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Editor,—Leishmaniasis is caused by infection of the protozoan Leishmania and is clinically classified as Old and New World cutaneous leishmaniasis (CL), mucocutaneous leishmaniasis, or visceral leishmaniasis. In the Old World, CL exists in the Middle East, Mediterranean regions, southern Asia, and northern and central parts of Africa.1 CL has been continuing endemically for ages in Sanliurfa, a city in south eastern Turkey.2
CL usually affects unclothed parts of the body, such as the face, legs and arms, that can easily be bitten by a female sandfly vector.3 Also, CL may rarely appear in the eyelid. CL generally begins as a red-brown papule or nodule at the site of inoculation.4 The initial nodular erythematous lesion usually breaks down to form an ulcer. About 90% of such lesions heal spontaneously in months, usually leaving a scar.5
A case of cutaneous leishmaniasis of ocular involvement resulting in mechanical ptosis and lagophthalmos is reported.
A 13 year old Turkish boy complained of an erythematous and swollen lesion of his right upper lid that had enlarged slowly for 1 year. He complained about being unable to close his right eyelid during sleep for the past 8 months.
On examination in the eye clinic at the school of medicine, Harran University, a crusted lesion adherent to firm subcutaneous tissue, parallel to the right upper eyelid margin, was identified in the centre of an indurated and erythematous area. A decrease of 2.5 mm in the palpebral aperture, 6 mm in the levator function and 3 mm lagophthalmos were determined (Fig 1). Visual acuity was normal and there were no retinal lesions on funduscopy. Systemically he was in good health. After the patient was referred to a dermatologist, oriental sore was suspected. Amastigotes were identified in a Giemsa stained smear obtained from edge of the lesion. Needle aspirated was cultured on NNN medium and promastigots grew. In the light of the clinical and laboratory findings CL was diagnosed. After the diagnosis, chemotherapy with intramuscular injections of meglumine antimoniate (Glucantime 60 mg/kg/day) were given to the patient consecutively for 20 days. He had no adverse reactions to treatment.
Six weeks after starting treatment, induration and oedema were completely resolved, leaving minimal scar tissue in the centre of the lesion. The levator function improved 5 mm, and ptosis has almost completely resolved. However, lagophthalmos remained at the same level as before treatment (Fig 2). Repeated microbiological tests were negative. After 6 months lagophthalmos reduced about 1 mm.
As sandflies bite uncovered areas of skin, the face is the most commonly affected area of the body.3 Ocular manifestations are usually restricted to the eyelids and occur only in 2–5% of patients with facial lesions.6 According to Morgan, the rarity of eyelid lesions is due to eyelid movements preventing the fly vector from biting the skin in this area.7 Also O’Neillet al have supported this hypothesis by attributing the eyelid CL in a patient with neurogenic ptosis to the inability of eyelid movement for innervational reasons.6
Even though cases with conjunctivitis and eyelid involvement caused by the species of Leishmania have been reported in the literature, CL causing mechanical ptosis and lagophthalmos of the eyelid has not been reported.89Mechanical ptosis preventing the levator movement develops as a result of the massive volume on the upper eyelid, inflammation, or scar formation.10 In our case, inflammation caused by the ulcerated CL lesion adjacent to the subcutaneous tissue, resulted in mild mechanical ptosis in the upper eyelid on the right eye and moderate decrease in the levator function. Surprisingly, subcutaneous induration, inflammation, and perilesional oedema also caused lagophthalmos of 3 mm by preventing the contraction of the lid. The presence of lagophthalmos even 6 months after treatment was thought to be caused by the scar tissue left by the lesion on the eyelid. The lagophthalmos might have improved if this patient had been treated earlier.
CL is a self limiting condition and there is a tendency to allow uncomplicated lesions to heal spontaneously without specific treatment. None the less, the majority of lesions involute with disfiguring scar tissues. As in our case, ptosis could lead to cosmetic and emotional problems. Lagophthalmos, developing as a result of scar formation in the eyelid, has the potential not only to cause cosmetic problems but also to threaten vision. Early diagnosis and treatment are necessary since the case of cutaneous leishmaniasis with eyelid involvement may cause ocular complications.