Ocular Leprosy

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ocular leprosy
  Chapter: 9 Ocular leprosy Structure: 9.1   Introduction 9.2   Causes of ocular involvement in leprosy 9.3   Causes of blindness in leprosy 9.4   History & Examination of eye 9.4.1   History for ocular lesions: 9.4.2   Examination of eye: 9.4.3   Lesions due to involvement of ocular tissue 9.4.4   Red Eye- Differential Diagnosis 9.4.5   Ocular lesions due to involvement of nerves 9.4.6   Consequences of nerve paralysis 9.4.7   Grading of Disability (WHO) 9.5   Management of ocular lesions in leprosy 9.5.1   Basic principles for management of ocular lesions 9.5.2   Management of Episcleritis / Scleritis: 9.5.3   Management of Acute Dacyrocystitis 9.5.4   Management of conjunctivitis 9.5.5   Management of corneal lesions 9.5.6   Management of Iritis/ iridocyclitis: 9.5.7   Prevention & treatment of lagophthalmos 9.5.8   Management of cataract 9.6   Self - Care of eye: 9.6.1   Principles of eye care: 9.6.2   Protect eyes from dryness, sun, dust and injury: 9.6.3   Early detection of signs of irritation, injury and involvement of ocular tissue Training Methodology: Lecture Discussion using power point presentation, demonstration and hand on practice for examination of eye. Learning Objectives: Learning Objectives:  At the end of the session trainees will be able to    Enlist common lesions of ocular tissue in leprosy    Describe the precautions one must take as medical officer to preserve vision in a person affected with leprosy   - 81 - 9.1   Introduction: Eye is the most important organ to be affected in the disease process. Eyes are affected by direct invasion of bacilli or during lepra reaction. Most eye complications may lead to visual impairment and blindness. Early detection and appropriate treatment of ocular lesions is essential to prevent blindness. During early stages person with ocular lesions may remain asymptomatic. Hence, routine examination of eye is important for detection ocular lesions 9.2   Causes of ocular involvement in leprosy Ocular manifestations of leprosy are due to:   Direct invasion of ocular tissue:  Infiltration of ocular tissue by M. Leprae is followed, at a much later stage by inflammatory reaction and may lead to conjunctivitis, episcleritis, scleritis, keratitis, Iritis &/or Iridocyclitis. It is common in  persons with MB leprosy Involvement of nerves: Involvement of trigeminal and facial nerves leads to loss of sensation of cornea & weakness of muscles of eyelid (orbicularis oculi) respectively,  predisposing eye to exposure keratitis, repeated injury, secondary infection and other lesions. It is more common among PB leprosy having patch on the face with or without Type I reaction ( Unilateral) and MB leprosy of long duration ( Bilateral ) 9.3   Causes of blindness in leprosy: Three major causes of blindness due to leprosy are: Corneal opacity due to exposure of cornea associated with lagophthalmos and diminished corneal sensation. Lid abnormalities like entropion and ectropion may also affect cornea. Iridocyclitis and its squelae especially in persons with multi-bacillary leprosy Cataract as a complication of disease process. It also occurs due to complication of uveal and corneal disease Preservation of Vision is very important in Persons affected with Leprosy Persons with high risk of ocular lesions:    Skin lesion on face  –   PB leprosy with or without Type I Reaction    In untreated MB Leprosy of long duration it is usually bilateral.    Present or past Type 2 reaction    Present or past ocular pathology    Present or past Type 1 reaction and lagophthalmos   - 82 - 9.4   History & Examination of eye Involvement of eye must be detected in the early stages to prevent impairment of vision and  blindness  9.4.1   History for ocular lesions: While taking history; ask for:  Any problem in the eye, pain in the eye & blurring of vision Duration of the problem & its progress Photophobia  –   Does light makes eye painful (iridocyclitis)/ uncomfortable   Blurring of vision: Does blurring clears on blinking the eye (due to discharge/ stickiness of eye) Past H/O Red eye and any treatment taken for it H/o any surgery in the past for eye problem 9.4.2   Examination of eye: Look for the following conditions during examinaiton  9.4.3 Lesions due to involvement of ocular tissue  Changes can be seen in almost all the parts of the eye. Some changes are seen only through Slit-lamp bio microscope. Changes that are of importance and can be detected by simple physical examination of eye are described below: (i)Eyebrows:   Thinning of eyebrows  (lateral half)/ complete loss of eyebrows (Superciliary madarosis) due to deep infiltration. (ii) Eyelids:   Thickening of eyelids  occurs due diffuse infiltration of skin and eyelid structures following invasion by M. leprae & results in loss of elasticity of the skin and heavy  drooping of upper eyelid   Entropion: In-turning of eyelid margins Ectropion : Out  –  turning of Eyelid margin Macule/nodule  on the eyelids Weakness of eyelid movement   Thin floppy upper eyelid occurring due to atrophy of the tarsal plate & pre-tarsal muscles rendering eyelid less effective in spreading the tears and cleaning of cornea  Note: While taking history; observe for frequency of blinking of the eye.    Count the no. of Blinks per minute  –   each eye separately without the knowledge of the patient.   - 83 - (iii) Eye lashes: Scanty, small & thin/ loss   of eye lashes due to atrophy of the tissue supporting hair follicles (ciliary madarosis) Trichiasis - In turning of eye lashes rubbing against bulbar conjunctiva & Cornea. Person with insensitive cornea may ignore the situation and may get corneal abrasions and ulcers . Persons must be instructed specifically to look for trichiasis. Corneal ulcer may heal leaving corneal   opacities . (iv) Meibomian glands: Dryness of eye occurs due   infiltration and atrophy of meibomian glands resulting in  poor quality of tears. (v) Naso lacrimal Apparatus: Dacyrocystitis: Blockage of naso-lacrimal duct may occur due to bacillary infiltration in the nasal mucosa. Nasal ulceration/ scarring or nasal collapse causes stagnation of the secretions & acute, sub-acute or chronic infection of the lacrimal sac. Pus can be expressed from lacrimal punctum by pressing the fundus of the lacrimal sac between eye & nose, at the medial canthus of the eye. In case of chronic dacryocystitis redness &/or swelling and tenderness over lacrimal sac (between eye and nose) can be noticed.  (vi) Sclera: Episcleritis:   Benign inflammation of the Tenon‟s capsule overlying Sclera is called Episcleritis. Hard, dirty yellow nodule, most commonly on upper outer quadrant is seen with or without any symptom. Sometimes, nodules may become inflamed causing epiphora (overflowing of tears), pain and general ocular discomfort. It is a superficial lesion and rarely has long-term complications. Scleritis: Inflammation of the sclera. Scleritis in Leprosy is found in Multibacillary cases and is associated with iridocyclitis. Eye is painful and tender. Initially, a deep red, tender, scleral patch may be seen. Repeated episodes of scleritis results in scleral thinning and  pigmented tissues of the Uveal tract are seen bulging through sclera and is called Anterior staphyloma, which may even  perforate. Person may complain of severe deep circum-orbital pain radiating back to temple. Ask the patient to look down: Palpate above the upper tarsal plate through the closed eye lids to elicit tenderness in the Red eye. Development of scleritis
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