XerophthalmiaXerophthalmia Literaly means “dry eye”Literaly means “dry eye” Ocular abnormalities from vitamin A Ocular abnormalities from vitamin A

deficiency (nutritional deficiency)deficiency (nutritional deficiency) Include night blindness, conjunctival and Include night blindness, conjunctival and

corneal xerosis, corneal ulceration and corneal xerosis, corneal ulceration and meltingmelting

If in severe stage will have liquefactive If in severe stage will have liquefactive corneal necrosis (Keratomalacia)corneal necrosis (Keratomalacia)

Literaly means “dry eye”Literaly means “dry eye” Ocular abnormalities from vitamin A Ocular abnormalities from vitamin A

deficiency (nutritional deficiency)deficiency (nutritional deficiency) Include night blindness, conjunctival and Include night blindness, conjunctival and

corneal xerosis, corneal ulceration and corneal xerosis, corneal ulceration and meltingmelting

If in severe stage will have liquefactive If in severe stage will have liquefactive corneal necrosis (Keratomalacia)corneal necrosis (Keratomalacia)

CausesCauses Vitamin A deficiencyVitamin A deficiency Protein malnutritionProtein malnutrition systemic diseases systemic diseases

Eg. Sjogren' s syndrome, SLE, rheumatoid Eg. Sjogren' s syndrome, SLE, rheumatoid arthritis, scleroderma, sarcoidosis, amyloidosis, arthritis, scleroderma, sarcoidosis, amyloidosis, hypothyroidismhypothyroidism

medications medications antihistamines, nasal decongestants, tranquilizerantihistamines, nasal decongestants, tranquilizer

s, and anti-depressant drugss, and anti-depressant drugs

EpidemiologyEpidemiology Remains a worldwide problem especially Remains a worldwide problem especially

in in the developing countriesthe developing countries peak incidence is 3-5 years of agepeak incidence is 3-5 years of age associated with vitamin A deficiency and associated with vitamin A deficiency and

malnutrition in general malnutrition in general

METABOLISMMETABOLISMFOOD

GUT

LIVERBLOOD

TARGET TISSUE

Absorp 50-90% retinol

Retinyl palmitate+ retinal binding

protein

Photoreceptor,Epithelial tissue

FUNCTIONSFUNCTIONS Gene expressionGene expression Epithelial cell differentiationEpithelial cell differentiation Normal growthNormal growth Photopic visionPhotopic vision Immune functionImmune function AntioxidantAntioxidant

Clinical FeaturesClinical Features Night BlindnessNight Blindness

Difficulty seeing in the dark. Difficulty seeing in the dark. Abnormal dark adaptationAbnormal dark adaptation Xerosis (Dry Eyes)Xerosis (Dry Eyes)

The white of the eye loses its shine and begins to wrinThe white of the eye loses its shine and begins to wrinkle.kle.

Bitot's SpotsBitot's Spots Patches of little gray bubbles on the whites of the eye.Patches of little gray bubbles on the whites of the eye.

Corneal UlcerationCorneal Ulceration Dullness or damage to the cornea.Dullness or damage to the cornea.

KeratomalciaKeratomalcia Soft or bulging cornea.Soft or bulging cornea.

Night blindnessNight blindness

require some time for their eyes to adjust from brightly lit areas to dim ones. Contrast vision may also be greatly reduced.

Xerosis (Dry Eyes)Xerosis (Dry Eyes)

Marked conjunctival Marked conjunctival and corneal xerosisand corneal xerosis

Bitot's SpotsBitot's Spots

Corneal changesCorneal changes

Corneal punch-out lesion

Corneal UlcerationCorneal Ulceration

Corneal scar

Liquefaction of part or all of the Liquefaction of part or all of the cornea, leading to rupture, with cornea, leading to rupture, with extrusion of the eye contents and extrusion of the eye contents and subsequent shrinking of the globe subsequent shrinking of the globe (phthisis bulbi), or to anterior bulging (phthisis bulbi), or to anterior bulging (corneal ectasia and anterior (corneal ectasia and anterior staphyloma) and blindnessstaphyloma) and blindness..

KeratomalaciaKeratomalacia

DiagnosisDiagnosisMost -Most -clinical diagnosisclinical diagnosis

Laboratory testsLaboratory tests ((UnusualUnusual))

A serum retinol studyA serum retinol study - costly but direct measure - costly but direct measure

- - high-performance liquid chromatographyhigh-performance liquid chromatography- >20 mg/dl : adequate- >20 mg/dl : adequate- <10 mg/dl : grossly deficient- <10 mg/dl : grossly deficient- plasma vitamin A level or - plasma vitamin A level or <<0.35 mmol/L0.35 mmol/L

- <- <0.7 mg/L in children younger than 12 years is 0.7 mg/L in children younger than 12 years is

considered lowconsidered low - - respect to light and temperaturerespect to light and temperature

Total retinol binding proteinTotal retinol binding protein- - easier to perform and less expensive easier to perform and less expensive

- detected by an immunologic assay. - detected by an immunologic assay.

- more stable compound than retinol - more stable compound than retinol

- less accurate because they are affected by - less accurate because they are affected by

serum protein concentrationsserum protein concentrations - zinc deficiency interferes with RBP production - zinc deficiency interferes with RBP production

Conjunctival impression Conjunctival impression cytologycytology

- histologic appearance of superficial histologic appearance of superficial epithelial layersepithelial layers

- Conjunctival xerosisConjunctival xerosis - -The The epithelium is characterized by epithelium is characterized by keratinizationkeratinization

- - KeratomalaciaKeratomalacia - Stromal necrosis is - Stromal necrosis is covered by keratinized epitheliumcovered by keratinized epithelium

conjunctival xerosisconjunctival xerosis : : The epithelium is characterized by The epithelium is characterized by keratinization, keratinization,

a prominent granular cell layer, and distended a prominent granular cell layer, and distended squamous cells with large, open nuclei squamous cells with large, open nuclei

and and prominent nucleoli. prominent nucleoli.

Keratomalacia Keratomalacia : : The sharply demarcated area of stromal The sharply demarcated area of stromal necrosis is covered by keratinized epitheliumnecrosis is covered by keratinized epithelium

Vitamin A orally is given. May be Vitamin A orally is given. May be given by intramuscular injection given by intramuscular injection also and repeated.also and repeated.

Correct malnutritionCorrect malnutrition Diet: Plenty of milk, butter, dark green Diet: Plenty of milk, butter, dark green

leafy vegetables, carrots, orange, cod-leafy vegetables, carrots, orange, cod-liver oil required.liver oil required.

Topical lubrication and retinoic Topical lubrication and retinoic acid may be use as adjunctive acid may be use as adjunctive

If infection is present in eyes - If infection is present in eyes - antibiotic ointment may be antibiotic ointment may be applied.applied.

TreatmeTreatmentnt

Emergency Patient Care Emergency Patient Care In order to treat or prevent a In order to treat or prevent a

secondary bacterial infection, which secondary bacterial infection, which would compound corneal damage.would compound corneal damage. Apply an antibiotic eye ointment, e.g. Apply an antibiotic eye ointment, e.g.

tetracycline or chloramphenicol. tetracycline or chloramphenicol. Protect the eye with an eye shield in order to Protect the eye with an eye shield in order to

prevent trauma. prevent trauma. In the case of young children, it may be In the case of young children, it may be

necessary to restrain arm movements while necessary to restrain arm movements while applying the shield. applying the shield.

Vitamin A must be administered Vitamin A must be administered orally immediately upon diagnosis. orally immediately upon diagnosis.

For treatment of For treatment of xerophthalmia according to the xerophthalmia according to the schedule shown below. schedule shown below. TimingTiming <1 year <1 year

of age of age

((IUIU))

≥≥1 year 1 year of ageof age

((IUIU))

Immediately on Immediately on diagnosisdiagnosis

100,000100,000 200,000200,000

Next dayNext day 100,000100,000 200,000200,000

Within 2-4 Within 2-4 weeksweeks

100,000100,000 200,000200,000

Severe Severe protein protein energy energy malnutritionmalnutrition

Monthly until Monthly until PEM resolvedPEM resolved

100,000100,000 200,000200,000

Treatment : Women with Treatment : Women with XerophthalmiaXerophthalmia

Women of reproductive age require sp Women of reproductive age require speciaeciall attention because of the potenti attention because of the potenti

al teratogenic effects of very high dos al teratogenic effects of very high dos e ret e retinin ol early in pregnancy ol early in pregnancy

Women of reproductive age with Women of reproductive age with night blindness or Bitot's spots night blindness or Bitot's spots should be treated with should be treated with A daily oral dose of 5,000-10,000 IU of A daily oral dose of 5,000-10,000 IU of

vitamin A for at least 4 weeks. vitamin A for at least 4 weeks. Such a daily dose should never exceed Such a daily dose should never exceed

10,000 IU, although a weekly dose not 10,000 IU, although a weekly dose not exceeding 25,000 IU may be substituted.exceeding 25,000 IU may be substituted.

All women of reproductive age, All women of reproductive age, whether or not pregnant, who whether or not pregnant, who exhibit severe signs of exhibit severe signs of xerophthalmia (i.e. acute corneal xerophthalmia (i.e. acute corneal lesions) should be treated with lesions) should be treated with three dose treatment.three dose treatment.

ImmediateImmediately on ly on

diagnosisdiagnosis

Next dayNext day 2 weeks 2 weeks laterlater

200,000IU200,000IU 200,000IU200,000IU 200,000IU200,000IU

Drug of choiceDrug of choice Retinol palmitate, 110 mg orRetinol palmitate, 110 mg or Retinol acetate , 66 mgRetinol acetate , 66 mg

→ → 200,000 IU Vit.A 200,000 IU Vit.A oral, immediately and again the following dayoral, immediately and again the following day Additional dose every 1-2 week to restore liver Additional dose every 1-2 week to restore liver

reserve.reserve. Parenteral replacement essential Retinol Parenteral replacement essential Retinol

acetate 100,000 IU in 55 mg water can replace acetate 100,000 IU in 55 mg water can replace first oral dose.first oral dose.

Correct protein energy malnutritionCorrect protein energy malnutrition

PreventionPrevention Short-termShort-term

High dose VIT A supplementHigh dose VIT A supplement VIT A supplement can reduce child VIT A supplement can reduce child

mortality by 34%mortality by 34% VIT A supplement is on the most cost-VIT A supplement is on the most cost-

effective preventioneffective prevention Distributed by health facilities or teamsDistributed by health facilities or teams

Age Dose (IU) TimingInfants (0-6 mo.) 25,000 1-3 timesChildren (6-12 mo.)

100,000 Once every 4-6 months

Children (>12 mo.)

200,000 Once every 4-6 months

Woman (postpartum)

200,000 Within 1 month of delivery

Pregnant and lactating woman

5-10,000 Daily

Vitamin A prophylaxis schedule

Medium-termMedium-term Introducing food Introducing food

fortified with VIT fortified with VIT A such as milk, A such as milk, tea, cerealtea, cereal

•Long-term- Improve socioeconomic level- Improve health and nutrition education

THANK YOUTHANK YOU

FOR YOUR ATTENTIONFOR YOUR ATTENTION