2. Xerophthalmia Literaly means “dry eye”
Ocular abnormalities from vitamin A deficiency (nutritional deficiency)
Include night blindness, conjunctival and corneal xerosis, corneal ulceration and melting
If in severe stage will have liquefactive corneal necrosis (Keratomalacia)

3. Causes Vitamin A deficiency Protein malnutrition systemic diseases
Eg. Sjogren' s syndrome, SLE, rheumatoid arthritis, scleroderma, sarcoidosis, amyloidosis, hypothyroidism
medications
antihistamines, nasal decongestants, tranquilizers, and anti-depressant drugs

4. Epidemiology
Remains a worldwide problem especially in the developing countries
peak incidence is 3-5 years of age
associated with vitamin A deficiency and malnutrition in general

7. METABOLISM FOOD TARGET TISSUE GUT BLOOD LIVER Photoreceptor,
Epithelial tissue
GUT
Absorp 50-90% retinol
BLOOD
LIVER
+ retinal binding
protein
Retinyl palmitate

8. FUNCTIONS Gene expression Epithelial cell differentiation
Normal growth
Photopic vision
Immune function
Antioxidant

10. Clinical Features
Vitamin A Deficiency

11. Clinical Features Night Blindness Xerosis (Dry Eyes) Bitot's Spots
Difficulty seeing in the dark. Abnormal dark adaptation
Xerosis (Dry Eyes)
The white of the eye loses its shine and begins to wrinkle.
Bitot's Spots
Patches of little gray bubbles on the whites of the eye.
Corneal Ulceration
Dullness or damage to the cornea.
Keratomalcia
Soft or bulging cornea.

12. Night blindness

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

15. Xerosis (Dry Eyes)

16. Marked conjunctival and corneal xerosis

17. Bitot's Spots

22. Corneal punch-out lesion
Corneal changes
Corneal punch-out lesion

23. Corneal Ulceration

24. Corneal scar

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

30. Most -clinical diagnosis

31. Laboratory tests (Unusual)
A serum retinol study
- costly but direct measure
- high-performance liquid chromatography
- >20 mg/dl : adequate
- <10 mg/dl : grossly deficient
- plasma vitamin A level or <0.35 mmol/L
- <0.7 mg/L in children younger than 12 years is considered low
- respect to light and temperature

32. Total retinol binding protein - easier to perform and less expensive
- detected by an immunologic assay.
- more stable compound than retinol
- less accurate because they are affected by serum protein concentrations
- zinc deficiency interferes with RBP production

33. Conjunctival impression cytology
histologic appearance of superficial epithelial layers
Conjunctival xerosis -The epithelium is characterized by keratinization
- Keratomalacia - Stromal necrosis is covered by keratinized epithelium

34. conjunctival xerosis : The epithelium is characterized by keratinization, a prominent granular cell layer, and distended squamous cells with large, open nuclei and prominent nucleoli.

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

36. TREATMENT

37. Treatment
Vitamin A orally is given. May be given by intramuscular injection also and repeated.
Correct malnutrition
Diet: Plenty of milk, butter, dark green leafy vegetables, carrots, orange, cod-liver oil required.
Topical lubrication and retinoic acid may be use as adjunctive
If infection is present in eyes - antibiotic ointment may be applied.

38. Emergency Patient Care
In order to treat or prevent a secondary bacterial infection, which would compound corneal damage.
Apply an antibiotic eye ointment, e.g. tetracycline or chloramphenicol.
Protect the eye with an eye shield in order to prevent trauma.
In the case of young children, it may be necessary to restrain arm movements while applying the shield.
Vitamin A must be administered orally immediately upon diagnosis.

39. For treatment of xerophthalmia according to the schedule shown below.
Timing
<1 year of age
(IU)
≥1 year of age
Immediately on diagnosis
100,000
200,000
Next day
Within 2-4 weeks
Severe protein energy malnutrition
Monthly until PEM resolved

40. Treatment : Women with Xerophthalmia
Women of reproductive age require special attention because of the potential teratogenic effects of very high dose retinol early in pregnancy
Women of reproductive age with night blindness or Bitot's spots should be treated with
A daily oral dose of 5,000-10,000 IU of vitamin A for at least 4 weeks.
Such a daily dose should never exceed 10,000 IU, although a weekly dose not exceeding 25,000 IU may be substituted.

41. Immediately on diagnosis
All women of reproductive age, whether or not pregnant, who exhibit severe signs of xerophthalmia (i.e. acute corneal lesions) should be treated with three dose treatment.
Immediately on diagnosis
Next day
2 weeks later
200,000IU

42. Drug of choice Retinol palmitate, 110 mg or Retinol acetate , 66 mg
→ 200,000 IU Vit.A
oral, immediately and again the following day
Additional dose every 1-2 week to restore liver reserve.
Parenteral replacement essential Retinol acetate 100,000 IU in 55 mg water can replace first oral dose.
Correct protein energy malnutrition

43. PREVENTION

44. Prevention Short-term High dose VIT A supplement
VIT A supplement can reduce child mortality by 34%
VIT A supplement is on the most cost-effective prevention
Distributed by health facilities or teams

45. Vitamin A prophylaxis schedule Timing 1-3 times Once every 4-6 months
Age
Dose (IU)
Timing
Infants (0-6 mo.)
25,000
1-3 times
Children (6-12 mo.)
100,000
Once every
4-6 months
Children (>12 mo.)
200,000
Woman (postpartum)
Within 1 month of delivery
Pregnant and lactating woman
5-10,000
Daily

46. Medium-term Long-term
Introducing food fortified with VIT A such as milk, tea, cereal
Long-term
- Improve socioeconomic level
Improve health and nutrition
education

48. THANK YOU
FOR YOUR ATTENTION