Xerophtalmia

XEROPHTHALMIA
• Spectrum of ocular disease caused by
vitamin A deficiency.
• Nutritional blindness
• CAUSES: malnutrition, malabsorption,
chronic alcoholics, diseases which
precipitate malnutrition like measles,
malaria, diarrhoea , acute illness in children.
• Symmetrical and bilateral
Distribution of Vit A deficiency, 1995
 Vitamin A
Vitamin A serves varied functions in the human body

• A major role of vitamin A is as part of the visual

pigment rhodopsin
• Forms of vitamin A are also involved in:
– Gene expression
– Maintenance of epithelial tissue
– Regulation of growth and differentiation of cells,
including some cells of the immune system
 MECHANISM
• VITAMIN A is essential for the synthesis of retinal
photo pigments & conjunctival glycoproteins.
• RHODOPSIN  Visual cycle  delayed dark
adaptation / Night Blindness
• Conjunctival epithelial dysfunction  ocular
surface dryness
Mechanism of delayed dark adaptation
XEROPHTHALMIA
Grade Ocular signs Peak age Type of deficiency Risk of
group death
XN Night blindness 2-6; adult Long standing; not blinding +
women
X1A Conjuctival xerosis 3-6 Long standing; not blinding +

X1B Bitot’s spot 3-6 Long standing; not blinding +

X2 Corneal xerosis 1-4 Acute deficiency; can be ++

blinding
X3A Corneal ulcer <1/3rd of 1-4 Severe acute deficiency; +++
cornea blinding
XS Corneal ulcer/ 1-4 Severe acute deficiency; ++++
keratomalsia ≥1/3rd of blinding
cornea
XF Corneal scarring (from X3) >2 Consequence of corneal +/_
ulceration
Xeropthalmic fundus Adults Long standing; not blinding; _
Rare
 Prevalence criteria for determining the public health
significance of xerophthalmia and vitamin A deficiency
in children aged 6 months to 6 years

Indicator Minimum prevalence, %

• Night blindness (XN) >1
• Bitot’s spots (X1B) >0.5
• Corneal xerosis/corneal ulceration
/keratomalacia (X2/X3A/X3B) >0.01
• Corneal scar (XS) >0.05
 XEROPHTHALMIA

XN: NIGHT BLINDNESS

• Earliest symptom
• Responds rapidly to vitamin A therapy
[ within 24-48 hours]
 CONJUNCTIVAL XEROSIS
• X1 A :
• The conjunctival epithelium undergoes
KERATANISING METAPLASIA.
– i.e. the normal columnar epithelium is transformed
into stratified squamous epithelium.
• Goblet cells will be lost & keratinization occurs.
• Conjunctival xerosis – starts at the temporal
side
CONJUNCTIVAL XEROSIS
 BITOT’S SPOT
• keratin + saprophytic bacilli [
CORYNEBACTERIUM XEROSIS]
accumulate on the xerotic surface  FOAMY
APPEARANCE= BITOT’S SPOT
• Bulbar conjuctiva at 3 or 9 o’clock position
• More common on temporal side
• Begin to resolve within 2-5 days & disappear
by 2 weeks of treatment in chldren 3-6 yrs
• In Chronic cases, the spots will not disappear
BITOT’S SPOT
 CORNEAL XEROSIS – X2

• Lustreless dry appearance , in the inferior

limbus
• Responds within 2-5 days, disappear
within 2 weeks of treatment
CORNEAL XEROSIS
 X3A & X3B : KERATOMALACIA

• LIQUAFACTIVE NECROSIS  sterile

corneal melting
• Round or oval punched out ulcers
involving the inferonasal quadrant
• Perforation  adherent leukoma, anterior
staphyloma, phthisis bulbi
Corneal xerosis and deep corneal ulcer
KERATOMALACIA
 XEROPHTHALMIA- XS &XF
• XS: CORNEAL SCARRING
-Nebula, macula , leukoma
• XF: XEROPHTHALMIC FUNDUS
/UYEMURA’S FUNDUS
-Small white lesions in the retina
Corneal opacity
Corneal opacity with staphyloma
XEROPHTHALMIC FUNDUS
 TREATMENT - MEDICAL EMERGENCY

• VITAMIN A: ( 3 DOSES)
2 00000 I.U - ORALLY OR
100000 – I.M
• 1ST DAY, 2ND DAY & WITHIN 1-4 WEEKS
(usually day 14)
• CHILDREN BETWEEN 6-11 MONTHS: HALF
THE DOSE
• CHIDREN < 6 MONTHS : QUARTER THE
DOSE
 TREATMENT
OCULAR LESIONS:
• Lubricants
• Broad spectrum antibiotics
• Cycloplegics
• FORTIFIED DIET
 Public Health programs for Vitamin A deficiency
control

A. Food Based strategies

B. Vitamin A supplementation
 A. Food Based strategies

• Food based strategies are a long term approaches to

controlling VAD
1. Fortification of staple food
• Feasible in countries with adequate industrial &
commercial infrastructure
• Fortification of foods like flour, sugar & oil with pre-formed
Vit A (retinol)
• Can be very cost effective way of reducing VAD
• The fortified food should be eaten by those at risk of VAD
(young children and mothers) regularly
• To increase accessibility, the appearance, shelf-life and
costs of the fortified food should be comparable
 Food Based strategies

2. Multi-micronutrient powders
• Entails home fortification of food with micronutrient
powders
• Mothers are thought how to add Sackets of
micronutrient powder to their child′s food eg. Rice
or maize porridge
• Successful in refugee camps, emergency
situations, child health and nutrition programs
 Food based strategies...
3. Dietary diversification and improvement
• Regular access to foods that are naturally rich in vitamin
A
• Important for long term prevention of VAD
• Encouraging exclusive breast feeding as also one
strategy (breast milk as good source of Vit A)
• Teaching the community members how to grow store &
cook Vit A rich plants
• Using innovative approach for home gardening
• Keeping chicken egg yolk is a good source of Vit A
 Vitamin A- food sources and metabolism
Vitamin A
– Fat soluble vitamin found in the form of retinol from
animal sources (eg. Liver, fish, egg yolk, milk products
including breats milk)
– In the form of carotenes from plant sources (alpha, beta
& gamma)converted to retinol in small intestine
– Plant sources include green leafy vegetables and
intensely coloured fruits (spinach, papaya, mango,
carrot, pumpkin, orange maiz)
– Vit . A is destroyed with over cooking and drying on sun
light
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Vitamin A food sources

32
 B. Vitamin A Supplementation
• When implemented in large scale, Vit. A supplementation
is fast and cost effective intervention to improve Vit. A
status of a population
• High dose supplements are given for children 6-59 months
in areas where VAD is a severe public health problem
• When night blindness is >1% in children 24-59 months or
prevalence of VAD ≥20 % in children 6-59 months- VAD is
a public health problem
• Low dose Vit. A supplements may be recommended for
pregnant women if night blindness occurs in >5% of
pregnant mothers
 Vitamin A Supplementation...
• Best way to increase coverage is making
supplementation integral part of child health
services
• In Ethiopia, national guidelines recommend Vit A
supplementation every 6 months for children 6-59
months.
 Vit. A supplementation schedule
Target Age Oral dose Frequency Administration
group
6-11 months 100,000 IU Once Oral liquid, oil
based preparation
of retinyl palmitate
or retinyl acetate
12-59 months 200,000 IU Every 6 months >>
Pregnant 10,000 IU or Daily for 12 >>;
women weeks Recommended
OR 25, 000 IU Weekly for 12 only if VAD is a
weeks severe public
health problem