1. Leprosy Ocular Erythema nodosum leprosum
S.R. Rathinam FAMS PhD
Uveitis service
Aravind Eye Hospital
Madurai.

2. History 45 year old male patient with lepromatous leprosy
he was advised treatment several times, but because of
recurrent ENL reaction, patient never took proper treatment.

3. First Examination OS: leproma with hypopyon
aqueous tap, staining for Mycobacterium lepra +
hypopyon is reported but very rare in leprosy

4. Treatment Standard multi drug anti leprosy treatment
20 mg oral steroids
600 mg Rifampicin and 300 mg Clofazimine on day 1 of every month
100 mg Dapsone daily and
50 mg Clofazimine for months

5. Follow up - Day 7 developed very severe type 2 reactions,
experienced fever, malaise, and polyarthralgia as well as an abrupt onset of numerous tender, erythematous nodules over the face, extremities and over the trunk.
This is termed erythema nodosum leprum (ENL) and tends to occur
with poor cellular immunity but strong humoral immunity to M. leprae,
more specifically in patients with high bacillary load

6. Follow up – Day 7
severe ocular ENL resulted in ocular perforation
because of severe pain the globe was enucleated
histopathological staining

7. Histopathology
limbal region LE
Polymorphonuclear cells in ENL

8. Ciliary body ENL

9. POLYMORPHS IN ENL

10. Treatment Options
Corticosteroids are highly useful for type 1 and type 2 reactions, but
Thalidomide is the most effective agent to treat severe forms of type 2 reactions
Thalidomide was not available freely but would have helped this patient

12. Ocular
leprosy
Bacilli in the eye
Type II
Type I

13. Type 1(Reversal reaction)
Ocular Leprosy
Type 1(Reversal reaction)
Type 2 (ENL)
Immune status
Spontaneous enhancement of Cellular immunity
Spontaneous enhancement of
Humeral immunity
Ocular findings
5th and 7th nerve palsy
Episcleritis, Scleritis, Uveitis
Uveitis was
found in 56%
In HPE
Clinically 5-6 %

14. Type III Hypersensitivity
Erythema nodosum leprosum (ENL) is induced in a Type 2 lepra reaction
Type 2 lepra reactions are acute inflammatory complications that often present as medical emergencies during the chronic course of treated or untreated Hansen's disease