Ocular
Leprosy
William W. Richards, MD
Twenty-four years ago, a 47-year-old Samoan man had complaints of a stuffy nose, unexplained brow hair loss, and swollen hands and feet. Twelve years later, he developed a "dead area" near his left knee, and the diagnosis of lepromatous leprosy was made from a skin biopsy specimen. Recently, the main ocular complaints have been reduced vision and tearing of both eyes. Examination showed both eyes to have similar changes, but they were some¬ what more marked in the left (Fig 1) than in the right. The best corrected visual acuity was 20/60 in each eye. There was a loss of cilia from the upper lids, and the brow hair was absent. There was a mild entropion and trichiasis secondary to the leprous lid involvement. There was a superior and inferior vascularized leprotic keratitis with a superimposed band keratopathy inferiorly and in the interpalpebral region. On the iris were multiple pearls about the size of salt granules representing miliary lepromas. The pupil was vertically oval due to posterior synechias, and there was a second ciliary flush secondary to low-grade chronic leprotic uveitis with moderate cells and flare in the aqueous. The corneal sensation was reduced, and the lids did not close fully during sleep, which may be a contributing factor to the inferior corneal pathological condition. The patient received 2% atropine drops three times a day, 1% prednisolone drops six times a day, and subconjunctival steroids (20 mg, Kenalog) on a num¬ ber of occasions. He also received systemic leprosy medication (dapsone, rifampin, ethionamide, and clofazimine-B663). In spite of this, his corneal changes and uveitis persisted, resulting in a decreased vision due to progressive lens changes. Cataract extraction was performed on both eyes with improvement of his vision (Fig 2). He continued to have low-grade uveitis in the left eye. The iridectomy specimen was submitted to the Armed Forces Institute of Pathology (ACC No. 1485583) and multiple sections were made. These were stained by the Fite method, which demonstrated in one-minute focus (presumably in one of the iris pearls) acid-fast bacilli diag¬ nostic of leprosy (Fig 2, arrow) (x 2,150). Note.—The photographs on the opposite page are stereoscopic pairs and can be viewed by placing a +5 sphere before both eyes, either in a trial frame or held up to the eyes and viewed from a distance of approximately 10 inches. To avoid converging on the photograph, a sheet of paper can be placed at the junction of the two photographs and extended up to the nose. In this way, the two pictures can be fused into a stereoscopic image to show the depth relation¬ ships within the staphylomas.
Downloaded From: http://archopht.jamanetwork.com/ by a University of Manitoba User on 06/21/2015
Fig
1
Fig
2
Downloaded From: http://archopht.jamanetwork.com/ by a University of Manitoba User on 06/21/2015
Leprosy
William W. Richards, MD
Twenty-four years ago, a 47-year-old Samoan man had complaints of a stuffy nose, unexplained brow hair loss, and swollen hands and feet. Twelve years later, he developed a "dead area" near his left knee, and the diagnosis of lepromatous leprosy was made from a skin biopsy specimen. Recently, the main ocular complaints have been reduced vision and tearing of both eyes. Examination showed both eyes to have similar changes, but they were some¬ what more marked in the left (Fig 1) than in the right. The best corrected visual acuity was 20/60 in each eye. There was a loss of cilia from the upper lids, and the brow hair was absent. There was a mild entropion and trichiasis secondary to the leprous lid involvement. There was a superior and inferior vascularized leprotic keratitis with a superimposed band keratopathy inferiorly and in the interpalpebral region. On the iris were multiple pearls about the size of salt granules representing miliary lepromas. The pupil was vertically oval due to posterior synechias, and there was a second ciliary flush secondary to low-grade chronic leprotic uveitis with moderate cells and flare in the aqueous. The corneal sensation was reduced, and the lids did not close fully during sleep, which may be a contributing factor to the inferior corneal pathological condition. The patient received 2% atropine drops three times a day, 1% prednisolone drops six times a day, and subconjunctival steroids (20 mg, Kenalog) on a num¬ ber of occasions. He also received systemic leprosy medication (dapsone, rifampin, ethionamide, and clofazimine-B663). In spite of this, his corneal changes and uveitis persisted, resulting in a decreased vision due to progressive lens changes. Cataract extraction was performed on both eyes with improvement of his vision (Fig 2). He continued to have low-grade uveitis in the left eye. The iridectomy specimen was submitted to the Armed Forces Institute of Pathology (ACC No. 1485583) and multiple sections were made. These were stained by the Fite method, which demonstrated in one-minute focus (presumably in one of the iris pearls) acid-fast bacilli diag¬ nostic of leprosy (Fig 2, arrow) (x 2,150). Note.—The photographs on the opposite page are stereoscopic pairs and can be viewed by placing a +5 sphere before both eyes, either in a trial frame or held up to the eyes and viewed from a distance of approximately 10 inches. To avoid converging on the photograph, a sheet of paper can be placed at the junction of the two photographs and extended up to the nose. In this way, the two pictures can be fused into a stereoscopic image to show the depth relation¬ ships within the staphylomas.
Downloaded From: http://archopht.jamanetwork.com/ by a University of Manitoba User on 06/21/2015
Fig
1
Fig
2
Downloaded From: http://archopht.jamanetwork.com/ by a University of Manitoba User on 06/21/2015
