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Ocular Leprosy in South Vietnam
OCULAR LEPROSY I N SOUTH VIETNAM ALBERT HORNBLASS,
M.D.
Brooklyn, New. York
There are 16 million people in the world with leprosy, and the ocular manifestations of this disease, a common complication, are more serious in Caucasians and Mongo lians1"3 than in patients with darker skins. Previous reports4"6 indicate that the inci dence of ocular manifestations is highest in the lepromatous form of leprosy. We did not find this to be true in our Vietnamese pa tients. The ocular manifestations of leprosy in the Montangard people of South Vietnam are reported here for the first time. MATERIAL AND METHODS
We examined the eyes of 51 randomly se lected Montangard patients at the Pleiku Leprosy Center and the United States Army 71st Evacuation Hospital on several occa sions during 1969-70. All had biopsy proven leprosy. All were or had been treated with the microbial, Dapsone; 28 patients had le promatous, 16 tuberculoid and seven di morphous or mixed leprosy. The mean age was 37 years ; 39 were males. Eye complica tions in this disease may be primary, due di rectly to ocular invasion by Mycobacteriae leprae, or there may be secondary involve ment caused by facial nerve palsy with resul tant lagophthalmous and exposure keratopathy. The cornea was involved in 31 of our pa tients (Table 1). The various types of corneal lesions and their frequencies are shown in Table 2. Seventh nerve paresis, episcleritis, decreased corneal sensitivity, and loss of eyebrows and lashes were also common find ings.
TABLE 1 FREQUENCY OF OCULAR INVOLVEMENT IN 5 1 PATIENTS WITH LEPROSY Area of Involvement
No. and % of Patients
Cornea Seventh nerve Episclera Fifth nerve (corneal) Eyebrows (madarosis) Iris Eyelids (tylosis) Lens Retina
31 (61) 14 (27)* 11 (21) 10 (20) 8 (16)* 8 (16) 6(12) 4(8) 2(4)
* In eight patients with seventh nerve involve ment, and in all patients with madarosis, involve ment was bilateral.
The "chalky white spot" or punctate keratitis forms a pathognomonic picture of lep rosy. Irregular minute white spots first ap pear superiorly and then spread to involve the upper half of the cornea. They are subepithelial and sometimes appear in the midst of discrete milky gray stromal opacifications. Pannus formation is not uncommon and ex tends around the entire corneal circumfer ence, in contrast to the pannus of trachoma that occurs superiorly. Some of the corneal manifestations are also secondary to lagophthalmos or intraocular inflammation. Loss of eyelashes and eyebrows particu larly in the outer third should be looked for TABLE 2 TYPES AND INCIDENCE OF CORNEAL LESIONS IN 3 1 PATIENTS Lesions Chalky white spots (subepithelial opacities) Punctate keratopathy Dense opaque stroma Lepromatous nodules Adherent leukomas Bullous keratopathy Interstitial keratitis Keratic precipitates
From the Division of Ophthalmology, Depart ment of Surgery, State University of New York Downstate Medical Center, Brooklyn. Reprint requests to Arthur Hornblass, M.D., Di vision of Ophthalmology, Department of Surgery, State University of New York Downstate Medical Center, Brooklyn, New York 11203. 478
No. Patients 14 7 7 5 3 3 3 3
VOL. 75, NO. 3
OCULAR LEPROSY
Fig. 1 (Hornblass). Montangard with photophobia and bilateral loss of eyebrows and lashes.
Fig. 2 (Hornblass). A 46-year-old Montangard man with madarosis and tylosis.
in the early stages, along with lagophthalmus (Figs. 1 and 2 ) . Prevention of dryness and associated infection is important. Tarsorraphy or other oculoplastic proce dures may then be performed to protect the cornea from exposure keratitis. A patient with a leprotic stare is shown in Figure 3. Mydriatics and topical corticosteroids are also important in the early treatment of intraocular inflammation.10 In 78% of the lepromatous, 70% of the dimorphous, and 75% of the tuberculoid cases there was ocular involvement for an overall incidence of 76%. In the majority of these patients, serology was positive.
479
noted in the sixth century in Europe and during an epidemic there six centuries later, it spread to Asia. It probably spread to Indo china during the seventh century. The Montangard people are a primitive group of around 800,000 persons in South Vietnam. They resemble the American In dian in appearance. Prior to the Vietnam War they were primarily hunters, but due to the destruction of most of the game,' they have resorted to rice farming. Their families are large and yet they live in huts with usu ally a single large room. Rice and a minimal amount of fish is the usual diet. Montangard physicians in South Vietnam are fion-existant and the general health care offered to them is poor. Miliary lepromata or iris pearls are com mon.7"9 These are 0.25 mm aggregates of leprosy bacilli resembling the white spots found in the cornea, and these were seen in six of our patients. "Plastic" iridocyclitis is the principle cause of blindness in ocular leprosy. A secluded pupil often occurs and this, along with corneal involvement, was re sponsible for low vision (hand movement or less) in five of our patients. Barros 3 studied 1279 cases of leprosy and classified 64% as lepromatous, 20% tubercu loid, and 15% mixed. He found that 65% of the Lepromatous but only 2 % of the tuber-
DISCUSSION
Leprosy is one of the oldest recorded dis eases affecting man and numerous Biblical references to leprosy or metzoraath can be found in the Old and New Testament. It was
Fig. 3 (Hornblass). A 42-year-old Montangard woman with bilateral seventh nerve paresis and the "leprotic stare."
480
AMERICAN JOURNAL OF OPHTHALMOLOGY
culoid cases had ocular involvement. Harley 2 found that 9 0 % of the lepers in Panama had ocular manifestations and Weerekoon 1 found only 4 7 % of patients with leprosy in Ceylon had eye involvement. O f our pa tients, 7 6 % who had systemic leprosy had ocular involvement. T h e r e was no correla tion between the severity of the systemic dis ease and ocular signs. I t is of interest that all but one of the females with systemic leprosy had eye involvement. T h e reason for this is yet unclear. Most previous studies 11 " 14 show a prepon derance of eye manifestations in the lepro matous type of leprosy. I n contrast, we found only a slight increase of eye involve ment in lepromatous cases, with almost a n equal incidence in tuberculoid and mixed, in cluding eye manifestations due to direct in volvement of the globe and those due to indi rect damage. SUMMARY
Fifty-one Montangards in South Vietnam with proven leprosy were studied ophthalmologically. Of these, 39 had ocular involve ment. T h e cornea was involved in 31 of the 39 patients. About the same percentage of ocular complications were seen in cases of lepromatous leprosy as tuberculoid and the mixed type. Five patients were blind.
MARCH, 1973
ACKNOWLEDGMENT
I thank Dr. Stephen Waltman of the Walter Reed Army Hospital, Washington, D.C., for re viewing this manuscript. REFERENCES
1. Weerekoon, L. : Ocular leprosy in Ceylon. Brit. J. Ophth. 53:457, 1969. 2. Harley, R. D. : Ocular leprosy in Panama. Am. J. Ophth. 29:29S, 1946. 3. Barros, J. M. : The ocular complications of leprosy. Am. J. Ophth. 29:162, 1946. 4. Brubaker, M. D., and Johwick, E. B. : Tenyear-review of hospital admissions of patients with leprosy. Pub. Hlth. Rep. 83:155, 1968. 5. Richards, W. W., and Arrington, J. W. : Un suspected ocular leprosy. Am. J. Ophth. 68:492, 1969. 6. Choyce, O. P. : Diagnosis and management of ocular leprosy. Brit. J. Ophth. 53:217, 1969. 7. Allen, J. H., and Byer, J. L. : The pathology of ocular leprosy. 1. Cornea. Arch. Ophth. 64:216, 1966. 8. Allen, J. H. : The pathology of ocular leprosy. 2. Miliary lepromas of the Iris. Am. J. Ophth. 61 : 987, 1960. 9. Gerhard, A. : Ocular complication of leprosy. Bull. Soc. Ophth. Franc. 70:122, 1970. 10. Holmer, W. J. : Leprosy of the eye : Present status and future challenge. Int. J. Lep. 38:308, 1970. 11. Slem, G. : Clinical studies of ocular leprosy. Am. J. Ophth. 71:431, 1971. 12. Kraus, A. : Corneal sensitivity in lepromatous leprosy. Int. J. Lep. 38:427, 1970. 13. Enna, C. D., and Trautman, J. R. : Leprosy in the military services. Milit. Med. 134:1423, 1969. 14. Welsh, M. H., and Pretorios, M. : Ocular signs in leprosy : Results of surgery in a leper insti tute. South African Med. J. 44 (Suppl.) : 9, 1970.
M.D.
Brooklyn, New. York
There are 16 million people in the world with leprosy, and the ocular manifestations of this disease, a common complication, are more serious in Caucasians and Mongo lians1"3 than in patients with darker skins. Previous reports4"6 indicate that the inci dence of ocular manifestations is highest in the lepromatous form of leprosy. We did not find this to be true in our Vietnamese pa tients. The ocular manifestations of leprosy in the Montangard people of South Vietnam are reported here for the first time. MATERIAL AND METHODS
We examined the eyes of 51 randomly se lected Montangard patients at the Pleiku Leprosy Center and the United States Army 71st Evacuation Hospital on several occa sions during 1969-70. All had biopsy proven leprosy. All were or had been treated with the microbial, Dapsone; 28 patients had le promatous, 16 tuberculoid and seven di morphous or mixed leprosy. The mean age was 37 years ; 39 were males. Eye complica tions in this disease may be primary, due di rectly to ocular invasion by Mycobacteriae leprae, or there may be secondary involve ment caused by facial nerve palsy with resul tant lagophthalmous and exposure keratopathy. The cornea was involved in 31 of our pa tients (Table 1). The various types of corneal lesions and their frequencies are shown in Table 2. Seventh nerve paresis, episcleritis, decreased corneal sensitivity, and loss of eyebrows and lashes were also common find ings.
TABLE 1 FREQUENCY OF OCULAR INVOLVEMENT IN 5 1 PATIENTS WITH LEPROSY Area of Involvement
No. and % of Patients
Cornea Seventh nerve Episclera Fifth nerve (corneal) Eyebrows (madarosis) Iris Eyelids (tylosis) Lens Retina
31 (61) 14 (27)* 11 (21) 10 (20) 8 (16)* 8 (16) 6(12) 4(8) 2(4)
* In eight patients with seventh nerve involve ment, and in all patients with madarosis, involve ment was bilateral.
The "chalky white spot" or punctate keratitis forms a pathognomonic picture of lep rosy. Irregular minute white spots first ap pear superiorly and then spread to involve the upper half of the cornea. They are subepithelial and sometimes appear in the midst of discrete milky gray stromal opacifications. Pannus formation is not uncommon and ex tends around the entire corneal circumfer ence, in contrast to the pannus of trachoma that occurs superiorly. Some of the corneal manifestations are also secondary to lagophthalmos or intraocular inflammation. Loss of eyelashes and eyebrows particu larly in the outer third should be looked for TABLE 2 TYPES AND INCIDENCE OF CORNEAL LESIONS IN 3 1 PATIENTS Lesions Chalky white spots (subepithelial opacities) Punctate keratopathy Dense opaque stroma Lepromatous nodules Adherent leukomas Bullous keratopathy Interstitial keratitis Keratic precipitates
From the Division of Ophthalmology, Depart ment of Surgery, State University of New York Downstate Medical Center, Brooklyn. Reprint requests to Arthur Hornblass, M.D., Di vision of Ophthalmology, Department of Surgery, State University of New York Downstate Medical Center, Brooklyn, New York 11203. 478
No. Patients 14 7 7 5 3 3 3 3
VOL. 75, NO. 3
OCULAR LEPROSY
Fig. 1 (Hornblass). Montangard with photophobia and bilateral loss of eyebrows and lashes.
Fig. 2 (Hornblass). A 46-year-old Montangard man with madarosis and tylosis.
in the early stages, along with lagophthalmus (Figs. 1 and 2 ) . Prevention of dryness and associated infection is important. Tarsorraphy or other oculoplastic proce dures may then be performed to protect the cornea from exposure keratitis. A patient with a leprotic stare is shown in Figure 3. Mydriatics and topical corticosteroids are also important in the early treatment of intraocular inflammation.10 In 78% of the lepromatous, 70% of the dimorphous, and 75% of the tuberculoid cases there was ocular involvement for an overall incidence of 76%. In the majority of these patients, serology was positive.
479
noted in the sixth century in Europe and during an epidemic there six centuries later, it spread to Asia. It probably spread to Indo china during the seventh century. The Montangard people are a primitive group of around 800,000 persons in South Vietnam. They resemble the American In dian in appearance. Prior to the Vietnam War they were primarily hunters, but due to the destruction of most of the game,' they have resorted to rice farming. Their families are large and yet they live in huts with usu ally a single large room. Rice and a minimal amount of fish is the usual diet. Montangard physicians in South Vietnam are fion-existant and the general health care offered to them is poor. Miliary lepromata or iris pearls are com mon.7"9 These are 0.25 mm aggregates of leprosy bacilli resembling the white spots found in the cornea, and these were seen in six of our patients. "Plastic" iridocyclitis is the principle cause of blindness in ocular leprosy. A secluded pupil often occurs and this, along with corneal involvement, was re sponsible for low vision (hand movement or less) in five of our patients. Barros 3 studied 1279 cases of leprosy and classified 64% as lepromatous, 20% tubercu loid, and 15% mixed. He found that 65% of the Lepromatous but only 2 % of the tuber-
DISCUSSION
Leprosy is one of the oldest recorded dis eases affecting man and numerous Biblical references to leprosy or metzoraath can be found in the Old and New Testament. It was
Fig. 3 (Hornblass). A 42-year-old Montangard woman with bilateral seventh nerve paresis and the "leprotic stare."
480
AMERICAN JOURNAL OF OPHTHALMOLOGY
culoid cases had ocular involvement. Harley 2 found that 9 0 % of the lepers in Panama had ocular manifestations and Weerekoon 1 found only 4 7 % of patients with leprosy in Ceylon had eye involvement. O f our pa tients, 7 6 % who had systemic leprosy had ocular involvement. T h e r e was no correla tion between the severity of the systemic dis ease and ocular signs. I t is of interest that all but one of the females with systemic leprosy had eye involvement. T h e reason for this is yet unclear. Most previous studies 11 " 14 show a prepon derance of eye manifestations in the lepro matous type of leprosy. I n contrast, we found only a slight increase of eye involve ment in lepromatous cases, with almost a n equal incidence in tuberculoid and mixed, in cluding eye manifestations due to direct in volvement of the globe and those due to indi rect damage. SUMMARY
Fifty-one Montangards in South Vietnam with proven leprosy were studied ophthalmologically. Of these, 39 had ocular involve ment. T h e cornea was involved in 31 of the 39 patients. About the same percentage of ocular complications were seen in cases of lepromatous leprosy as tuberculoid and the mixed type. Five patients were blind.
MARCH, 1973
ACKNOWLEDGMENT
I thank Dr. Stephen Waltman of the Walter Reed Army Hospital, Washington, D.C., for re viewing this manuscript. REFERENCES
1. Weerekoon, L. : Ocular leprosy in Ceylon. Brit. J. Ophth. 53:457, 1969. 2. Harley, R. D. : Ocular leprosy in Panama. Am. J. Ophth. 29:29S, 1946. 3. Barros, J. M. : The ocular complications of leprosy. Am. J. Ophth. 29:162, 1946. 4. Brubaker, M. D., and Johwick, E. B. : Tenyear-review of hospital admissions of patients with leprosy. Pub. Hlth. Rep. 83:155, 1968. 5. Richards, W. W., and Arrington, J. W. : Un suspected ocular leprosy. Am. J. Ophth. 68:492, 1969. 6. Choyce, O. P. : Diagnosis and management of ocular leprosy. Brit. J. Ophth. 53:217, 1969. 7. Allen, J. H., and Byer, J. L. : The pathology of ocular leprosy. 1. Cornea. Arch. Ophth. 64:216, 1966. 8. Allen, J. H. : The pathology of ocular leprosy. 2. Miliary lepromas of the Iris. Am. J. Ophth. 61 : 987, 1960. 9. Gerhard, A. : Ocular complication of leprosy. Bull. Soc. Ophth. Franc. 70:122, 1970. 10. Holmer, W. J. : Leprosy of the eye : Present status and future challenge. Int. J. Lep. 38:308, 1970. 11. Slem, G. : Clinical studies of ocular leprosy. Am. J. Ophth. 71:431, 1971. 12. Kraus, A. : Corneal sensitivity in lepromatous leprosy. Int. J. Lep. 38:427, 1970. 13. Enna, C. D., and Trautman, J. R. : Leprosy in the military services. Milit. Med. 134:1423, 1969. 14. Welsh, M. H., and Pretorios, M. : Ocular signs in leprosy : Results of surgery in a leper insti tute. South African Med. J. 44 (Suppl.) : 9, 1970.