British Journal of Ophthalmology, 1981, 65, 243-248

Cataract surgery in the management of the latecomplications of lepromatous leprosy in South KoreaT. J. FFYTCHEFrom St Thomas's Hospital, Lambeth Palace Road, London SE] 7EH

SUMMARY Clinical examination of 113 patients in South Korea with lepromatous leprosy andsevere visual impairment showed that the main cause of visual loss was the combined effect ofcorneal and lens opacities associated with small nonreacting pupils and iris atrophy. Cataractsurgery with broad iridectomy and inferior sphincterotomy offers these patients with chroniclepromatous complications the best chance of preserving vision. Eighty-one cataract operationswere performed under local anaesthesia, and in 90% vision improved; in 60% this improvementwas 2 Snellen's lines or more.

Leprosy has probably existed in the KoreanPeninsular since the 10th century AD, havingspread there from China in the wake of the manyChinese invasions that have been such a feature ofKorean history, and the disease was still endemic ageneration ago.12 The Korean population is especia-ally susceptible to leprosy for 2 main reasons.Firstly, the climatic conditions are suitable, forcontrary to popular belief the disease flourishes asmuch in temperate climates as in tropical ones andhas been seen in Iceland, Alaska, Germany, Russia,Japan, China, and the colder parts of the UnitedStates.3 Secondly, there is still a large peasantpopulation living at subsistence levels in close-knit communities with their inherent overcrowdingand poor sanitation-conditions known to encouragethe development and spread of the disease.

Chinese and Mongolian races have a higherincidence of the lepromatous type of leprosy4 6and a temperate climate also encourages this form4 6and it is lepromatous leprosy that is associated withthe major ocular complications which lead toblindness. The only previous epidemiological studyin Korea by Holmes in 19572 reported ocularcomplications in 10% of lepromatous cases, butthis figure is certainly too low, as many authorsrecognise a much higher incidence of ocular involve-ment in lepromatous leprosy: 51 % in WestMalaysia,7 76% in Vietnam,8 and 89% in Nepal.9Indeed Pinkerton10 and later Harley"1 felt that allpatients with lepromatous leprosy eventually deve-loped ocular complications.A recent report by Les Amis du Pere Damien"2 on

Correspondence to Mr T. J. ffytche.

the global distribution of leprosy patients shows thatthere are 28 255 registered cases in the Republic ofSouth Korea out of a total population of 36 million,a rate of 0-8 per thousand. This figure must be con-sidered as an underestimate as it takes no account ofthe large proportion of affected individuals who forsome reason or other do not seek attention. Thepresent Korean policy for the care of leprosypatients is to avoid institutionalisation and to aim atresettlement, but many patients prefer to remain incommunities among similarly affected individuals,where they can be looked after and supervised byGovernment resources and welfare organisationsoften sponsored by foreign charities and the Church.An important centre in the southern part of SouthKorea is the Wilson Leprosy Centre and Rehabilita-tion Hospital at Yosu, founded in 1909 as aPresbyterian Mission by Dr. R. M. Wilson. Thecentre is well known for its orthopaedic work in themanagement of leprosy and poliomyelitis and for itscare of leprosy patients. An associated leprosycommunity has been in existence for many years, andin 1973 it numbered 509,13 but has since then beenreduced to 201 through an active policy of resettle-ment (A. M. Topple, personal communication).A few miles to the west the Government-sponsoredcommunity on the Island of Sorokdo houses some2500 individuals, and to the East there are severalscattered communities centred around the city ofChinju.

Materials and methods

The Wilson Leprosy Centre was visited in 1978 and1979 for the purpose of studying and treating the

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ocular complications of leprosy. During these 2visits patients were also seen at Sorokdo and Chinjuand surgery on selected patients from all 3 centreswas carried out. The preliminary results from thevisit in 1978 have already been published.'4 Patientswere chosen and referred for surgery because ofsevere visual disability, thought mainly to be causedby cataract, although the majority had other ocularcomplications involving the anterior segment. Thesepatients therefore represented a highly selectedgroup showing the late complications of lepromatousleprosy, and no statistical conclusions can be drawnon the incidence of ocular complications in thegeneral leprosy population.Although over 200 patients with advanced lepro-

matous eye disease were seen during the 2 visits,only 113 had a full ophthalmic assessment with slit-lamp examination. Eighty of these 113 cases weremales (71 %), with ages ranging from 42 to 79(mean 62 7). The age of onset of the disease wasdifficult to determine accurately in many patients,but the average duration was estimated as 41 yearsin males (17-63) and 35 years in females (12-54). In5 cases leprosy had been contracted under the age of10; in 15 patients the disease had been present formore than 50 years and in 2 patients for more than60 years. Only 4 patients had had leprosy for lessthan 20 years.

110 patients had the lepromatous form of thedisease, 2 had the tuberculoid form, and 1 patientwas classed as borderline; only 3 cases had positiveskin tests. 85% of the remaining lepromatouspatients had had negative skin tests for at least 5years, and all patients had received some form ofantileprosy therapy, including combinations ofchaulmoogra oil, dapsone, lamprene, and steroids,and most patients were still on some form ofsystemic therapy. Many of the patients had severeinvolvement of the face and limbs which, coupledwith the visual impairment, lead to extreme forms ofdisability ((Fig. 1).

VISUAL ACUITYVisual acuities were measured with glasses, if worn,on a Snellen's test type modified for use withKorean symbols; the relatively few illiterate patientswere tested with the standard Snellen E-test. Refrac-tions were not undertaken.The results of the visual acuity measurements in

224 eyes (2 eyes had been enucleated) are shown inFig. 2. Eighty four of the 113 patients (74%) hadbinocular visual acuity of less than 6/60 and wouldtherefore be eligible for blind registration in theUnited Kingdom; 13 of these had binocular visionof less than counting fingers and 5 had less thanhand movements.

OPHTHALMIC EXAMINATIONSAn analysis of the ocular findings in the 113 patientsexamined with the slit-lamp is shown on Table 1.The lid abnormalities included lagophthalmos andtrichiasis, and several patients had previously hadmedial or lateral tarsorrhaphies and other forms of

Fig. 1 Deformation of the hands produced by chroniclepromatous leprosy.

70

60

50

40

30

20

10

* FEMALES

Q MALES

6 6 6 6 6 6 6 3CFHM3PLNP

Fig. 2 Visual acuity in 224 leprotic eyes.

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Cataract surgery in lepromatous leprosy in South Korea

surgery for the complications of facial nerve palsy(Figs. 3 and 4).

Corneal disease was considered to exist if therewere significant corneal opacities, though these didnot necessarily interfere with sight. A detailed

Table 1 Ocular disease in 113 leprosy patients

226 Eyes: Enucleated 2Phthisis 17Madarosis 190Lid abnormalities 55Dacryocystitis 2Corneal disease 154Pterygium 28

198 Eyes: Iris atrophy 113Posterior synechiae 66Cataract 152Aphakia 22Dislocated lens 2Glaucoma 2

analysis of the different corneal manifestations wasnot possible, but it was noted that a form of band-shaped degeneration occurred in 32 nonphthisicaleyes (16 %), and in 14 eyes (7%) the cornea wascompletely vascularised (Fig. 5). In 3 cases there wasa lipoid infiltration of the cornea which possiblyrepresented an old corneal leproma (Fig. 6), but inonly 3 eyes were enlarged corneal nerves identified.Iris atrophy with loss of stromal architecture andgross thinning was observed in 113 nonphthisicaleyes (57 %), and posterior synechiae occurred in 66eyes (33 %), though the 2 conditions were combinedin only 49 eyes (25 %). In 110 eyes (55 %) the pupilwas found to be grossly reduced in size, at timespinpoint, and in 7 eyes there was complete seclusiopupillae. At the time of surgery these small pupilswere found to be unreactive to atropine and pheny-lephrine. Active iritis with aqueous flare and cellswas seen only in 3 cases, and a further 6 eyes had oldkeratic precipitates. Iris pearls were observed in 4

Fig. 3 Patient with advanced lepromatous leprosy Fig. 4 Patient with lepromatous leprosy showingshowing facial and nasal deformities. Medial and bilateral facial palsy. An ectropion repair with skinbilateral lateral tarsorrhaphies have been carried out. grafts has been carried out on each lower lid.

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Fig. 5 Vascularised corneal opacity in lepromatousleprosy.

Fig. 6 Irregular lipoid infiltrates in the superficialstromal layers of the cornea in lepromatous leprosy.

50 .

40 .

30 .

20 .

10 .

I ,IRM6 6 6 6 3

CF HM PL NPL-9 i-r2 i-8s N 'j r6 O

Fig. 7 Preoperative visual acuity in 81 eyes.

cases (2 %). Examination of the lens was made verydifficult by the small nonreacting pupils, but signifi-cant lens opacities were observed in 152 eyes (76 %).Examination of the fundi in 46 patients operated onin 1978 and before failed to show any choroidal or

retinal pathology that could be ascribed to leprosy.

SURGERYSurgery was offered to those patients who were

thought most likely to benefit from cataract opera-

tion, and in whom there were no gross axial cornealopacities or evidence of active iritis. A total of 81lens extractions in 79 patients were carried out, andthe preoperative vision in these 81 eyes is shown inFig. 7.

All cases were operated on under local anaesthesiaby an ab-externo technique with a broad iridectomyand inferior sphincterotomy; the lens was removed

by forceps combined with expression in the mannerpreviously described.'4 Routine antibiotic drops wereinstilled for 24 hours before surgery and the operationwas followed by a subconjunctival injection ofsteroid and steroid/antibiotic drops. The techniqueof lens extraction was modified to suit the localconditions and instruments, no cryotherapy beingavailable. An analysis of the surgical procedures andcomplications is presented in Table 2.

Postoperative visual acuity was measured with a+10 lens after a follow-up period of between 3 and18 months, and the results are shown on Fig. 8. Com-parison of the preoperative and postoperative visualacuity in each of the 81 operations is shown in Fig. 9.

Discussion

Several factors in the cause of blindness and visualimpairment in this group of patients emerge in thissmall series. In the first place it will be evident thatthe majority of patients (97 %) had the lepromatousform of leprosy and in all but 3 cases the disease hadbeen sucessfully treated, as shown by the negativeskin tests. Indeed 85% of the cases had had noevidence of active disease for at least 5 years. Theaverage age of the patients-61 5 years for men and

Table 2 Eighty-one lens extractions

Intracapsular 66Extracapsular 15 -1 planned

-7 capsule removedVitreous loss 14 -10 intracapsular

-4 extracapsularPostop. hyphaema 3Endophthalmitis 1Postop. uveitis 2Retrobulbar haem. 1Increased corneal

opacification 3

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20,

10

6 6 6 6636

3CF HM PL NPL

Fig. 8 Postoperative visual acuity in 81 eyes.

NPL

P HMRE

CFpER 3/60A

T

V 6/60E

A 6/36

IT 6/24y

6/18

6/12

6/9

mUmME Uon

:: * * **

* an a *mas* o* /

6/6 6/9 6/12 6/18 6/24 6/36 6/60 3/60 CF HM PL NPL

Fig. 9 Postoperative visual acuity in 81 eyes.

62 7 for females-represents a lower average age

than that of nonleprosy patients having cataractsurgery, and suggests that other factors apart fromthe ordinary development of senile cataract may beinvolved in the causation of visual impairment.Clinically it was certainly very difficult in many cases

to determine the precise degree of lens opacitypresent because of the pupil abnormalities andcondition of the iris. Almost all the patients had hadleprosy for at least 20 years, and the average durationof the disease was 41 years for males and 35 years

for females. This high incidence of anterior segmentcomplications in patients with disease of longduration agrees with the findings of other authorswho have studied lepromatous leprosy,4 10111516 andfailure to recognise these late effects may be respons-

ible for some of the low figures in the literature onthe ocular complications of the disease. The con-clusion can be drawn that ocular complications maydevelop long after the disease has been successfullytreated systemically and that no patient with lepro-matous leprosy should be regarded as safe fromocular damage despite negative skin tests andcontinued therapy.The high preponderance of affected male patients

(71 %) also conforms with the findings of otherauthors in different parts of the world:- 590% inMalaysia,'6 61 % in Tanganyika,"7 62 % in Thailand,18690% in Australia,19 71% in the United States,20 and820% in Egypt.21Many authors have noted that leprosy affects the

anterior part of the eye, with involvement mainly ofthe cornea and iris. Leprotic disease of the fundusand optic nerve, although described, is very rare.Indeed there was no evidence of any fundus lesionsattributable to leprosy in the case examined in thisseries. Disease of the posterior pole can therefore beeliminated as a significant cause of blindness inleprosy.

Clinically a prominent cause of blindness andvisual impairment in this series was the small size ofthe pupil. Although corneal opacities were presentin 680% of cases, it was noted that they did notnecessarily interfere with sight on their own and werenot often the main cause of visual disability. Allenand Byers22 also found that the corneal manifesta-tions of leprosy were usually not serious for visionunless corneal deposits in the centre were substantial.It was the combination of a small nonreacting pupilwith minor degrees of corneal opacification or lensopacities which was responsible in the majority ofcases for the visual impairment, and the role of'chronic iritis' in the causation of blindness inlepromatous leprosy was investigated and forms thesubject of a further publication.23The treatment of these late anterior segment

complications of lepromatous leprosy was basicallysurgical. At this stage of the disease local anti-lepromatous therapy such as sodium glucosuphone(Promin) drops are not beneficial,24 and in theabsence of active uveitis local steroid therapy haslittle to recommend it; in addition pupil dilatationcould not be obtained by sympathomimetic orparasympatholytic mydriatics. In 34% of thesecases definite posterior synechiae were present andresponsible for pupil abnormalities, but nonreactingpupils associated with iris atrophy were equallycommon, and no synechiae found at operation.Medical therapy by dilating drops or ointments wasnot therefore found to be beneficial in reducingvisual impairment, although local antibiotics werevaluable in the prevention of secondary infections.

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The choice of operation lay between opticaliridectomy and lens extraction combined withiridectomy. For a long time surgeons have com-mented on the friability of the iris in chronic lepro-matous leprosy making any sort of iris surgery suchas a conventional broad iridectomy very diffi-cult,"120 25-27, and iridectomy often failed because ofa tendency for the iris to be drawn up and theiridectomy to close. For this reason an inferiorsphincterotomy has been recommended to avoiddrawing up of the iris into the section.214 In many casesin this series it was obvious that there were con-siderable lens opacities whose extent and distributioncould not be accurately determined because of thesmall nonreacting pupils. The optical iridectomyalone under these circumstances might not prove tobe beneficial, and an inferior sphincterotomy wouldhave required a larger corneoscleral section. Inaddition many patients living far away in remotecommunities might not have another opportunity toattend for surgery if there proved to be extensivelens opacities.Lens extraction combined with broad iridectomy

and inferior sphincterotomy was therefore under-taken in all patients with small nonreacting pupilswhose visual loss could not be explained by cornealopacities alone. The results showed an improvementof the visual acuity of at least 2 lines on the Snellen'schart in 60 %, with only 13% showing no change orworse (Fig. 9). Vitreous loss during surgery wasmanaged by anterior vitrectomy and did not provein the short-term follow-up period to be a majorcomplication, though obviously these patients willhave to be kept under observation. The incidence ofpostoperative inflammation was very low (2 out of81 cases), and this agrees with the reported safety ofcataract surgery in leprosy patients.' 11 15 19 28 29Fig. 9 shows that 5 out of 81 cases (4%) were worseafter surgery, in 3 cases there was increased cornealopacification, in 1 case there were considerablecapsule remnants, and the remaining case developedan intractable endophthalmitis-this last patientbeing the only one who did not receive a 24-hourcourse of preoperative antibiotics.

It was evident therefore that in a large proportionof cases blindness occurred through the relativelysimple mechanism of the presence of a small non-reacting pupil caused by chronic iris changescombined with corneal or lens opacities.Although cataract surgery by the method des-

cribed provides a reasonably safe surgical answer tothe late complications of lepromatous leprosy andcan improve vision sufficiently to benefit thesealready severely disabled people, there is an urgentneed for energetic research into the cause of theseiris changes with a view to possible prophylaxis.

I am grateful to Dr Stanley C. Topple, Dr Mia Topple, DrAkiko Obara, Dr Yoo Kyeung Un, and all the staff of theWilson Leprosy Centre and Rehabilitation Hospital, Yosu,South Korea, for their invaluable help and assistance duringmy 2 visits to their hospital.

I am indebted to LEPRA and St Thomas's Hospital forfinancial aid, and I thank Mr K. Sehmi for the preparationof the figures and illustrations and Mrs Lesley Gibbons forher secretarial assistance.

References1 Kennedy PL. Ocular manifestations in leprosy. Am JOphthalmol 1952; 35: 1360-4.

2 Holmes WJ. Leprosy of the eye in South Korea. Int JLepr 1957; 25: 99/103.

3 Pinkerton FJ. Leprosy of the eye, ear, nose and throat.Trans Pac Coast Otoophthalmol Soc 1954; 35: 179-88.

4 Cochrane RG. Leprosy in Korea. Lepr Rev 1956; 27: 1-19.5 Cameron AN. Leprosy and its ocular manifestations.

Trans Ophthalmol Soc UK 1961; 81: 637-47.6 Emiru VP. Ocular leprosy in Uganda. Br J Ophthalmol

1970; 54: 740-3.7 Weekeroon L. Ocular leprosy in Ceylon. Br J Ophthalmol

1969; 56: 106-13.8 Hornblass A. Ocular leprosy in South Vietnam. Am J

Ophthalmol 1973; 75: 478-80.9 Malla OK, Brandt F, Anten JGF. In press.10 Pinkerton FJ. Leprosy of the eye: an analysis of the

record of 512 cases of leprosy in the Hawaiian Islands.Arch Ophthalmol 1927; 56: 42-51.

11 Harley RD. Ocular leprosy in Panama. Am J Ophthalmol1946; 29: 295-316.

12 World Atlas of Leprosy. Les amis du Pere Damien.Brussels: 1979.

13 Rock R, Obara A, Amundsen AM. Report on an ophthal-mological survey of colony patients at Wilson leprosycentre. 1973.

14 ffytche TJ. Cataract surgery in leprosy patients. Proc RSoc Med 1979; 72: 826-30.

15 Choyce DP. The diagnosis and management of ocularleprosy. Br J Ophthalmol 1969; 53: 217-23.

16 Hobbs HE. Leprotic iritis and blindness. Int J Lepr 1972;40: 366-78.

17 Mclaren DS, Shaw MJ, Dalley KR. Eye disease inleprosy patients: a study in central Tanganyika. Int JLepr 1961; 29: 20-8.

18 Wangspa S, Limpaphayom P. Ocular leprosy in Thailand.Trans Asia Pac Acad Ophthalmol 1976; 5: 153-61.

19 Gibson JB. Eye complications of leprosy. Med J Aust1950; i: 8-14.

20 Prendergast JJ. Ocular leprosy in the United States.Arch Ophthalmol 1940; 23: 112-37.

21 Wasfy IA, Abdel-Rehim DE. Ocular leprosy in Assiut.Bull Ophthalmol Soc Egypt 1971; 64: 299-327.

22 Allen JH, Byers JL. The pathology of ocular leprosy.I. Cornea. Arch Ophthalmol 1960; 64: 216-20.

23 ffytche TJ. Role of iris changes as a cause of blindness inlepromatous leprosy. Br J Ophthalmol 1981; 65: 231-9.

24 Bouzas A. Long term observation of local application ofpromine in ocular leprosy. Arch Ophtalmol (Paris)1971; 31: 629-34.

25 Wood DJ. Ocular leprosy. Br J Ophthalmol 1925; 9: 1-4.26 Ebenezer R. Symposium on Uveitis. Proc All-India

Ophthalmol Soc 1963; 19: 183-8.27 Sivasubramaniam P. Some aspects of ocular leprosy in

Ceylon. Trans Ophthalmol Soc Ceylon 1971; 10: 13-21.28 Kirwan EWOG. Ocular leprosy. Proc R Soc Med 1955;

48: 112-8.29 Weekeroon L. Ocular leprosy in Ceylon. Br J Ophthalmol

1969; 53: 457-65.

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