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The Eye Signs of Vitamin a Deficiency

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The Eye Signs of Vitamin a Deficiency XEROPHTHALMIA The eye signs of vitamin A deficiency Clare Gilbert Signs of chronic, long- Co-director: International Centre for Eye Health, Disability Group, London School standing VAD of Hygiene and Tropical Medicine, NOTE: To examine the eye, use a bright London, UK. ICEH torch in natural light. It is vitally important to realise that many Night blindness children who are vitamin A deficient will This can affect children as well as not have the eye signs, known as xeroph- pregnant and lactating women and is one thalmia (dry eye). This means that of the more common manifestations of children with the eye signs are only the deficiency. If VAD is prevalent in the ‘tip of the iceberg’ – there will be many community then there are often local other children in the community who are names for it. It is useful to find out what vitamin A deficient but who have completely these terms are so they can be used when normal eyes and vision. This is why asking about night blindness. It is more community approaches to control are difficult to find out if a child has night so vitally important (page 69–70). blindness, as children do not complain. The different eye signs of vitamin A Mothers need to be asked whether they deficiency (VAD) in children, as graded by have noticed that their child behaves the WHO, are: differently after the sun goes down or • Night blindness (XN) when they are in a dark room. The child • Conjunctival xerosis (X1A) will become less active, and may be • Bitot’s spots (X1B) Picture drawn by a child to illustrate fearful of moving around. Night blindness • Corneal xerosis (X2) night blindness tends to affect women who are pregnant • Corneal ulcer covering less than 1/3 of or lactating, and children aged 2–6 years. three times more likely to die as those the cornea (X3A) from the same community without night Conjunctival xerosis • Corneal ulcer covering at least 1/3 of the blindness, and children with both night This presents as dryness of the cornea, defined as keratomalacia (X3B) blindness and Bitot’s spots were almost conjunctiva (Figure 1) and is another sign • Corneal scarring (XS) nine times more likely to die.1 A study of long-standing deficiency. It can be It is very important to realise that children from Bangladesh showed that almost quite difficult to detect and is therefore do not first develop night blindness, then two-thirds of children with the most not a very reliable sign. Bitot’s spots and then corneal ulcers. severe form of xerophthalmia – known Figure 1. Conjunctival xerosis. Note the Some eye signs reflect long-standing as keratomalacia (a corneal ulcer affecting slight wrinkling of the temporal conjunctiva VAD, whereas other eye signs reflect more than a third of the cornea) – had severe, acute, sudden-onset VAD. A child died within a few months.2 who is vitamin A deficient, but who does Long-standing VAD is most prevalent not have any of the eye signs of long- in children aged 3–6 years (with night standing deficiency, may develop one of blindness, children as young as 2 years the severe eye signs, such as corneal old can be affected). Acute VAD is most ulcers, as a result of infection or diarrhoea. prevalent among children aged 1–4 years Children with any of the eye signs of (see Table 1). To prevent blindness and VAD are at high risk of dying. One of the child mortality from VAD, interventions first studies in Indonesia showed that must therefore be targeted at pre-school- children with night blindness were almost aged children. Clare Gilbert Table 1. World Health Organization (WHO) classification of vitamin A deficiency and the age groups most affected Peak age group Grade of xerophthalmia Type of deficiency Risk of death (years) XN Night blindness 2 – 6; adult women Long standing. Not blinding + X1A Conjunctival 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/ <1/3 cornea 1 – 4 Severe acute deficiency. Blinding +++ X3B Corneal ulcer/keratomalacia ≥1/3 1 – 4 Severe acute deficiency. Blinding ++++ XS Corneal scarring (from X3) >2 Consequence of corneal ulceration +/– XF Xerophthalmic fundus Adults Long standing. Not blinding. Rare – 66 COMMUNITY EYE HEALTH JOURNAL | VOLUME 26 ISSUE 84 | 2013 Bitot’s spots Corneal ulcer usually because they were vitamin A Bitot’s spots (Figure 2) are characteristic If the acute deficiency is not reversed as deficient and the measles infection of VAD and are not caused by any other a matter of urgency, the cornea can resulted in depletion of their vitamin A condition. The slightly elevated, white become ulcerated and melt away. The stores. If you are not sure whether the foamy lesion is usually seen on the bulbar ulcer may have the appearance of a child you are seeing has keratomalacia, conjunctiva near the limbus, at the three small, punched-out area in the cornea ask about recent illness, particularly o’clock or nine o’clock positions. Bitot’s (Figure 4, top image), or the ulcer may measles. spots are more common on the temporal have a more fluffy appearance (Figure 4, Figure 6. Keratomalacia side. The white deposit consists of lower picture). In the absence of keratin, which the conjunctiva starts to secondary infection, the eye can look produce because the deficiency has led surprisingly white, as in both images in to ‘squamous metaplasia’ with the cells Figure 4; however, secondary infection in the conjunctiva becoming more like of the ulcer is common, leading to an skin than a mucous membrane. To a acutely inflamed eye (Figure 5). certain extent the white foamy material Figure 4. Corneal ulceration (X3a) can be wiped away from the surface of without secondary infection the conjunctiva, but does not disappear completely, even after the vitamin A Allen Foster deficiency has been treated. Hence, this sign does not necessarily mean that the The end result of corneal child is currently vitamin A deficient. ulceration Bitot’s spots usually appear in children The end result of corneal ulceration and aged 3–6 years. Bitot’s spots that do not keratomalacia is corneal scarring (Figure 7), respond to vitamin A treatment are more staphylomas (forward bulging of a badly common in school-aged children. damaged cornea) or phthisis bulbi (an eye that has shrivelled up), depending on Figure 2. Bitot's spots at the temporal the extent of the pathology in the cornea. Allen Foster limbus Most of the eye signs of VAD are symmetrical and bilateral, and so can lead to blindness. Figure 7. Corneal scarring Clare Gilbert Clare Gilbert Signs of acute, sudden- onset VAD Alfred Sommer Acute, sudden-onset VAD leads to poten- Figure 5. Corneal ulceration (X3a with tially blinding eye signs and is associated secondary infection with a very high mortality rate in children. Corneal xerosis This is drying of the cornea (Figure 3) and Clare Gilbert is a sign of sudden, acute deficiency. The cornea becomes dry because glands in If a child is found to have the eye signs of the conjunctiva no longer function VAD, spend time talking to his or her normally. This leads to loss of tears and mother or carer. Ask the mother about also loss of mucous, which acts as a the food the child is given, and how ‘wetting agent’. The lack of mucous Allen Foster often he/she is fed. Ask specifically together with lack of tears not only leads about foods which are rich in vitamin A. to the dry appearance but also increases Keratomalacia Ask if the child has been ill recently, or the risk of infection. The most severe form of xerophthalmia is had diarrhoea. Explain that the child is at keratomalacia (Figure 6), in which more Figure 3. Corneal xerosis risk of infection and that they need more than one-third of the cornea is affected. than one dose of vitamin A to treat the The cornea may become oedematous and problem, as is described on page 68. thickened, and then melt away. This Remember that other young children in occurs because the structure of the the family and the community are also collagen in the cornea is affected by a likely to be at risk. process known as necrosis. The cornea can be destroyed in just a few days. References 1 Sommer A, Tarwotjo I, Hussaini G, Susanto D. Children with keratomalacia are often Increased mortality in children with mild vitamin A malnourished, but children who previously deficiency. Lancet. 1983;2(8350):585–8. appeared relatively healthy can also 2 Cohen N, Rahman H, Sprague J, et al.Prevalence and determinants of nutritional blindness in develop keratomalacia following measles Bangladeshi children. World Health Stat Q. Alfred Sommer infection or episodes of diarrhoea; this is 1985;38(3):317–330. © The author/s and Community Eye Health Journal 2013. This is an Open Access article distributed under the Creative Commons Attribution Non-Commercial License..
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