Anterior segment optical coherence tomography findings of iris granulomas in Hansen's disease: a case report
© Mahendradas et al.; licensee Springer. 2013
Received: 5 October 2012
Accepted: 17 January 2013
Published: 11 February 2013
A 50-year-old male was diagnosed to have a right eye sclerouveitis and left eye granulomatous anterior uveitis due to Hansen's disease. We are reporting the anterior segment optical coherence tomography (ASOCT) findings of iris granuloma in this case.
Skin biopsy revealed plenty of acid fast bacilli with a bacteriological index of 5 suggestive of multibacillary polar lepromatous leprosy. ASOCT revealed well-demarcated smooth-surfaced nodular lesion with internal hyporeflectivity corresponding to the areas of granuloma which decreased in size following treatment with antileprosy drugs and systemic and topical steroids.
ASOCT is a non-invasive technique to assess the extent of involvement of anterior segment in Hansen's disease and is a useful tool in follow-up. This is also the first report on ASOCT findings of iris granuloma in Hansen's disease.
Leprosy (Hansen's disease or Hanseniasis) is one of the systemic diseases which can give rise to a plethora of features in the eye. The incidence of ocular involvement in leprosy has been variously quoted as 51% to 69% [1–3]. Iris nodules and lepra pearls are characteristics of the ocular manifestation of this disease and help in its diagnosis. In this study, we report the anterior segment optical coherence tomography (ASOCT) findings of iris granulomas in leprosy.
Ocular features commonly reported in leprosy are madarosis; lid abnormalities such as ectropion, entropion, trichiasis and lagophthalmos; dacryocystitis; chronic conjunctivitis; scleritis or episcleritis; and corneal involvement in the form of loss of corneal sensations, superficial keratitis, corneal opacities, interstitial keratitis, adherent leucoma, corneal ulcer or pannus and uveal involvement [2–5]. Three different types of uveal involvement have been described : (a) typical acute granulomatous iridocyclitis with keratic precipitates, posterior synechiae and hypopyon with or without conjunctival leproma; (b) neuroparalytic uveitis in the form of dilator muscle atrophy; and (c) presence of iris pearls and lepra pearls with complicated cataract. Ocular hypotony in conjunction with hypotension has been reported in patients under therapy for multibacillary leprosy .
Ocular features noted in our patient were sclerouveal granuloma (leproma) with acute iridocyclitis in the right eye and iris leproma and iris pearls with acute iridocyclitis in the left eye. This case can be classified as type IV - immune-mediated granulomatous anterior uveitis due to leprosy . Cornea was found to be the most commonly affected structure in the eye in a case series studied by Sanjiv et al. , of which loss of corneal sensations was the most common finding which in our case was notably absent. Lagophthalmos is another common ocular finding which was absent in this case. Ocular leproma can be secondary to taking dapsone monotherapy irregularly and can signify dapsone resistance . Incidentally, our patient gave history of having taken some medications for a few months for the dry scaly skin lesions which he discontinued by himself.
ASOCT imaging of granulomatous lesions has been described earlier in tuberculosis as poorly demarcated amorphous lesion  and as absorbent, hyporeflective areas . The lesions in our case were well demarcated with internal hyporeflectivity and after shadowing. The extent of involvement was easily made out on ASOCT, but the limitation of optics disallows the interpretation of depth of lesion.
Granulomatous ocular leproma can be secondary to irregular anti-leprotic therapy or its discontinuation. Systemic steroids may be necessary along with anti-leprotic therapy for Immune-mediated granulomatous anterior uveitis seen in leprosy. ASOCT acts as a non-invasive technique to gauge the extent of involvement of anterior segment and is a useful tool for follow-up in patients of Hansen's disease with uveal involvement.
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