thickened corneal nerves, subepithelial punctate corneal opacities and presence of any academic lesion of leprosy. On multivariate and discriminant analysis, female gender, thickened corneal nerves and duration of leprosy > 7 years were significantly associated with sight threatening lesions.

A survey of blindness and poor vision in leprosy patients.

OBJECTIVE: To determine the prevalence, cause and distributions of blindness and poor vision in patients with leprosy. METHODS: An epidemiological survey of blindness and poor vision among 1045 cases of leprosy was carried out in Taixing City of Jiangsu Province, China. RESULTS: The prevalence of bilateral blindness was 7.67%, unilateral blindness 4.4%, bilateral poor vision of various degrees 9.28% and unilateral poor vision 5.84%. The prevalence of eye complications varied significantly among different groups of patients; females had a higher prevalence than males, multibacillary patients higher than paucibacillary patients, and in-patients higher than out-patients. Corneal disease was the most common cause of blindness in study groups, followed by iritic disease and cataract; while the main cause of poor vision was cataract, then corneal and iritic diseases. Treatable blindness accounted for 62.7% of the cases and treatable poor vision for 88.6% of the patients studied. 56.62% of cases with eye complications expressed their willingness to be treated. CONCLUSIONS: Although prevention and treatment of low vision and blindness in leprosy patients is very hard, it is necessary for doctors and medical workers to make clear of the factors to cause low vision and blindness, especially those in leprosy patients so that some measures for prevention and treatment of the disease could be taken accordingly.

Leading causes of blindness worldwide.

The main causes of blindness and visual disabilities, as described in documents published by the World Health Organization (WHO), are discussed.

Knowledge and practice of eye-care among leprosy patients.

In one hundred and thirty leprosy patients attending the Schieffelin Leprosy Research and Training Center, Karigiri, Tamil Nadu, India, the knowledge, attitude and practice of eye-care were ascertained using a questionnaire developed by Mathews & Mangalam. 74.6% the patients surveyed were aware of the disease, 60% knew about the early signs of leprosy, 74.6% considered leprosy curable and 36.9% knew the duration of treatment with MDT. Less than half of the patients (40.8%) knew that blindness occurred in leprosy and was preventable. More males had this knowledge (46.5%) than females (22.6%) (P = 0.001). Knowledge on how to take care of the eyes (26.9%), that eyes become anaesthetic due to leprosy (27.7%), and that precautions should be taken if sensation is lost (27. 7%) was very poor. Knowledge on prevention of damage in eyes (57.7%) and the fact that rubbing eyes could cause damage (55.4%) was found in more than half the patients. More males (64.6%) had knowledge on the prevention of damage in eyes than females (35.5%) (P = 0.008). Only 25.4% of the patients tried some measures to prevent eye injury, 21.5% used home remedies and all had the help of family members in their eye-care. More males (26.3%) used home remedies than females (6.5%). The older age group had better knowledge on taking care of the eyes than those aged 40 and below (P = 0.026). Although more patients with existing complications knew to take care of their eyes than those who did not have complications, the knowledge and practice of eye-care in both these groups were poor. Knowledge of leprosy in illiterate patients was not different from those who had some formal schooling, but the practice of eye-care differed significantly (P = 0.02). Health education must be undertaken to increase the knowledge of eye-care among leprosy patients, especially among illiterate persons, women and younger patients.