Annals of Tropical Medicine & Parasitology

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Prevention of blindness in leprosy: an overview

of the relevant clinical and programme-planning
issues

S. Lewallen

To cite this article: S. Lewallen (1997) Prevention of blindness in leprosy: an overview of the
relevant clinical and programme-planning issues, Annals of Tropical Medicine & Parasitology, 91:4,
341-348, DOI: 10.1080/00034983.1997.11813148

To link to this article: http://dx.doi.org/10.1080/00034983.1997.11813148

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Annals of Tropical Medicine and Parasitology, Vol. 91, No. 4, 341-348 (1997)

REVIEW

Prevention of blindness in leprosy:

an overview of the relevant clinical
and programme-planning issues
BY S. LEWALLEN*
B. C. Centre for Epidemiologic and International Ophthalmology, University of British Columbia,
St Paul's Hospital, 1081 Burrard Street, Vancouver, British Columbia, V6Z 1 Y6, Canada
Received 1 April 1997, Revised 24 April 1997,
Accepted 25 April 1997

Visual disability continues to be a significant problem in leprosy patients due to cataract, chronic
iridocyclitis, and corneal disease. Clinical and epidemiological aspects of these problems are described and
the current status of eye care in leprosy programmes is discussed.

In 1873, Gerhard Armauer Hansen wrote,
'There is no disease which so frequently gives
rise to disorders of the eye, as leprosy does'
(Bull and Hansen, 1873). More than a century
later, when new diseases have been identified
and our knowledge of many old diseases has
expanded, this observation might not be ac-
cepted as strictly true, but the fact remains
that the ocular complications of leprosy con-
tinue to afflict many and to be a major dis-
abling feature of the disease.
In estimating the total number of leprosy
patients worldwide in 1997, one must keep in
mind the criteria used to define a 'leprosy
patient'. The World Health Organization's es-
timates of the numbers of leprosy patients fell
from 10.6 million in 1975 to 1.8 million in
1995 (WHO, 1995). However, this apparent
dramatic improvement in the situation is due
largely to a change in the definition of a
leprosy patient. With the advent of multi-drug
therapy (MDT), it has become common in
many places to regard each patient who has
completed a course of MDT as 'cured' and to
remove him or her from the registers of lep-
rosy patients. There are undoubtedly social
"E-mail: lewallens@aol.com; fax: + 1 360 733
and psychological benefits in doing this, but
there are hazards as well. Since many leprosy
patients have nerve damage at the time of
diagnosis, the stage is already set for develop-
ment of disabilities which MDT will not pre-
vent. After these patients are discharged from
the health-care system, their existing disabili-
ties may worsen or new disabilities may occur
and be neglected. Among these disabilities are
visual impairment and blindness.
In this overview of leprosy and the eye, the
clinical aspects of the problem are described
first, concentrating on those which lead to
visual dysfunction. The epidemiological infor-
mation is then reviewed and, finally, the status
of eye care in leprosy-control programmes (i.e.
what is being done and what needs to be done
to prevent blindness in leprosy patients today)
is discussed.
CLINICAL ASPECTS
There are several pathophysiological mecha-
nisms by which the eye may be affected in
leprosy, including nerve damage, inflamma-
tory reactions, and direct infiltration of struc-
7825. tures by the bacilli. Structures in the eye may

0003-4983/97/040341-08 $9.00 1997 Liverpool School of Tropical Medicine

Carfax Publishing Ltd
342 LEWALLEN
be affected by one or a combination of these
mechanisms and it is convenient to consider
damage according to structure.
The Eyelids and Lacrimal System
Lagophthalmos, the inability to completely
close the eye, is a result of damage to the
zygomatic or, less commonly, to the temporal
branch of cranial nerve VII, which innervates
the orbicularis oculi muscle. The orbicularis
oculi consists of two parts: the outer, orbital
part, which allows forced closure of the lids;
and the central, more delicate, palpebral
fibres, which make up the bulk of the eyelid
and control blink and gentle closure of the lid.
Usually the delicate palpebral part of the mus-
cle is affected first, so that a patient who does
not blink properly and who sleeps with his or
her eyes open may still be able to close them
by making a forced effort.
Lagophthalmos is not only a cosmetic de-
formity, which stigmatises leprosy patients,
but it also has serious consequences for the
cornea, which are discussed below. In ad-
dition, the lacrimal system requires proper
positioning of the eyelids, particularly the
lower lid, in order to function optimally.
When the lid falls away from the globe (ectro-
pion), tears may pool, stagnating or
overflowing down the cheek. This predisposes
a patient to inflammation and infection of the
lacrimal sac (dacryocystitis).
In multibacillary patients especially,
infiltration of the eye-lid skin may result in
leprosy nodules or in loss of support for the
eye lashes, either of which may deform the
lids and lead to lashes which are misdirected
into the eye (trichiasis). Chronic abrasion of
the cornea by these lashes leads to corneal
scarring and opacification.
Although lagophthalmos occurs in both
multi- and pauci-bacillary leprosy patients,
there is epidemiological evidence to indicate
that the aetiology of lagophthalmos in these
two groups is not the same. A study among
paucibacillary patients demonstrated that
lagophthalmos in this group is primarily asso-
ciated with the presence of facial patches over
the malar region or around the eye in patients
undergoing Type-1 (reversal) reactions
(Hogeweg et al., 1991). In multibacillary pa-
tients, however, it is likely that inadequate
treatment over many years results in prolifera-
tion of Mycobacterium leprae in nerve tissues,
which causes damage to branches of nerve V,
with subsequent weakness of the orbicularis
muscle (Courtright et al., 1995).
These different pathogenic mechanisms
have clinical consequences: most cases of
lagophthalmos among paucibacillary patients
occur early in the course of disease whereas
lagophthalmos is more often a late manifesta-
tion in multibacillary patients (Yan et al.,
1993; Courtright et al., 1995). Also, lagoph-
thalmos is more often unilateral in paucibacil-
lary patients and bilateral in multibacillary
patients (Yan et al., 1993).
TREATMENT
Prevention of lagophthalmos is, of course, the
goal. This can often be achieved in paucibacil-
lary patients if those with patches involving
the skin around the eyes are properly treated
with systemic steroid during reactions (Kiran
et al., 1991). In multibacillary patients, early
detection and administration of MDT pre-
sumably may prevent lagophthalmos, by gen-
erally preventing nerve damage.
The reality is that, for many years to come,
there will be patients with lagophthalmos who
need treatment. Those with lagophthalmos
only in gentle closure, who can close the lids
fully with forced effort, may benefit from daily
exercising of the remaining functioning orbic-
ularis muscle. They also need to use a lubri-
cant at night to keep the cornea moist. Once
lagophthalmos is present in forced closure,
however, the only treatment is surgical. Nu-
merous techniques have been advocated, with
advantages and disadvantages for each (Cour-
tright and Lewallen, 1995), but no trials com-
paring the success rates of these in field
situations have been undertaken.
The Cornea
Ultimately, the eye lids serve to protect the
cornea, and it is damage to this latter structure
which results in visual dysfunction for many
patients.

The cornea may be affected in leprosy in
several ways. When lagophthalmos exists, the
lids do not properly serve their function of
lubricating (moistening) the cornea and keep-
ing it free of debris. The cornea may become
dry, with subsequent breakdown of the ep-
ithelium and infection and ulceration of the
stroma, which leads to scarring; neovascular-
ization from the limbal vessels may ac-
company this. The dangers of lagophthalmos
cannot be overemphasised. Data from newly
diagnosed multibacillary patients in China
show that 87.5% of patients with lagophthal-
mos had some form of corneal disease (kerati-
tis, ulcer or opacity) compared with only 2%
of patients without lagophthalmos (Courtright
et al., 1995).
Corneal damage is further exacerbated by
damage to the ophthalmic division of cranial
nerve V, which results in loss of corneal sen-
sation and heightens vulnerability to damage
from dryness and relatively minor foreign
bodies. The precise contribution of decreased
corneal sensation to the development of
corneal scarring has not been ascertained, but
loss of corneal sensation is probably a compli-
cation of long-standing disease (Lubbers et al.,
1994).
In multibacillary patients, direct infiltration
of the cornea by bacilli may also occur, either
along corneal nerves (beading) or in the
stroma. This complication is most common in
the superotemporal cornea and only causes
visual disability if it progresses to involve the
central cornea. Corneal leproma or nodules are
not common but may also occur in multibacil-
lary patients.
TREATMENT
Acute corneal disease, such as ulceration,
requires urgent treatment with appropriate
topical antibiotics. The prevailing micro-
organisms vary regionally and the support of a
proper microbiological laboratory is rarely
available for identification of microbes; in
practice, one usually employs the best, broad-
spectrum, topical, ocular antibiotic or combi-
nation of antibiotics available.
When treating chronic, low-grade keratitis
LEPROSY AND THE EYE 343
or a dry cornea secondary to exposure from
lagophthalmos, the goal is to protect the cor-
nea with a bland lubricant (methyl cellulose
eye drops, or tetracycline eye ointment if that
is all that is available) until the lagophthalmos
can be repaired surgically. If the lagophthal-
mos is present only in gentle closure, educat-
ing the patient to 'think blink' and exercise the
lids by forceful closure is often the most
practical approach. The success of this is
likely to depend on the enthusiasm and dedi-
cation of the health workers who must provide
the education and follow-up of the patients.
Once the cornea is scarred enough to cause
visual dysfunction, the only treatment is
corneal grafting, but this of course is almost
universally unavailable for leprosy patients.
Prevention is the only practical approach.
The Iris and Ciliary Body
There are several ways in which the iris and
ciliary body may be affected in leprosy. The
most important of these, in terms of numbers
of patients affected, is chronic iridocyclitis,
which occurs almost exclusively in multibacil-
lary patients. The pathophysiology of this
condition is not completely understood. The
inflammation is very low grade and it takes
many years before evidence of it can be seen
on clinical examination. The clinical picture
which results is that of a very small pupil, an
atrophic iris, sometimes with holes in it, often
adhesions between the iris and the lens, and
sometimes pigment and cellular precipitates
scattered on the endothelium of the cornea.
The pupil sometimes becomes small enough
to limit visual acuity. Long-standing chronic
iridocyclitis may be accompanied by low intra-
ocular pressure (presumably because of dys-
function of the ciliary body) or, more rarely,
the synechia between iris and lens may lead to
a secondary glaucoma. The chronic, low-grade
inflammation and the changes in aqueous flow
due to the small pupil may both predispose
patients to the development of secondary cat-
aract. Indeed, Brandt and Kalthoff (1983)
have shown that multibacillary patients gener-
ally get cataract about 10 years earlier than
paucibacillary patients.
344 LEWALLEN
The absence of clinical signs of
inflammation (inflammatory cells in the ante-
rior chamber, corneal endothelial precipitates,
or lens-iris synechiae) in the presence of ex-
tremely small pupils has been noted in a
number of patients and it has been hypothe-
sised that damage to the ocular autonomic
nerves may be responsible for some of the
changes in the chronic iridocyclitis of leprosy
(ffytche, 1981). In addition to small and
poorly reacting pupils, low intra-ocular pres-
sures have been documented. Although it has
been suggested that these low pressures could
be due to ocular autonomic dysfunction, by
some unproved mechanism (Lewallen et a!,
1986; Hussein et al., 1989), the role played by
autonomic dysfunction in the pathogenesis of
chronic iridocyclitis is far from clear.
Acute iridocyclitis may occur in one or both
eyes of patients who are undergoing leprosy
reactions and should always be suspected in a
patient undergoing reaction who develops a
red eye. Such acute iridocyclitis may be severe
enough to lead to rapid visual loss if it is not
recognized and treated urgently.
TREATMENT
The treatment of chronic iridocyclitis poses a
difficult problem. Since the inflammation is so
low-grade, it is not clinically apparent until it
has already done some damage. If it can be
established that there are lens-iris adhesions
or that the pupil is abnormally small and
poorly reactive, regular dilation of the pupil
may prevent worsening. However, by the time
these signs are noticed the pupil may be
unresponsive to dilating eye drops. The only
topical medicine which dilates the pupil with-
out cycloplegia (which blurs near vision) is
phenylephrine, but this drug is not a strong
mydriatic and it is often not available in devel-
oping countries. The cycloplegia caused by
the other class of mydriatics (parasympa-
tholytic drugs such as atropine) makes them
unpleasant for patients to use on a routine
basis. Although regular slit-lamp examination
is the most sensitive way to detect early signs
of chronic inflammation, this is not available
to most patients. It has been suggested that
low intra-ocular pressure may be a relatively
early sign of chronic iridocyclitis which might
be useful in guiding treatment, but there are
conflicting findings in this regard and it is
probably not practical for primary-health
workers to measure intra-ocular pressure ac-
curately in the field. Once again, early detec-
tion of leprosy and treatment with MDT
might help avoid visual dysfunction from this
condition.
Acute iridocyclitis in leprosy patients un-
dergoing reaction should be treated with high
doses of steroid eye drops and pharmacologi-
cal dilation of the pupil until the inflammation
is resolved.
The Lens
Most cataracts in leprosy patients are age-
related and not a complication of leprosy per
se. Chronic iridocyclitis no doubt increases the
prevalence of cataract but the specific contri-
bution of this inflammation to cataract blind-
ness is not known. Because leprosy patients
often have limited access to general eye-care
services, cataract remains a major cause of
blindness in these patients.
TREATMENT
Although cataract, including secondary
cataracts due to intra-ocular inflammation, can
be successfully treated by surgery, the prob-
lem is how to get the relevant services to the
people who need them. This problem has not
been solved, which is why cataract remains
overwhelmingly the greatest cause of blind-
ness in the general population worldwide. The
special problems for leprosy patients include
the fact that they may lack access (for social or
other reasons) to such general eye-care ser-
vices as do exist. The secondary (complicated)
cataracts in long-standing multibacillary
patients pose technical problems which make
them less likely to be removed successfully by
lesser trained surgeons with less sophisticated
equipment. Nonetheless, most cataracts in
leprosy patients are the simple, age-related
type and integration of leprosy patients into
general eye-care services needs to be strongly
encouraged.

Summary of Clinical Aspects
The three major causes of visual disability and
blindness in leprosy patients are corneal
opacification (most often secondary to lagoph-
thalmos and ectropion), chronic iridocyclitis
and cataract. It is noteworthy that there is
potential for prevention or cure of all of these.
EPIDEMIOLOGICAL ASPECTS
It is estimated that there are about 250 000
blind leprosy patients worldwide (Courtright
and Johnson, 1988). Half of these are blind
from pathology directly related to leprosy and
the other half are blind from other causes,
chiefly cataract.
The worldwide distribution of leprosy does
not entirely reflect the distribution of the
ocular complications of this disease. Important
factors determining the distribution of ocular
complications include variations in: (1) the
distribution of leprosy type (paucibacillary v.
multibacillary); (2) implementation of MDT
in the area; and (3) the socio-economic status
and eye-care services available to patients.
Distribution of Leprosy Type
The relative distribution of paucibacillary and
multibacillary disease varies considerably; East
and South-east Asian countries as well as
many countries in the Americas have a pre-
dominance of multibacillary disease whereas
the Indian sub-continent and Africa have a
predominance of paucibacillary disease.
Consequently, chronic uveitis is a leading
cause of ocular morbidity and blindness re-
lated to leprosy in East and South-east Asia
but corneal disease is a more common cause in
India and Africa. With the general ageing of
the population in all leprosy-endemic settings,
cataract is (or will soon be) the most common
cause of blindness.
Multi-drug Therapy
At present it is estimated that, worldwide,
about 70% of all leprosy patients are regis-
tered and that MDT has reached > 75% of
LEPROSY AND THE EYE 345
the registered cases (WHO, 1995). Although
there is an impression that MDT has had a
significant impact on the incidence of ocular
morbidity in leprosy patients, this contribu-
tion has not been measured.
Determining the contribution of MDT to a
reduction in the incidence of ocular disease is
complicated by the fact that ocular disease is
often present at the time of leprosy diagnosis.
Recent data from Nepal indicate that 5% of
newly diagnosed leprosy patients had leprosy-
related, sight-threatening pathology (defined
as lagophthalmos, iris involvement or dimin-
ished corneal sensation) and 18% had lens
changes at the time of their disease diagnosis
(Lubbers et al., 1994). In China, there is
evidence indicating that about 10% of patients
will have pre-existing ocular pathology at di-
agnosis (Courtright et al., 1994). This pathol-
ogy cannot be reversed by MDT. It remains
unclear what the incidence of ocular pathology
will be during and after the completion of
MDT. There is considerable anecdotal evi-
dence that a proportion of mycobacteriologi-
cally-negative leprosy patients (particularly
those who previously had multibacillary dis-
ease) has progressive ocular pathology. It is
certain that, if pre-existing lagophthalmos re-
mains untreated, there is a high likelihood that
progressive corneal degradation will occur.
What remains to be determined is how much
progression (if any) of other nerve damage is
to be expected.
Socio-economic Status and Eye-care
Services
In most countries which have experienced a
rise in socio-economic status, there has been
an accompanying expansion of health-care ser-
vices, including eye care. As a consequence,
basic treatment of all eye disease has improved
and this may influence the geographical distri-
bution of the ocular complications of leprosy.
However, it should not be assumed that a
general improvement in eye-care services is
always of benefit to leprosy patients. Firstly,
leprosy patients usually live in rural areas and
many of the same barriers that prevent use of
eye-care services by all rural poor (cost of

TABLE
Title
Care of the Eye in Hansen's Disease (by M. Brand)
Eye Care in Hansen's Disease: a Screening Too/for Nurses (by M. Brand,
P. Courtright and V. Demarest)
Leprosy and the Eye: a General Outline (by V. C. Joffrion and M. Brand)
Guide to Ocular Leprosy for Health Workers (by P. Courtright and S. Lewallen)
Training Health Workers to Recognize, Treat, Refer, and Educate Patients about
Ocular Leprosy (by P. Courtright and S. Lewallen)
Eye in Leprosy (video)
Keep Blinking (video)
The Red Eye (video)
Health Workers and Blindness Prevention in Leprosy (video, by P. Courtright
and S. Lewallen)
Ocular Leprosy (slide set)
Ocular Complications in Leprosy (Asia) (slide set and script, by M. Hogeweg)
Ocular Complications of Leprosy (Africa) (slide set and script, by M. Hogeweg)
w
0\
""'"
Source z
The Star, Gillis Long Center, Carville, LA 70721, U.S.A.
Gillis Long Center, Carville, LA 70721, U.S.A.
Gillis Long Center, Carville, LA 70721, U.S.A.
Leprosy Mission, 80 Windmill Road, Brentford TW8 OQH, U.K.
Leprosy Mission, 80 Windmill Road, Brentford TW8 OQH, U.K.
Schieffelin Leprosy Research and Training Centre, SLR Sanatorium
P.O., PIN 632 106, N. Arcot District, Tami1 Nadu, India
Schieffe1in Leprosy Research and Training Centre, SLR Sanatorium
P.O., PIN 632 106, N. Arcot District, Tamil Nadu, India
Schieffe1in Leprosy Research and Training Centre, SLR Sanatorium
P.O., PIN 632 106, N. Arcot District, Tamil Nadu, India
Orbis International, 330 West 42nd Street, Suite 1900, New York,
NY 10036, U.S.A.
American Leprosy Missions, 1 ALM Way, Greenville, SC 29601,
U.S.A.
NSL-INFOLEP, 1097 DN Amsterdam, The Netherlands
NSL-INFOLEP, 1097 D.CS Amsterdam, The Netherlands
 LEPROSY AND THE EYE 347

care, lack of awareness of its availability, dis-
tance to eye-care facilities, fear of surgery etc)
also apply to leprosy patients. Secondly, lep-
rosy patients often lack access to whatever
general eye-care services do exist. Many are
hampered by a prevailing segregation, whether
engendered by cultural or psychological
forces, that reduces their access to eye-care
and other health-care services. In some set-
tings, they are still totally barred from using
general eye-care services.
Guidelines for determining when a general
leprosy-control programmes may need an eye-
care component have been described (Cour-
tright and Lewallen, 1992). In general, these
are the programmes with many long-standing
patients (particularly multibacillary type),
many patients with a long duration between
disease onset and detection and treatment, and
many patients with a long history of treatment
in the pre-MDT era. It is crucial that patients
at risk of eye disease be followed up after they
have completed MDT.

EYE CARE IN LEPROSY-CONTROL

PROGRAMMES CONCLUSIONS

In most areas where leprosy is endemic, lep-
rosy-control programmes exist. Although these
have often been run by non-governmental
organizations, increasingly there are efforts to
integrate them within the general health-care
structure. Most programmes have been well
organized and the focus has been on case
finding and drug delivery, with some work in
disability prevention and rehabilitation. Eye
care has been largely neglected. This is unfor-
tunate, not only because visually disabled lep-
rosy patients with anaesthetic hands are at a
particularly high risk for increased disability,
but because the nature of the major, blinding,
eye complications of leprosy make them par-
ticularly suitable for detection and manage-
ment by primary-health-care workers such as
most leprosy-control programmes already em-
ploy. Teaching materials on primary eye care
have been developed specifically for leprosy
workers (see Table) but it is too early to know
what impact these may have.
In summary, much of the information and
many of the tools to prevent or cure most
leprosy-related visual disability are available.
Success will take a concerted effort. Firstly,
within leprosy-control programmes, workers
at all levels must be educated about the ocular
complications of leprosy. Secondly, the direc-
tors of leprosy-control programmes and those
of programmes for the prevention of blindness
must make efforts to integrate their services.
Leprologists and ophthalmologists must work
together to ensure that an efficient referral
system is in place and to educate those at all
levels in the system's appropriate use. As
leprosy-control programmes become inte-
grated within general health care, there will be
opportunities to integrate the eye care of lep-
rosy patients within the existing eye-care
structures; specific efforts to see that this
occurs must be made if the burden of visual
disability among leprosy patients is to be re-
duced.

REFERENCES

BRANDT, F. & KALTHOFF, P. G. (1983). The incidence oflagophthalmos and posterior synechiae of the iris
during chemotherapy or leprosy (morbus hansen). Tropenmedizin und Parasitologie, 34, 75-78.
BULL, 0. B. & HANSEN, G. A. (1873). The Leprous Diseases of the Eye. Christiana, Norway: Albert
Cammermeyer.
COURTRIGHT, P. &]OHNSON, G.]. (1988). Prevention of Blindness in Leprosy. London: International Centre
for Eye Health.
COURTRIGHT, P. & LEWALLEN, S. (1992). Considerations in the integration of eye care into leprosy care
services. Leprosy Review, 63, 73-77.
348 LEWALLEN

COURTRIGHT, P. & LEWALLEN, S. (1995). Current concepts in the surgical management of lagophthalmos
in leprosy. Leprosy Review, 66, 220--223.
CoURTRIGHT, P., Hu, L. F., LI, H. Y. & LEWALLEN, S. (1994). Multidrug therapy and eye disease in
leprosy: a cross sectional study in the People's Republic of China. International Journal of Epidemiol-
ogy, 23, 835-842.
COURTRIGHT, P., LEWALLEN, S., LI, H. Y., Hu, L. F. & YANG,J. W. (1995). Lagophthalmos in a multibacil-
lary population under multidrug therapy in the People's Republic of China. Leprosy Review, 66,
214-219.
FFYTCHE, T.]. (1981). Role of iris changes as a cause of blindness in lepromatous leprosy. British Journal
of Ophthalmology, 65, 231-239.
HOGEWEG, M., KrRAN, K. U. & SUNEETHA, S. (1991). The significance of facial patches and Type I
reaction for the development of facial nerve damage in leprosy. A retrospective study reaction for the
development of facial nerve damage in leprosy. A retrospective study among 1226 paucibacillary
leprosy patients. Leprosy Review, 62, 143-149.
HUSSEIN, N., COURTRIGHT, P., OSTLER, H. B., HETHERINGTON,}. & GELBER, R. H. (1989). Low intraocular
pressure and postural changes in intraocular pressure in patients with Hansen's Disease. American
Journal of Ophthalmology, 108, 80--83.
KlRAN, K. U., HoGEWEG, M. & SUNEETHA, S. (1991). Treatment of recent facial nerve damage with
lagophthalmos, using a semistandard steroid regimen. Leprosy Review, 62, 150--154.
LEWALLEN, S., COURTRIGHT, P. & LEE, H. S. (1986). Ocular autonomic dysfunction and intraocular
pressure in leprosy. British Journal of Ophthalmology, 73, 946--949.
LUBBERS, W. ]., SCHIPPER, A., HOGEWEG, M. & SOLDENHOFF, R. (1994). Eye disease in newly diagnosed
leprosy patients in eastern Nepal. Leprosy Review, 65, 231-238.
WoRLD HEALTH ORGANIZATION (1995). Progress toward the elimination of leprosy as a public health
problem. Weekly Epidemiologic Record, 26, 177-182.
YAN, L. B., CHANG, G. C. & LI, W. Z. (1993). Analysis of 2ll4 cases of lagophthalmos in leprosy. China
Leprosy Journal, 9, 6--8 (in Chinese).