INTERNATIONAL JOURNAL OF LEPROSY^ Volume 55, Number 3

Printed in the U.S.A.

Unusual Histological Lesions in theEye of a Leprosy Patient'

Zhou Hui-Min, Shi Zhen-Rong, and Charles K. Jobe

Descriptions of the histopathology of eyelesions in leprosy, both in humans and inexperimental animals, have rarely appearedin the literature. The lesions reported werealmost all lepromatous infiltrations, pre-dominantly in the anterior segment of theeyeball. We had a case of eye involvementin a leprosy patient. In this eye a granu-lomatous reaction composed of epithelioidcells, lymphocytes and giant cells, infiltrat-ing mainly the anterior segment of the eye-ball and also the retina was seen. We reporton the unusual features of the reactions inthis eyeball of a leprosy patient.

MATERIALS AND METHODSThe eyeball of this male patient, 42 years

of age, was submitted to us from a leprosycontrol unit in Shandong Province, People'sRepublic of China, in the mid-1960s withonly a too brief clinical diagnosis of lepro-matous leprosy and a one-sentence descrip-tion of the patient's ailment: 10 years ofpain in the eye and blindness. This was allthe information we could obtain.

The eyeball was fixed in Formalin andsubsequently dehydrated in graded alcoholand embedded in celloidin, as is our routine.Ten of the serial sections cut, 20 pm thickeach, were stained with hematoxylin andeosin (H&E), and the others have been pre-served. In 1986, two old preserved celloidinsections were stained for acid-fast bacilli(AFB) with a modified Fite method.

RESULTSHistopathology of the eyeball

Conjunctiva. There was only a small stripof conjunctiva attached, and no remarkablechange was found.

' Received for publication on 17 October 1986; ac-cepted for publication in revised form on 8 April 1987.

= Dr. H.-M. Zhou, Professor of Pathology; Dr. Z.-R.Shi, Professor of Ophthalmology and Ocular Pathol-ogy, Qingdao Medical College, Qindao, People's Re-public ofChina. C. K. Job, M.D., F.R.C.Path., F.A.M.S.,Chief, Pathology Research Department, GWL Han-sen's Disease Center, Carville, Louisiana 70721, U.S.A.

Cornea. The thickness of the epitheliallayer of the cornea was not even, and therewas atrophy of Bowman's layer. Neovas-cularization, distortion of lamellae, and in-flammatory cell infiltrations were seenthroughout the stroma of the cornea, butmost prominently in the superficial stratum.

Sclera. The anterior and superficial partof the sclera was similarly infiltrated as thecornea, but milder. In the area adjacent tothe ciliary body, there were abundant lym-phocytes, macrophages, and neutrophils.Along the course of the nerves traversingthe sclera, granulomas composed of mac-

FIG. I. Posterior part of the sclera, immediatelyadjacent to the nerve traversing it, showing a granu-loma composed of macrophages, epithelioid cells, lym-phocytes, giant cells, and some neutrophils. Melanindeposition approximately marks the boundaries of thenerve (H&E x 180).

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508^ International .lournal of Leprosy^ 1987

FIG. 2. Section of a nerve in the sclera posterior tothe one in Figure 1 and near the optic nerve, showingperineural thickening (H&E x 300).

rophages, epithelioid cells, lymphocytes, andLanghans' giant cells, with some neutro-phils, were seen (Fig. 1). Some nervesshowed perineural thickening (Fig. 2).

Uvea. Granulomas, with compositionsimilar to those in the sclera, were seen inthe ciliary body, iris, and anterior portionof the suprachoroid, but not in the bulk ofthe choroid. The ciliary body and iris, be-sides the granulomas, were also densely in-filtrated by macrophages, plasma cells, andsome neutrophils. There was a diffuse pe-ripheral anterior synechia of the iris with abreakdown of the pigment epithelium, andthe posterior surface of the iris was adheredto the lens capsule by a fibrovascular mem-brane. The pigment epithelium of the ciliarybody was disrupted locally.

Retina. Besides other alterations, severalsmall granulomas were seen in the retina(Fig. 3) and in the vitreous attached to theinner surface of the retina, in one of whicha Langhans' giant cell was seen. Other al-

FIG. 3. A small collection of macrophages, epithe-lioid cells, and lymphocytes in the retina. One giantcell and some macrophages and lymphocytes are seenin the vitreous attaching the retina (H&E x 180).

terations included edema, flat detachment,disappearance of the ganglia cells, local de-struction of the pigment epithelium, andchronic inflammatory cell infiltrationsaround the blood vessels.

Optic nerve. The optic nerve was atrophicwith some lymphocyte infiltrations locally.

Lens. There was a cataract change.Anterior chamber. The chamber angle was

completely obliterated, and the chamber wasfilled with serous exudate.

Vitreous body. In the vitreous, some lym-phocytes, macrophages, and neutrophilswere seen. Local fibrosis of the exudate nearthe ciliary body and some collections ofmacrophages and epithelioid cells were alsoobserved.

There was no evidence of caseous necro-sis in any of the lesions.

Acid-fast staining of the old preservedcelloidin sections with a modified Fitemethod was not satisfactory. The granules

55, 3^ Zhou, et al.: Unusual Eye Lesions^ 509

of the mast cells, which almost always staindeep red with this method, were of a veryfaint pink tint and just recognizable. No AFBwere found in the sections.

DISCUSSIONThe only clinical information on this pa-

tient we could get from a leprosy controlunit was the diagnosis of lepromatous lep-rosy with a 10-year eye problem. Granu-lomas composed of epithelioid cells, mac-rophages, lymphocytes, and Langhans' giantcells, with some polymorphonuclear cellswere distributed predominantly in the an-terior segment of the eye specimen, sparingthe bulk of choroid, and were also seen alongthe course of nerves in the sclera and in theretina.

The lesions in the eyes, and in many otherinternal organs, reported in the literaturewere mostly found in lepromatous-type pa-tients and animals with a lepromatous re-action ('• 2 . 4- '). However, in the testes ofsome borderline cases in the reactive phase,a tuberculoid granulomatous reaction withAFI3 has been well documented ( 3 ). The re-action in the eye of our case was quite sim-ilar to that seen in those testes. Althoughwe could not stain our old sections wellenough to demonstrate AFB, the perineuralthickening of the nerve in the sclera, thegranulomatous lesions around it and withinthe iris and the anciliary body, make themost likely interpretation of the lesions bor-derline leprosy.

It is well documented that many leprosypatients are complicated with tuberculosis,and some authors consider "that the occa-sional reports of leprosy in posterior partsof the eye may have been due to syphilis ortuberculosis" rather than leprosy ( 2 ). But,tuberculosis of the inner eyes is almost al-ways a hematogenous infection; the gran-ulomas are distributed in the iris, ciliarybody, choroid, and retina where the bloodsupply is rich, and show no site preference.The distribution of the lesions in this eye,such as the involvement of the nerves in thesclera, the sparing of the choroid, and thegranulomas present preferentially in the an-terior segment of the eyeball, make the di-agnosis of tuberculosis unlikely. Therefore,it is reasonable to state that this patient hadborderline lepromatous disease of the eye.

Leprosy lesions are mainly found in theanterior aspect of the eye, involving the iris,ciliary body, and the anterior aspects of thesclera and episclera. Lesions in the posteriorsegment of the eyes are extremely uncom-mon. In a study of 250 leprosy patients,retinal lesions were reported in only two (6 ).Therefore, the finding of microgranulomasin the retina of this patient is of special in-terest.

SUMMARYA pathological study of an eye from a

leprosy patient is reported. In addition tothe granulomatous lesions in the anterioraspect of the eye, microgranulomas aredemonstrated in the retina of this patient,a very uncommon finding in leprosy.

RESUMENSc reporta el cstudio patológico de un ojo de un

paciente con lepra. Ademas de las lesiones granulo-matosas en la parte anterior del ojo, se demostraronmicrogranulomas en Ia retina de este paciente, unhallazgo muy cornan en lepra.

RÉSUMÉ

On relate ici Ics resultats dune etude anatomo-pa-thologique do l'oeil chez un malade de la lépre. Outreles lesions granulomateuses notées a l'examen ante-rieur de l'oeil, on a releve des microgranulomes dansIa reline de cc maladc. Ccci constitue unc trouvaillcfort inhabituelle dans la lépre.

REFERENCES1. DESIKAN, K. V. and JOB, C. K. Report on the study

of eye lesions in three autopsied cases of leprosy.Lepr. India 42 (1970) 1-3.

2. Howls, H. E., HARMAN, D. J., REES, R. J. W. andMCDOUGALL, A. C. Ocular histopathology in ani-mals experimentally infected with Mycobacteriumleprae and M. lepraenturium. Br. J. Ophthalmol. 62(1978) 516-524.

3. JOB, C. K. and MACADEN, V. P. Leprous orchitis inreactional borderline cases. Int. J. Lepr. 31 (1963)273-279.

4. POWELL, C. and SWAN, L. Pathological changes ob-served in 50 consecutive necropsies. Am. J. Pathol.31 (1955) 1131-1147.

5. Ribuy, D. S. and Jolt, C. K. The pathology ofleprosy. In: Leprosy. Hastings, R. C., ed. New York:Churchill Livingstone, 1985, pp. 127-128.

6. SOMERSET, E. J. and SEN, N. R. Leprosy lesions ofthe fundus oculi. Br. J. Ophthalmol. 40 (1956) 167-172.