Xerophthalmia

The symptoms of xerophthalmia depend upon the severity of deficiency and age of the patient and gradually progress through the following stages:

• Night blindness: Impaired sensitivity of the eye to light. This is the first sign of xerophthalmia, in which the person is unable to see in dim light and may bump into objects or show reduced mobility.
• Conjunctival xerosis: Characterized by a dull, dry, thick, wrinkled appearance of the conjunctiva, developing due to changes in mucin secretion that lubricates the conjunctiva.
• Bitot spots: Whitish, foamy, opaque deposits on the conjunctiva.
• Corneal xerosis: The cornea appears dull, dry, and hazy.
• Corneal ulceration or Keratomalacia: Corneal xerosis often leads to ulcers and softening of the cornea, which can result in perforation and destruction of the cornea.
• Corneal scars: Scarring of the cornea is a late and severe symptom of xerophthalmia.
• Xerophthalmic fundus: Refers to structural changes in the fundus (the inside, back surface of the eye).

Vitamin A is an essential nutrient responsible for several central functions of the eyes:

• A form of vitamin A, called retinal, combines with a protein called opsin to form rhodopsin, an essential light-absorbing molecule needed for vision in dim light and color sensitivity.
• Vitamin A plays an important role in maintaining clear vision by supporting the functioning of the cornea, the protective outer layer of the eye.
• Vitamin A helps stimulate the lacrimal glands to produce moisture in the eyes, preventing issues like dry eyes.

The deficiency of Vitamin A is the main cause of xerophthalmia. The causes of the deficiency include:

A. Inadequate dietary intake of Vitamin A

Low intake of dietary sources of Vitamin A can be attributed to:

• Insufficient food supply
• Chronic alcoholism
• Highly selective eating
• Difficulty in swallowing
• Mental illness

Here are ways you can help and support a friend or family member coping with mental illness, which might be significantly affecting their dietary patterns.

B. Impaired absorption of Vitamin A

The leading causes of insufficient absorption of Vitamin A are diseases affecting the pancreas, liver, and intestines, such as:

• Chronic liver disease (progressive damage of the liver for more than 6 months)
• Inflammatory bowel disease (inflammation in the digestive tract)
• Pancreatitis (inflammation of the pancreas)
• Celiac disease (hypersensitivity to certain foods leading to impaired digestion)
• Pancreatic insufficiency (improper functioning of the pancreas)
• Short bowel syndrome (improper absorption of nutrients from food)
• Chronic diarrhea
• Upper gastrointestinal surgery
• Giardiasis (intestinal infection accompanied by fever and diarrhea)
• Abetalipoproteinemia (impaired absorption of fats and vitamins)

C. Reduced storage of Vitamin A

Reduced storage of Vitamin A due to the following reasons can also cause xerophthalmia:

• Liver diseases
• Cystic fibrosis (inherited disorder that mainly affects the lungs and digestive system)

The following factors can trigger Vitamin A deficiency and eventually lead to xerophthalmia:

• Age: Infants and children are more prone to xerophthalmia due to their higher need for Vitamin A for growth and development. Children are also more susceptible to intestinal infections that may impair the absorption of Vitamin A. Worried about the health of your child? Know some easy and practical ways to ensure that your child does not develop nutritional deficiencies.
• Malnutrition: Malnutrition can lead to multiple vitamin deficiencies, including Vitamin A deficiency. People living in developing countries are more prone to xerophthalmia due to a higher likelihood of malnutrition.
• Zinc deficiency: Malnutrition, especially zinc deficiency, decreases the level of active Vitamin A in the body and increases the chances of developing xerophthalmia.
• Pregnancy: Pregnant and lactating women are at higher risk of developing xerophthalmia due to increased chances of Vitamin A deficiency during this period. Neonates born to Vitamin A deficient mothers are also at higher risk of developing xerophthalmia.
• Poor lactation: Breast milk provides various essential nutrients to neonates that are required for normal growth and development. It also protects infants from various infections in the initial years of life. Inadequate breastfeeding in infants younger than 6 months increases the risk of xerophthalmia.
• Medical conditions: Some diseases, such as chronic liver disease, liver cirrhosis, diarrhea, inflammation of the pancreas, and inflammatory bowel disease, make individuals more vulnerable to xerophthalmia.
• Comorbidities: Various diseases, such as pneumonia, jaundice, vomiting, and septicemia, also increase the risk of xerophthalmia.
• Low socioeconomic status: Individuals with low socioeconomic status are more prone to Vitamin A deficiency as they may not afford proper meals to meet their nutritional requirements.
• Lack of education: People who are not adequately educated about the importance of proper nutrition are more prone to nutritional deficiencies, including those of Vitamin A.
• Alcoholism: Excessive alcohol consumption lowers the level of Vitamin A in the body and predisposes individuals to xerophthalmia.

A thorough dietary, medical, and social history, including alcohol intake, is taken from the patient exhibiting signs of xerophthalmia. In cases with specific indications of night blindness or severe xerophthalmia, treatment with Vitamin A is initiated immediately. The diagnosis is primarily based on the symptoms.

Physical Exam

The doctor first examines the eyes of the patient for signs such as dry eyes and spots characteristic of xerophthalmia. The physical exam also includes an assessment of jaundice.

Blood Tests

• Serum Vitamin A/retinol: This test measures the level of Vitamin A in the body. Ocular symptoms related to Vitamin A deficiency have been shown to develop at concentrations <10 mcg/dL.
• Serum retinol binding protein: Vitamin A is transported to the tissues in the form of retinol after binding with the retinol binding protein (RBP). The level of RBP reflects retinol concentration, providing insight into Vitamin A status. The normal level of serum RBP is 30-75 µg/ml.
• Serum zinc: Decreased levels of zinc are associated with xerophthalmia. The normal levels of serum zinc are 75-120 mcg/dL.

Additional Tests

• Dark adaptometry and night vision threshold tests: These tests are utilized to diagnose night vision defects.
• Electroretinogram (ERG): ERG measures the electrical activity of the retina in response to a light stimulus, non-invasively. ERGs are recorded using an electrode placed in contact with the cornea.
• Impression cytology: This involves studying specimens of the conjunctiva (the clear tissue covering the white part of the eye) for the presence of goblet cells, which are specialized cells that produce and secrete mucins responsible for the hydration and lubrication of the eyes. A decrease in the number of these cells is also an indicator of Vitamin A deficiency.

All the following factors that maintain an adequate level of Vitamin A play a role in preventing xerophthalmia:

• Consuming adequate Vitamin A: The best way to prevent xerophthalmia is to take an adequate amount of Vitamin A through a healthy balanced diet rich in Vitamin A food sources such as carrots, milk, fish, eggs, green vegetables, yams, and sweet potatoes. People who are on restrictive diets or facing challenges in obtaining adequate amounts of Vitamin A should take the recommended dose of Vitamin A supplements. Appropriate intake of Vitamin A is also crucial during pregnancy and lactation to build stores of retinol in the liver.
• Environmental sanitation: The chances of Vitamin A deficiency increase in the presence of certain diseases such as respiratory tract infections, tuberculosis, diarrhea, and worm infestations. Proper sanitation of the living environment helps reduce the prevalence of these diseases. Hygiene is a critical measure of how a person lives. Someone who prioritizes self-hygiene not only feels comfortable in their own skin but also contributes to the comfort of those around them.
• Vaccination: Certain vaccine-preventable diseases such as measles serve as precipitating factors for xerophthalmia. Immunization helps eliminate such factors and may assist in preventing xerophthalmia.

1. Consume Vitamin A rich food

   People should include foods rich in Vitamin A in their diet, such as:

   • Carrots
   • Broccoli
   • Fish
   • Fortified cereals
   • Beef
   • Liver
   • Eggs
   • Chicken
   • Mangoes
   • Whole milk
   • Green leafy vegetables
2. Wear glasses

   Wearing glasses is beneficial as it reduces pressure on the eyes and assists individuals suffering from night blindness, helping them to focus better.

3. Avoid looking directly in the dark

   Individuals with night blindness should avoid looking directly at dark sources, as this may adversely affect the pupil (the black center of the eye).

4. Eye exercises

   Patients with xerophthalmia should keep their eyes in motion by looking in different directions, focusing on various points, and blinking. This serves as an eye exercise and aids in recovery.

5. Adaptation to darkness

   Individuals in the early stages of xerophthalmia, such as night blindness, should try to adapt to darkness by sitting in a dark room for 20-30 minutes daily. Wearing a sleep mask while sleeping can also make the eyes more comfortable in darkness and help prevent severe eye disorders.

6. Eye massage

   Eye massage can significantly improve overall eye health and should only be performed under expert supervision to avoid damaging the eye lens. To perform an eye massage:

   • Apply slight pressure on both eyes with the palms.
   • Maintain that pressure for about 5-10 seconds.
   • Vision may turn white instead of black momentarily.
   • When vision returns to normal, open the eyes.
   • This technique can significantly improve vision in the dark.

   Regular eye massage can help prevent night blindness to some extent.

Vitamin A deficiency can cause various complications due to severe malnutrition. It also increases the risk of mucosal infections.

• Keratomalacia
• Night blindness

These conditions can be life-threatening in children.

High doses of Vitamin A can treat early symptoms such as:

• Conjunctival xerosis
• Night blindness

However, corneal xerosis may sometimes lead to permanent vision loss.