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We present a case report of marked unilateral dermatochalasis in a gentleman of Nepalese origin found to have a diagnosis of lepromatous leprosy (LL) with histological confirmation.

A 56-year-old man of Nepalese origin was seen in the oculoplastics clinic with a 1 year history of gradually worsening swelling and drooping of his left upper lid.

On examination, there was left upper eyelid dermatochalasis with associated eyebrow thinning and thickened, coarse facial skin (leonine facial appearance). He underwent a left upper lid debulking procedure and blepharoplasty with the specimen sent for histology. This demonstrated skin diffusely infiltrated by bubbly histiocytes, many with uni-vacuoles (Histology slides available). A Wade-Fite stain showed dense purple colonies of acid fast, mycobacteria leprae bacilli within the vacuoles and present within the peripheral nerve tissue. The features were those of lepromatous leprosy (type LL). The patient was referred to the UK national leprosy centre and multidrug treatment was commenced.

Ocular involvement in leprosy is estimated to be 70-75%, about 10-50% of leprosy patients suffer from severe ocular symptoms and blindness occurs in about 5% of patients. We have yet to find a case of dermatochalasis alone leading to a diagnosis of lepromatous leprosy. The diagnosis of LL is typically a clinical one but ophthalmic presentations of the disease require a high index of suspicion aided by histopathological analysis. With an increasing trend towards international population migration, vigilance for tropical infections manifesting in Western ophthalmology departments is required, for prompt treatment and the prevention of blinding complications.