Xerophthalmia, and Its Sequels, Blindness and Death in Childhood, Simon Franken PH.D

Xerophthalmia, and its sequels, blindness and death in childhood, Simon Franken PH.D This booklet is not only for ophthalmologists going to developing countries, but is also meant for general practitioners, nurses and healthcare workers going and living there I do hope that it will somehow contribute to the realisation of responsibility in those who have the distribution of food for their task. Preface Having worked during 22 years in developing mainly tropical countries as teaching ophthalmologist I have at times taken pictures of various abnormalities which prompted patients to come to me for help and advise. For some time I had vague plans about publishing material on ophthalmic problems in developing countries. Now having finished my career I want to make my slides available to others for teaching purposes. The present selection described in this booklet is confined to the topic xerophthalmia. The 189 pictures concerning xerophthalmia and related subjects is the core of this small publication. Each of these pictures has been described in this booklet. It was unavoidable to let an introduction to the topic precede these descriptions. The introduction is continued between the descriptions of pictures. For a thorough introduction to the disease entity xerophthalmia the reader will have to consult Dr.Sommers book. In no way do I pretend to be complete. There is material enough and in order to remain informed about newer insights the regular publications by DSM under the title “Sight and Life” is heartily recommended. It is incorporating the Xerophthalmia Club Bulletin and is published by Dr. Klaus Kraemer in Basel. My introduction is further concerned with a number of accompanying details which in my opinion have found insufficient attention or have been overlooked by others who have worked in this field. As I consider the deficiency to cause the development of anterior polar cataract I include pictures of this abnormality here together with what affects conjunctiva and cornea. I do the same with the variety of scars seen in older people. Anyone who wants to use these illustrations with the fitting descriptions published here is free to do so but is requested to mention the source. I hope that this will contribute to the eradication of hunger and nutritional deficiencies. Xerophthalmia Xerophthalmia is the name for the complex of manifestations connected with deficiency of vitamin A. In summary these consist of night blindness, changes in the conjunctiva and in ultimate stages the loss of the cornea. These various abnormalities of this disease entity are little known in well to do countries. The conditions are not seen because the people are well to do in the twenty-first century. They have no shortage of essential food. They live in nutritional luxury. Only in very exceptional instances manifestations of the deficiency may occur in these countries. With the teaching material widely available for training in ophthalmology the theoretical knowledge may encompass the subject xerophthalmia. But ophthalmologists working on in their own country will never see the condition. In case someone is willing to spend some time working in a developing country he is anyhow facing surprising situations. When he or she is willing to work in a poor area of the host country they certainly will be confronted with clinical conditions they have never or seldom met before in their home country and the practitioner will still be unfamiliar with the manifestations of the overwhelming 1 pattern of diseases in his new not to say strange working situation. Apart from the strange language which requires the help of an interpreter, the customs, the way of doing things, the poverty, the limited means and many unforeseen details will be overwhelming. The gross abnormalities will demand their attention and as surgeons they may be inclined to spend their limited time on matters in which they can be effective, booking some tangible and satisfying results before they return home after their adventure. People born in developing countries trained as ophthalmologist in some developed country are not likely to learn during their training there about many conditions common in their home country. Moreover there seems to exist some tendency towards unbelief in this subject. On the whole there still is a widespread ignorance on the subject notwithstanding the work of Oomen, Escapini, Sommer, ten Doesschate and Sauter. In the countries Ghana, Tanzania, Kenya and Nigeria where the condition is seen fairly frequently I have met considerable ignorance on the subject among the nursing staff, sometimes also among the doctors even among some ophthalmologists. This seems part of the enigma shrouding this clinical entity. This may be partly understandable because the deficiency always sneaks in without undeniable manifestation. Only after the liver store of the vitamin is far below an acceptable level its first manifestation i.e. night blindness (nyctalopia) appears and it mostly appears in children. These do not complain about it and parents often do not notice the abnormality. They may guess what is wrong when a child is crying but they are less concerned when the child comes home after playing outside and is not crying. If the parents notice a slight abnormality at all they may think that this behaviour is so common among the youngsters as not to take action in this stage of the deficiency, which in fact is a dangerous condition and has to be called a disease. Here is probably the main snag of the enigma. The children have a deficient state of nutrition but are not ill. At the most they may be listless and have diarrhoea. Most children have diarrhoea and medical personnel thinks in the first place of an infection and blame the worms but do not know that retinol has also a function in and for the intestinal mucosa. Deficiency of vitamin A may cause diarrhoea thus inviting intestinal infection. Without this trigger the parents are not alarmed by the listlessness of their children and do not take action when the children come home before dark. Then there may not be any knowledgeable expert in the vicinity and parents have to use their time working instead of consulting somebody about what does not alarm them at all. Measles is caused by a virus, is very contagious and occurs in epidemic form. No child having contracted this disease is without symptoms. The same is true for whooping cough and chickenpox. The lack of vitamin A may occur on a large scale in a community without a single alarm raising sign. Xerophthalmia may unexpectedly become manifest when a sudden demand on the liver store is made. Xerophthalmia being a deficiency is evidently not contagious. Nevertheless it occurs usually in epidemic form. The people living in what is called a primitive community have an identical pattern of food supply. They share the same sort of belief and therefore have the same sort of taboo regarding foods fit or unfit for children. The pure form of the deficiency is rare. It is likely to occur when the menu is scanty and is combined with taboos concerning food for children. The most heartrending example I did encounter among children coming from an island in eastern Indonesia. They had their menu so limited that they lost their eyes without other signs of malnutrition. They had not lacked calories and did not suffer from an infectious disease. In East Africa I saw similar situations when the already marginal menu was further limited by failing rains, starving cattle and lacking harvests. In a short scheme we may mention the following stages which can be recognised by a clinician with increasing deficiency of vitamin A. First inability to see things after sunset, unless help is given by a bright light. Then there will be diminished production of mucous in 2 the conjunctiva followed by dryness- xerosis. Finally with continuing deficiency the cornea will be affected with diminished sight or blindness as a result. What the deficiency does to other parts of the body often leading to an early death can not find description here but has to be told by others. If carotene is lacking in the menu other necessary ingredients are usually also lacking. When children are struck by for instance measles while they have a shortage of vitamin A they will be subject to visible damage to their eyes while the first stage connected with the extremely low liver stores has not been noticed by anyone. Not only children, also their parents eating the same meal will be subject to the damage caused by the deficiency. Dekkers found that prisoners in Kenya, were night-blind after half a year in prison. They received monotonous food consisting of the staple food white maize and nothing else. The prison food was apparently a little worse than what they had at home. In other prisons in the same country vegetables were grown in the prison garden. These vegetables were added to the menu of the prisoners. It occurred that people coming in with night blindness were cured of their problem after eating a few weeks the better prison food. They did eat vegetables in the posho, the maize porridge! Such reports tell us that their liver stores of the vitamin were at an unacceptable low level before they got into prison. We know about a very exceptional experiment undertaken by a psychiatric patient in a western country who blamed her personal and other social problems on the ingestion of vitamin A and selected her food in such a way that she avoided any intake of this vitamin and its provitamins. It took her six years before she was night-blind. The deficiency has also been present on a large scale in western countries but has largely been forgotten after the signs did not occur anymore.

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