Leprosy Mailing List – March 26th, 2007
Ref.: Disability grading in
the eyes.
From: van Brakel W., Amsterdam,
The Netherlands
Dear Salvatore,
I would like to respond to
Ruth Butlin's request for comments on the changes in W.H.O. grading
for the eyes (LML March 13th, 2007). I was at the meeting where
this document was finalised and agree with (most of) its content. I must confess that the
statement that "the eyes are not given a grade of 1" has
slipped my notice. I can
understand it from the point of view that corneal anaesthesia (at
least as I understand it) is caused by local damage to peripheral
nerve endings, rather than nerve trunk damage to the trigeminal nerve.
I must confess that I don't know of any well-documented published
evidence that demonstrates that.
Since we do not give people with an anaesthetic skin patch on
their arm of leg a grade 1, it makes sense not to do this for the eye
either. Similar to
anaesthesia in skin patches, corneal anaesthesia is not treated with
corticosteroids, but with MDT and protective measures!
Similarly, corneal opacities
are often unrelated to leprosy, so shouldn't automatically be graded
as if they were. Uveitis
and visual impairment are still to be graded '2', as before. If you read the Guidelines
carefully about the Grade 2 criteria (section 4.6), it says "For
the eyes, this includes inability to close the eye fully ...",
etc. This means that
there is the recognition that there may be other conditions or signs
that would warrant a grade 2 for the eye; the list given is not
necessarily exhaustive. Therefore,
there is no reason not to give a grade 2 to a corneal
scar related leprosy.
From the point of view of
risk to the eye, however, corneal anaesthesia (CA) is at least as
dangerous and more so in terms of potential disability, than
anaesthesia of hands or feet. From
that angle, it would make sense to grade CA as '1'. Personally, I am also in
favour of grading motor impairment, that has not yet led to visible
impairment, as '1'. This
is because it is equivalent to sensory impairment, i.e., primary
neural impairment. Therefore,
people with weakness of the orbicularis oculi, but who have no lidgap
yet, I would grade as '1'.
Having said this,
fortunately, CA is becoming less and less common these days. In contrast to the programmes
apparently visited by Dr. Warren, the leprosy programmes I visit are
becoming more and more concerned with preventing disability! Also early case finding is
generally improving and, as a result, far fewer people have grade 2
disability at diagnosis. Because
of the increase attention for POD, reactions and nerve damage are
detected more often and earlier and are thus treated in time more
often. Due to these
various reasons, CA has become very uncommon in new cases. The same appears to be true
for lagophthalmos. In the
INFIR Cohort Study, in which over 300 MB cases were followed for two
years, hardly any facial impairment was detected. It is true, however, that the
incidence of leprosy-related eye impairments varies considerably
between countries, people of different ethnic groups and geographical
locations (reportedly more common in mountainous areas).
As far as testing for corneal
sensation is concerned, because of the danger of introducing infection
into the eyes, testing of corneal sensation with cotton wool has been
discouraged for many years. Just
note the presence/absence of a normal blink reflex. If a patient doesn't blink,
his eyes are at risk and appropriate action should be taken. Details can be found in the
ILEP Learning Guide on POD (no.4).
Everyone I talk to is very
happy with the new Operational Guidelines (at least those who have
actually read them carefully). They
are so much better than any previous W.H.O. document, with
regard to POD and rehabilitation, that we should be congratulating
W.H.O. for producing these Guidelines.
In view of the above, I think
very little, if anything, will change in the way we grade eye
impairments. The fact
that grading is now explicitly recommended in considerable detail in
the Guidelines will hopefully lead to health workers paying even more
attention to POD than was in the case until now.
With best wishes,
Wim van Brakel
KIT Leprosy Unit
