INTERNATIONAL JOURNAL OF LEPROSY Volume 61, Number IPrinted in the

Cataract Surgery in a LeprosyPopulation in Liberia'

Joseph Frucht-Pery and Sandy T. Feldman 2

The incidence of ocular involvement inpatients with leprosy has varied from as lowas 6% ( 3 ) to as high as 90% ( 5 ). Since manyof these patients have amputated limbs, vi-sion becomes extremely important for theirrehabilitation. Few studies have reported thevisual complications of leprosy in Africans( 2 . 9. "), and none have addressed the visualoutcome following cataract surgery. We re-port the results of cataract surgery in a lep-rosy population in Liberia.

PATIENTS AND METHODSTwo-hundred-forty patients with leprosy

were hospitalized and treated in the Reha-bilitation Center for Leprosy in MethodisticHospital in Ghanta, Liberia. Of this pop-ulation, 125 patients with ocular complaintswere examined between January 1985 andDecember 1986. Thirty patients, 17 menand 13 women, ranging in age between 30to 65 years old (mean 48 years) had signif-icant cataracts in 43 eyes and underwentcataract extraction. Of this group, 18 pa-tients had lepromatous leprosy, 8 had bor-derline leprosy, and 4 had tuberculoid lep-rosy. At the time of the surgery, all patientshad negative skin tests and had been treatedwith the usual antileprosy treatment.

Preoperatively, each patient unde'rwentan ophthalmic evaluation including visualacuity, slit-lamp examination, and intra-ocular pressure (IOP) measurement bySchiotz tonometry. The view of the funduswas obscured by a dense cataract in all ex-amined eyes.

Preoperative visual acuity was 25 cm to1 meter finger count in 9 eyes and hand

' Received for publication on 9 September 1992;accepted for publication in revised form on 5 January1993.

J. Frucht-Pery, M.D., Department of Ophthal-mology, Hadassah University Hospital, P.O. Box12000, 91120 Jerusalem, Israel. S. T. Feldman, M.D.,University of California San Diego, La Jolla, Califor-nia, U.S.A.

movements or less in 34 eyes. Mature, in-tumescent, or hypermature cataracts wereobserved in all except three eyes which hadmoderately cloudy corneas and progressivecataracts. The intraocular pressure wasgreater than 22 mmHg in three eyes. Theocular complications of leprosy in 43 eyesare presented in Table 1.

All surgery was performed by one surgeon(JF-P). Extracapsular cataract extraction(ECCE) was performed in 33 eyes of 22 pa-tients (with combined trabeculectomies in2 eyes) and intracapsular cataract extraction(ICCE) in 10 eyes of 8 patients. ECCE wasroutinely attempted in all except 3 eyes of2 patients with cloudy corneas. In these eyesplanned ICCE was performed.

Lignocaine 2% was used for retrobulbarblock (3 to 4 ml) and for akinesia of the lids(O'Brien modification-5 ml). A fornix-based conjunctival flap was made followedby limbal groove from 11 to 2 o'clock, thenthe anterior chamber (AC) was entered witha blade. Anterior synechiae were broken witha cyclodialysis spatula. If the iris wasatrophic and the pupil remained small fol-lowing synechialysis, or the visualization ofthe iris structures was markedly reduced,the limbal groove was extended, one pre-placed 8-0 silk suture was used and sectoriridectomy was performed followed by ICCEusing a disposable cryoprobe (7 eyes of 6patients). In the remaining 33 eyes of 22patients anterior capsulotomy, with a 25-gauge bent needle, was performed under ir-rigation. The limbal wound was enlarged to10 mm and the nucleus was extracted bysimultaneous depression of the sclera with0.12 corneal forceps at the level of the lim-bal incision and with a muscle hook at 6o'clock. The liquefied cortex was irrigatedwith a 23-gauge cannula connected to a bulbfilled with saline. In most eyes, the AC wasfree of cortical material and the wound wassutured. When residual cortical material re-mained in the AC, it was irrigated and as-pirated with coaxial I/A cannula (Visitec,

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61, 1^Frucht-Pery and Feldman: Cataract Surgery in Leprosy

TABLE 1. Preoperative ocular complica-tions of leprosy in 43 eyes.

ECCE.' ICCE''

No. eyes No. eyes

Lid abnormalitiesLagophthal mos 4 4Entropion 3 1

Corneal abnormalitiesLeproma I 3Interstitial keratitis I 0Opacity (other reasons) 3 2-

Iris atrophy 2_ 4Posterior syncchiae 2_ 6Glaucoma 2 IRecurrent iritis I 6

Patients undergoing ECCE surgery.'' Patients undergoing ICCE surgery.

Florida, U.S.A.). Optical iridectomies wereperformed when necessary. The wound wassutured with separate 8-0 or 10-0 sutures(total 5 to 6 sutures for ECCE and 8 to 10sutures for ICCE) and 5% chloramphenicolointment was applied into the lower fornix.

Postoperatively patients remained in therehabilitation center (for at least 6 months)and were treated with topical chloramphen-icol 0.5% four times a day, 1% atropine sul-fate four times a day, and topical dexa-methasone phosphate 0.1%, six times a dayfor 1 week. Then the chloramphenicol 0.5%was discontinued and the other drops wereused four times a day for 2 more months,then tapered and stopped after a total periodof 4 months. The patients were followed at1 week, 1, 2 and 3 months, then every 3months, or as needed in case of postoper-ative complications. Each postoperative ex-amination included: visual acuity taken witha +10.00 diopter lens, 10P measurement,and indirect and direct ophthalmoscopy ofthe posterior pole. Refraction was not per-formed in these patients. The patients werefollowed for 6-18 months, and the last ex-amination of each patient was used for theevaluation of the results.

RESULTSOf 240 patients in the Ghanta Leprosy

Center, 125 underwent eye examination. In57 patients (23.75%) cataractous changeswere discovered and 43 eyes of 30 patients(12.5%) underwent cataract surgery.

TABLE 2. Postoperative corrected visualacuity with + 10.00 diopter spectacles.

Visual acuityECCE ICCE

No. eyes No. eyes

20/40 or better 2_ 120/60 6 020/80 8 020/100 11 020/200 3 4

> 20/200 3 5

Postoperatively all eyes except two gainedat least two lines of vision (corrected with+10.00 diopter lens). Of the total 43 eyes,28 (65%) had functional visual acuity of bet-ter than 20/200 (Table 2).

In the group that underwent ECCE, 12 ofthe 22 patients had lepromatous leprosy, 7patients had borderline leprosy and 3 hadtuberculoid leprosy. Of the 33 eyes in thisgroup, 2 eyes had synechialysis, 3 had opticiridectomies, and 2 had combined ECCE +trabeculectomy. Postoperatively 27 eyes(82%) had functional visual acuity but onlytwo (6%) had vision better than 20/40 (Ta-ble 2). In three eyes (9%), the visual acuitywas less than 20/200 as a result of opticatrophy, macular scar, and glaucoma.

In the group that underwent ICCE, 6 ofthe 8 patients had lepromatous leprosy, 1patient had borderline leprosy and 1 hadtuberculoid leprosy. Of 10 eyes in this group,6 eyes had synechialysis, 3 eyes had opticiridotomies, and 1 had vitreous loss. Post-operatively only one eye (10%) had visionbetter than 20/200 and four eyes (40%) hadvision of 20/200. In five eyes (50%), thevision was less than 20/200 (range of fingercount between 1 to 5 meters). Of these 5eyes, 2 had significant corneal leproma, 1had optic atrophy, 1 had glaucomatous op-tic atrophy and 1 had chronic iritis.

Fifteen eyes of 11 patients had postop-erative complications (Table 3). Seven eyes(6 patients) had complications post-ECCEand eight eyes (5 patients) had complica-tions following ICCE. Six eyes had post-operative glaucoma (3 post-ECCE, 3 post-ICCE) and were controlled with topicaltimolol 0.5%, pilocarpine 2% to 4% and oralacetazolamide. In one case, intraocularpressure was steroid induced and droppedto normal levels after steroids were discon-

22^ International Journal of Leprosy^ 1993

TABLE 3. Postoperative complications.

ECCE^ICCE

No. eyes^No. eyes

Glaucoma^ 3^3Iritis^ 0^2-CME^ 1^IHyphema^ 1^IPosterior capsular

opacity^ 2_^0Vitreous loss^0^1

tinned. Two patients had post-ICCE iritis.Both had a history of iritis prior to the sur-gery and postoperatively were controlledwith topical steroids during the follow-upperiod.

Clinically significant cystoid macularedema (CME) was observed in 2 eyes (1post-ECCE, 1 post-ICCE). Two patients hadpostoperative hyphemas (1 post-ECCE, 1post-ICCE) that cleared within 3 days. Twoeyes post-ECCE had mild posterior capsularopacifications after 2 and 4 months, but nei-ther had a loss of visual acuity. One eyepost-ICCE had vitreous loss. No cases ofendophthalmitis were observed.

DISCUSSIONIn Africa, ocular leprosy has been re-

ported to be less prevalent than in Asia(1, 3, 5, 7, 8, 13.1J).) Cataract surgery has not beendocumented in this population. In theGhanta Rehabilitation Center (Liberia) themajority of the patients are handicapped andsome are immobile. All patients were avail-able for ocular examinations for at least 6months. Since no ophthalmologist had beenattainable in this area for at least 7 years, itis not surprising that almost 24% of thispopulation had cataracts and 14% neededcataract extraction. Significant lenticularopacities in a lepromatous population haveranged from 29 %— 79% (1, 3, 7, 8, II, I4 , .) Thesefindings may reflect the natural history ofcataract formation in leprosy in differentraces, the severity of ocular leprosy involve-ment, or the accessibility of ophthalmictreatment in different populations.

When eyes after ICCE and ECCE wereplaced into one group, 65% had vision bet-ter than 20/200. All eyes except two gainedat least 2 lines of vision. Furthermore, ofthe 43 eyes that were corrected with a

+10.00 diopter lens, 28 (65%) had func-tional visual acuity of better than 20/200.If refracted, better vision would probablyhave been achieved, but (at the present time)the standard aphakic spectacles of +10.00diopter power are the only optical deviceavailable for this population.

A large variety of visual results (func-tional vision in 27%-80%) following cat-aract surgery in leprosy populations hasbeen reported ( -4 'ft 12 ). The postoperativevisual results are probably related to thevariability of the types of leprosy in differ-ent populations, to the preoperative ocularinvolvement by leprosy, the different in-clusion criteria for cataract surgery, theuse of different surgical techniques, or thequantities of postoperative use of cortico-steroids (4.10,12). Blindness with visual acu-ity of hand motion or less coupled withsevere involvement of limbs results in anextreme form of disability. Therefore, anypostoperative visual acuity, of even fingercount, is of great importance for rehabili-tation of these handicapped patients.

Of the 30 patients in this study, 18 (60%)had lepromatous leprosy. However, the lep-romatous leprosy group comprised 75% ofthose who underwent ICCE and 55% of pa-tients who had ECCE surgery. Of the leprosypopulation, lepromatous leprosy presentsthe most severe involvement of the eye. Itis not surprising, therefore, that a majorityof the patients who underwent ICCE be-cause of the inability to perform ECCE be-longed to this group. These eyes had severemanifestations of ocular leprosy (Table I)including: cloudy corneas; small pupils;atrophic, nonresponsive and easily break-able irises. Postoperatively 8 of the 10 eyesafter ICCE had complications (Table 3) and9 (90%) of these eyes had vision of 20/200or less. The rate of complications, the poorvisual acuity post-ICCE, and the fact thatfour fellow eyes in these patients lost theirsight reflects the more serious ocular diseasein patients with advanced lepromatous lep-rosy (Table 1).

Planned ECCE had not been reportedpreviously in patients with leprosy, possiblydue to the prevalence of leprosy in com-munities with limited resources where op-erating microscopes and aspiration and ir-rigation units are not available. In addition,

Complications

61, 1^Frucht-Pery and Feldman: Cataract Surgery in Leprosy

ECCE in eyes with corneal haze and atro-phic, nonreactive iris may be a very com-plicated procedure.

In this study ECCE was performed onlywhen it was technically possible. Although12 of the 22 patients had lepromatous lep-rosy, preoperative evaluation revealed onlymild or moderate ocular complications ofleprosy (Table 1). Postoperatively, 30 ofthese eyes (91%) had visual acuity of 20/200 or better, not differing from a healthypopulation who also underwent cataractsurgery and received standard aphakic spec-tacles ( 12 ). Seven of the 33 eyes after ECCEhad nonsignificant postoperative compli-cations that could easily be controlled (Ta-ble 3). It is impossible to compare the com-plications of the ICCE group to those of theECCE group because the patients in the for-mer group had such severe eye disease thatit was impossible to perform ECCE. Ob-viously the ICCE group had more postop-erative complications. However, none of thecomplications in this study was severe.

Postoperative glaucoma was controlledwith medication in six eyes. Hyphema (twoeyes) cleared within the first postoperativeweek. Persistent postoperative iritis mani-fested in two eyes (6%) with preoperativeiritis. The inflammation was controlled withtopical steroids during the follow-up period.Two eyes (6%) had mild postoperativeopacification of the posterior capsule with-out loss of visual acuity. If vision becomescompromised in the future, capsulotomyshould restore the sight. We noticed the lowincidence of opacification of posterior cap-sules post-ECCE in mature and hyperma-ture cataracts in the healthy black popula-tion in Africa (unpublished data) as didHemo (6 ) in a similar population in Swa-ziland. Various rates of complications post-cataract surgery in populations with leprosyhave been reported in other studies ( 3 ' ' 1 ' 12 ).However, severe postoperative complica-tions which were reported in these studies,such as endophthalmitis or opacification ofthe cornea ( 3 ' 10), shallow anterior chambers(10, 1 2‘ ,) retained lens material in the anteriorchamber or retinal detachments ( 12 ), werenot observed in our patients.

In Liberia the operated patients were ob-served monthly for at least 6 months, whichwould allow medical or surgical interven-

tion had complications occurred. These ide-al circumstances are unusual in Third Worldcountries. One should consider the post-operative complications in terms of theability of the patient to present for exami-nation as well as the availability of an oph-thalmic surgeon in the district after the sur-gery is done. ECCE has the disadvantage ofpossible secondary capsular opacities whichare less common and less opaque than inthe Western population; furthermore, it mayreduce the sight but does not cause blind-ness as do other complications. ICCE hasgreater rates of other complications such ascystoid macular edema or retinal detach-ment. All of these complications can betreated but sometimes may lead to blind-ness, particularly when an ophthalmologistis unavailable. Regardless of these unfor-tunate circumstances, the surgeons in theseparts of the world should perform as manyECCE or ICCE surgeries as they can, andperhaps train other medical staff to followthe patients when the ophthalmologist is notavailable.

The use of the operating microscope forICCE or ECCE is advantageous over the ab-extern° technique (") or ICCE with cryo-probe without the microscope (10). How-ever, it does not necessarily replace thesetechniques. This study suggests that cataractsurgery should be encouraged in leproma-tous patients. While ECCE is advised in lesscomplicated cases, ICCE is suggested in therest of the patients.

SUMMARYIn Liberia, 43 eyes of 30 patients with

ocular leprosy underwent cataract extrac-tion; 33 eyes had extracapsular cataract ex-traction (ECCE) and 10 eyes had intracap-sular cataract extraction (ICCE). ICCE wasperformed in eyes with poor visualizationof the anterior chamber. In 95% of the eyes,the postoperative vision improved by 2Snellen lines or more, but functional visualacuity (better than 20/200) was achieved inonly 65% (82% post-ECCE and 10% post-ICCE). Fewer postoperative complicationswere observed after ECCE. These findingsmay have been related to less ocular in-volvement by leprosy preoperatively. ECCEshould be attempted when the visualizationof the anterior chamber is fair.

24^ International Journal of Leprosy^ 1993

RESUMENEn Liberia, 43 ojos de 30 pacientes con lepra ocular

se sometieron a extraction de cataratas; 33 ojos tuvie-ron extracción extracapsular de catarata (EECC) y 10ojcs tuvieron extracción intracapsular de catarata(EICC). La EICC se cfectuó en ojos con pobre visua-lización dc la cámara anterior. En el 95% de las ojosIa vision postoperative mejoth en 2 linens Snellen omás, pero Ia agudeza visual funcional (mejor de 20/200) solo se alcanze) en el 65% de los casos (82% post-EECC y 10% post-EICC). Tambien se observó que lasmenores complicaciones postoperatorias ocurrierondespués de Ia EECC; est° pudo haber estado en relacióncon menos afección ocular antes de la operación. LaEECC debt intentarse cuando Ia visualización de Iacámara anterior es buena.

RESUMEOn a opéré pour cataracte au Liberia 43 yeux de 30

malades de la lepre; on a realise. pour 33 yeux uneextraction extracapsulaire de la cataracte (EECC) etpour 10 ycux une extraction intracapsulaire (EICC).L'EICC a etc réalisée pour les yeux oil Ia chambreantérieure était mal visualisée. Pour 95% des yeux, lavision post-opératiore s'est améliorée d'un score de 2lignes Snellen, mais l'acuité visuelle fonctionnelle (plusde 20/200) n'a etc atteinte que dans 65% des cas (82%apres EECC et 10% apres EICC). On a observe moinsde complications post-opératoires apres EECC. Ces ob-servations pourraient etre 'lees A un moindre envahis-sement oculaire par la lepre en pre-operatoire. L'EECCdevrait etre tentée lorsquc la visualisation de Ia chambreanterieure est convenable.

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