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Ophthalmology (Eye Conditions)

Xerophthalmia (Vitamin A Deficiency)

A spectrum of eye conditions caused by Vitamin A deficiency (VAD), ranging from night blindness and dry eyes to corneal ulceration, melting (keratomalacia), and irreversible blindness. Primarily affects young children.

Also known as: Vitamin A Deficiency Eye Disease, Nutritional Blindness

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Referral and warning signs

When to refer

Urgent Referral to Hospital/Eye Specialist: ALL cases involving the cornea (X2, X3A, X3B). Any child with xerophthalmia and severe malnutrition or other danger signs.

Red flags

  • Any corneal involvement (haziness, ulceration, melting).
  • Severe general malnutrition.
  • Associated severe illness (e.g., severe measles).

Signs and symptoms

  • WHO Classification:
  • - XN: Night Blindness: Difficulty seeing in dim light (often earliest symptom).
  • - X1A: Conjunctival Xerosis: Dry, rough, non-wettable conjunctiva.
  • - X1B: Bitot's Spots: Foamy, white/cheesy patches on temporal conjunctiva (collection of keratinized epithelial cells).
  • - X2: Corneal Xerosis: Dry, hazy, non-wettable cornea.
  • - X3A: Corneal Ulceration/Keratomalacia <1/3 corneal surface: Ulceration or necrosis involving less than one-third of cornea.
  • - X3B: Corneal Ulceration/Keratomalacia >=1/3 corneal surface: Ulceration or necrosis involving one-third or more of cornea.
  • - XS: Corneal Scar: Scarring resulting from previous xerophthalmia.
  • - XF: Xerophthalmic Fundus: Fundus changes (less common).
  • Associated signs: General malnutrition, increased susceptibility to infections (measles, diarrhoea).

Risk factors

  • Inadequate dietary intake of Vitamin A (lack of animal products, fruits, vegetables).
  • Malnutrition (Protein-Energy Malnutrition).
  • Malabsorption syndromes.
  • Chronic diarrhoea.
  • Measles infection (precipitates VAD).
  • Young age (6 months - 5 years).
  • Living in areas with high VAD prevalence.

Diagnosis

Clinical assessment

Diagnosis based on history (night blindness, poor diet, recent measles) and clinical examination identifying characteristic eye signs (Bitot's spots, xerosis, corneal changes).

Investigations

  • Clinical examination is primary.
  • Serum Retinol levels (specialized labs, not routine clinical use).

Diagnostic criteria

Presence of characteristic clinical signs (WHO classification).

Management

Non-pharmacological management

  • Nutritional rehabilitation: Diet rich in Vitamin A (liver, eggs, dairy, dark green leafy vegetables, yellow/orange fruits & vegetables).
  • Treat underlying malnutrition and infections (measles, diarrhoea).

Pharmacological treatment

  • High Dose Vitamin A Supplementation (WHO Protocol): IMMEDIATE treatment. (LOC: HC2+)
  • - Day 1 (Immediately on diagnosis):
  • - Age <6 months: 50,000 IU PO
  • - Age 6-11 months: 100,000 IU PO
  • - Age >=12 months: 200,000 IU PO
  • - Day 2 (Next day): Repeat Day 1 dose.
  • - Day 14 (or 2-4 weeks later): Repeat Day 1 dose.
  • - *(Note: For pregnant women, therapeutic doses only under specialist guidance due to teratogenicity risk; prophylactic doses safe).*
  • Treatment of Corneal Ulceration (X3A/X3B):
  • - Treat as Ophthalmic Emergency - Urgent Referral required.
  • - Instill topical antibiotic eye drops/ointment (e.g., Chloramphenicol, Tetracycline) QID to prevent secondary bacterial infection. (LOC: HC4/H)
  • - Instill cycloplegic eye drops (e.g., Atropine 1%) TID to relieve pain/prevent synechiae. (LOC: HC4/H)
  • - Pad the eye(s) gently.
  • - Requires specialist ophthalmic management.

Monitoring

Monitor resolution of eye signs. Follow up nutritional status. Monitor for side effects of high-dose Vitamin A (rare - vomiting, headache, bulging fontanelle).

Complications

  • Corneal scarring.
  • Corneal perforation.
  • Endophthalmitis.
  • Phthisis bulbi.
  • Permanent blindness.
  • Increased mortality from associated infections (measles, diarrhoea).

Prevention

  • Routine high-dose Vitamin A supplementation for children 6m-5y (every 6 months - national programs).
  • Vitamin A supplementation for postpartum mothers (single high dose).
  • Promoting intake of Vitamin A rich foods.
  • Food fortification programs.
  • Measles immunization.
  • Prompt treatment of diarrhoea and malnutrition.

Patient education

  • Explanation of the condition as nutritional deficiency.
  • Importance of taking Vitamin A supplements correctly.
  • Dietary advice on Vitamin A rich foods.
  • Need for eye care if cornea involved.
  • Importance of routine Vitamin A supplementation for prevention.
  • Follow-up requirements.

Uganda-specific notes

VAD remains a public health concern, contributing to childhood morbidity/mortality. Routine Vitamin A supplementation integrated with immunization programs (e.g., Child Health Days) is a key strategy. Recognize eye signs during IMCI assessment.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 20, Section 20.1.9

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 19 (Nutrition - mentions Vit A in SAM)

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 17 (IMCI - Vit A for Measles/Malnutrition)

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