Case Reports

Cataract surgery in a patient with absence of pupil and zonular fragility after leprosy

Case Report Details

First Author: A.Magalhaes BRAZIL

Co Author(s):    M. Messias   M. Hollaender   F. Brugnara   P. Carricondo           

Abstract Details

Purpose:

Leprosy is an infectious disease caused by Mycobacterium leprae constituting a public health problem in developing countries, such as Brazil. Among ocular alterations, cataracts are more common in the multibacillary type and are the main cause of low visual acuity, with a prevalence increasing due to the longevity of the population and insufficient specialized services. In leprosy, cataracts can be senile, secondary to chronic steroid therapy or associated with chronic uveitis. The authors describe the case of a patient with ancient leprosy, who developed corectopy and cataract with zonular fragility, attended in January 2020.

Setting:

This case report was based on clinical examinations, surgery performed and patient follow-up, held at the Department of Ophthalmology, University of São Paulo (USP), São Paulo, Brazil.

Report of Case:

Female, 62 years old, referred to the cataract department with visual acuity “hand movement” in right eye and left eye 20/20. The patient has leonine facies and reports a history of leprosy for 30 years (treatment for 5 years). The first ophthalmology visits at USP 10 years ago due to uveitis in right eye and entropion in both eyes, ocular manifestations by leprosy. Right eye biomicroscopy it is observed quiet conjunctiva, transparent cornea, lower PKs, iris with important inferior temporal corectopy, absence of pupil, middle anterior chamber and advanced cataract are observed by the small opening of the iris; left eye without changes. Intraocular pressure 13/14mmHg in right/left eye respectively, retinal mapping impractical in right eye, left eye stained optic disc, papillary excavation 0.3 and applied retina. Right eye gonioscopy with synechiae and increased pigmentation at all angles in the four quadrants. Ultrasonic biomicroscopy in right eye shows diffuse iris thinning, absence of iris between 7-9 hours, hyper-reflective interface attached to the posterior surface of the cornea (healing process?), absence of pupillary orifice, anterior synechia between 6-8 hours, lens with irregularity of the central anterior face, heterogeneous tissue next to the anterior capsule, without rotation and adherence to the iris, subluxed upper nasal, lens with sparse zonular fibers elongated between 5-9 hours and 360º affiliated body. In surgery, opening of central iris was performed, proving a zonular fragility and intense anterior capsule fibrosis. Thus, we opted for intra-capsular facectomy and aphakia, with intraocular lens implantation in the second time. Histopathology of the lens showed extensive subcapsular fibrosis with foci of granular calcification and iris pigments adhered to the anterior capsule. The right eye fundoscopy at postoperative was an pale optic nerve with enlarged papillary excavation, correspond to glaucoma secondary to leprosy, but with good vision potential after refraction testing.

Conclusion/Take Home Message:

In our case, the main challenges during the facectomy were the absence of a pupil associated with corectopy and zonular fragility associated with anterior capsule fibrosis. The development of a surgical technique that would trigger the smallest possible inflammatory reaction in the intra and postoperative period was desirable for the better quality of life of the patient. In cases like this, after uveitis and with intense ocular manifestations, must be found an experienced cataract surgeon and aware of all the complications inherent to the long time of inflammation.

Financial Disclosure:

None