|Year : 2021 | Volume
| Issue : 4 | Page : 379-381
Hansen's disease with ocular manifestations: A case series
Palak Chirania1, Dipankar Das2, Balmukund Agarwal3, Ganesh Chandra Kuri4
1 Department of Ophthalmology, Sri Sankaradeva Nethralaya, Guwahati, Assam, India
2 Department of Ocular Pathology, Uveitis and Neuro-Ophthalmology, Sri Sankaradeva Nethralaya, Guwahati, Assam, India
3 Department of Cornea, Sri Sankaradeva Nethralaya, Guwahati, Assam, India
4 Department of Occuloplasty and Neuro-Ophthalmology, Sri Sankaradeva Nethralaya, Guwahati, Assam, India
|Date of Submission||08-Jun-2021|
|Date of Decision||07-Jul-2021|
|Date of Acceptance||10-Jul-2021|
|Date of Web Publication||21-Dec-2021|
Dr. Palak Chirania
Department of Ophthalmology, Sri Sankaradeva Nethralaya, Guwahati, Assam
Source of Support: None, Conflict of Interest: None
Hansen's disease is a chronic granulomatous disease caused by Mycobacterium leprae which is known to affect the cooler regions of the body. Posterior segment involvement is very rare. We present a case of a leprosy patient with a posterior segment manifestation, panuveitis, and anterior uveitis. The disease is still a significant health problem in developing countries like India. Even completion of anti-leprosy multidrug therapy does not seem to prevent the development of disabilities. Hence, early recognition with proper management is essential.
Keywords: Hansen's disease, posterior segment involvement, uveitis
|How to cite this article:|
Chirania P, Das D, Agarwal B, Kuri GC. Hansen's disease with ocular manifestations: A case series. TNOA J Ophthalmic Sci Res 2021;59:379-81
| Introduction|| |
Leprosy (Hansen's disease) is a chronic granulomatous disease caused by acid-fast bacilli. It affects the skin, nasal mucosa, earlobes, peripheral nerves, and the anterior segment of the eye for the bacillus has a strong preference for low temperatures.,
The global prevalence of leprosy was 0.32/10,000. India accounts for 58.8% of the global burden. It is still considered one of the significant health problems in developing countries like India. The involvement of the eye is a disaster for the leprosy patient, especially if he already has other deformities of hands and feet.
We hereby present three cases of leprosy patients who came to us with their complications.
| Case Reports|| |
A 54-year-old male presented with chief complaint of diminution of vision (DOV) in the right eye (OD) for 18 months and left eye (OS) for 2 years. He was a known case of leprosy with the history of the intake of the tablet dapsone for 2 years which he had stopped 1 month back. Best-corrected visual acuity (BCVA) in OD was counting the finger at 3 m for distance and 6/12 for near with reduced Snellen's chart. OS was hand movement positive. Refraction was deferred in OS due to the presence of a dull fundal glow. Slit-lamp examination (SLE) was normal in OD except for the presence of nuclear sclerosis Grade 3 with posterior subcapsular cataract. There was presence of lid lag, lagophthalmos, conjunctival congestion, corneal scarring with pannus formation [Figure 1]a, and shallow anterior chamber in OS. Iris appeared to be normal. Pupil, lens, and fundus could not be evaluated in OS due to the presence of corneal scarring. Intraocular pressure (IOP) in OD using noncontact tonometer (NCT) was 11 mmHg, in OS finger tension felt okay. Fundus in OD had clear media with a pale optic disc and the presence of healed choroiditis patches along the vascular arcade in the posterior pole [Figure 1]b. Systemic examination of the patient revealed madarosis, deformed fingers [Figure 1]c and toes with depressed nasal bridge, and the presence of erythematous macules in the hard palate [Figure 1]d. Ultrasonography (USG) B-scan in OS was normal. Optical coherence tomography showed hyperreflective membrane suggestive of epiretinal membrane in OD. Diagnosis of healed posterior uveitis and cataract in OD and lid lag with lagophthalmos in OS postleprosy was made. Optical penetrating keratoplasty was done at an interval of 10 months as the patient wanted. It was followed by lateral tarsorrhaphy after 4 days. On one of the follow-up visits after 6 months, electrolysis of the upper lid was done due to the presence of trichiasis.
|Figure 1: (a) Slit-lamp photo showing corneal scarring with pannus formation, (b) fundus photo showing pale optic disc with well-defined margins and healed choroiditis patches along the arcades at the posterior pole in right eye, (c) deformed fingers, (d) erythematous macules in the hard palate|
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A 50-year-old male presented with DOV in both eyes (OU) for 12 days. He was a known case of leprosy and was already on multidrug therapy (MDT). BCVA was OU-counting finger at 2 m. There was a presence of a dull glow OU. Adnexa, conjunctiva, and cornea were clear OU. SLE revealed AC cells 2+, flare 2+, iris atrophy, and 360° posterior synechiae OU. There was presence of nuclear sclerosis Grade 2 cataract OU. IOP was 5 mmHg OU with NCT. Fundus had a hazy view due to the presence of vitritis. USG B-scan was normal OU. Systemic examination revealed the presence of madarosis [Figure 2]a, saddle nose deformity [Figure 2]b, deformed fingers [Figure 2]c, and toes with tissue loss of the right little toe [Figure 2]d. Diagnosis of OU-Active Lepromatous panuveitis, hypotony with profound visual loss was made. The patient was asked to continue his MDT and was advised topical steroids and cycloplegics with oral corticosteroids. Sequential cataract surgery was performed after the eyes became quiet.
|Figure 2: This is the photograph of the patient showing (a) Madarosis, (b) Saddle nose deformity, (c) Deformed fingers, (d) Deformed toes with left little toe loss|
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A 70-year-old female presented to us with chief complaint of DOV OU for 2 years. The patient was a known case of leprosy and had received its complete treatment. BCVA OD was 6/24 and OS 6/36 with pinhole. Presence of dull glow OU. SLE revealed the presence of diffuse keratic precipitates, AC cells and flare 1+, posterior synechiae, dilated and sluggish reacting pupil, mild iris atrophy, and dense cataract OU. IOP was 10 and 11 mmHg with NCT. Fundus examination in OD and USG in OS was normal. There was presence of madarosis [Figure 3]a, saddle nose deformity [Figure 3]b, perioral parchment changes, thickened ulnar nerve and loss of fingers [Figure 3]c, and toes [Figure 3]d. Diagnosis of Hansen's disease, anterior uveitis with cataract was made OU. The patient was treated with topical steroids, cycloplegics, and subsequently, cataract surgery was performed in OU.
|Figure 3: This is the picture of the patient showing (a) Madarosis, (b) Saddle nose deformity (c) Loss of fingers and (d) Loss of toes|
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| Discussion|| |
Leprosy is a chronic disease with disabling complications. Ocular involvement in leprosy can be blinding and is influenced by the duration of the disease and the treatment received., Some studies from India and Nepal have found that about 57%–66% of patients develop some type of ocular complications.,, Another study from India showed that 24.3% of the patients had sight-threatening complications even after completion of MDT.,
The common eye features in leprosy include madarosis, trichiasis, hypometropic blink, paralytic lagophthalmos, corneal hypoesthesia, thickened corneal nerves, subepithelial lesions with pannus, exposure keratitis, iris pearls (pathognomonic), chronic granulomatous iridocyclitis, iris atrophy, cataract, glaucoma, and facial nerve palsy. Posterior segment involvement is very rare., In literature, four lesions that have been described are pedunculated nodules, highly refractile deposits, hypopigmented flat patches deep to the vessels, and a raised yellowish lesion.
Reddy and Raju in their study of 145 leprosy patients did not find even a single case of posterior segment involvement. We document two cases of leprosy with posterior segment involvement and case three has anterior uveitis with cataract and typical lepromatous tissue loss.
The guidelines recommend a 3-drug regimen (MDT) of rifampicin, dapsone, and clofazimine for the treatment of all leprosy patients-duration of which depends on the type of leprosy. It is given for 6 months in paucibacillary leprosy and for 12 months in multibacillary leprosy. Even after completion of appropriate course of MDT, our patients developed disabling complications, particularly of the eye. This review highlights the importance of ongoing care for all leprosy patients, including those considered cured. It is important to realize that the completion of systemic multidrug antileprosy treatment does not guarantee that the eyes are safe. Thus, there is a need for good baseline ophthalmological examination for all leprosy patients. Early detection and effective treatment are essential to reduce the complications and visual disability in an affected individual.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity.
Sri Kanchi Health and Education Foundation, Sri Sankaradeva Nethralaya, Guwahati, Assam, India.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Kaushik J, Jain VK, Parihar JK, Dhar S, Agarwal S. Leprosy presenting with iridocyclitis: A diagnostic dilemma. J Ophthalmic Vis Res 2017;12:437-9.
] [Full text]
Reddy SC, Raju BD. Ocular involvement in leprosy: A field study of 1004 patients. International Journal of Ophthalmology 2009;2:367-72.
Lamba PA, Kumar DS. Ocular involvement from leprosy. Indian J Ophthalmol 1984;32:61-3.
] [Full text]
Reddy GN, Reddy GA. Ocular manifestations of leprosy. Trop J Ophthalmol Otolaryngol 2019;4:414-8.
Malik AN, Morris RW, Ffytche TJ. The prevalence of ocular complications in leprosy patients seen in the United Kingdom over a period of 21 years. Eye (Lond) 2011;25:740-5.
Thompson KJ, Allardice GM, Babu GR, Roberts H, Kerketta W, Kerketta A. Patterns of ocular morbidity and blindness in leprosy – A three centre study in Eastern India. Lepr Rev 2006;77:130-40.
Daniel E, Koshy S, Rao GS, Rao PS. Ocular complications in newly diagnosed borderline lepromatous and lepromatous leprosy patients: Baseline profile of the Indian cohort. Br J Ophthalmol 2002;86:1336-40.
Ffytche TJ. Residual sight-threatening lesions in leprosy patients completing multidrug therapy and sulphone monotherapy. Lepr Rev 1991;62:35-43.
Samuel C, Sundararajan D.
Ocular manifestations in Hansen's disease-A clinical study. Int J Med Res Heath Sci 2014;4:829-32.
Somerset EJ. Leprous lesions of the eye. Indian J Ophthalmol 1956;4:7-14. [Full text]
Lee SB, Lee EK, Kim JY. Bilateral optic neuritis in leprosy. Can J Ophthalmol 2009;44:219-20.
Reddy SC, Raju BD. Ocular lesions in the inmates of leprosy rehabilitation centre. Int J Biomed Sci 2006;2:289-94.
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