Robert Adam Young Abstract: A 19 year old male was diagnosed with vitamin A deficiency (VAD). Clinical examination shows conjunctival changes with central and marginal corneal ulcers. Patient history and lab testing were used to confirm the diagnosis. I. Case History 19 year old Hispanic Male Presents with chief complaint of progressive blur at distance and near in both eyes, foreign body sensation, ocular pain, photophobia, and epiphora; signs/symptoms are worse in the morning upon wakening. Started 6 months to 1 year ago, and has progressively gotten worse. Patient reports that the right eye is worse than the left eye. Ocular history of Ocular Rosacea Medical history of Hypoaldosteronism, Pernicious Anemia, and Type 2 Polyglandular Autoimmune Syndrome Last eye examination was two weeks ago at a medical center Presenting topical/systemic medications - Tobramycin TID OU, Prednisolone Acetate QD OU (has used for two weeks); Fludrocortisone (used long-term per PCP) Other pertinent info includes reports that patient cannot gain weight, although he has a regular appetite. Patient presents looking very slim, malnourished, and undersized for his age. II. Pertinent findings Entering unaided acuities are 20/400 OD with no improvement with pinhole; 20/50 OS that improves to 20/25 with pinhole. Pupil testing shows (-)APD; Pupils are 6mm in dim light, and constrict to 4mm in bright light. Ocular motilities are full and smooth with no reports of diplopia or pain. Tonometry was performed with tonopen and revealed intraocular pressures of 12 mmHg OD and 11 mmHG OS. Slit lamp examination shows 2+ conjunctival injection with trace-mild bitot spots both nasal and temporal, OU. The right eye shows a central arcuate corneal ulcer that stains completely with NaFl staining, and inferior corneal neovascularization. The left eye shows an arcuate marginal corneal ulcer with corneal neovascularization and mild staining. Anterior segment photos were taken to document the clinical findings. III. Differential diagnosis Primary: Keratoconjunctivitis Sicca Viral Conjunctivitis 1 Robert Adam Young Allergic Conjunctivitis Retinitis Pigmentosa IV. Diagnosis and discussion Diagnosis: Xerophthalmia secondary to Vitamin A Deficiency Etiology: Dietary deficiency of Vitamin A, most often from chronic malnutrition May also stem inflammatory bowel disease, lipid malabsorption, celiac diseases, liver disease, or post pancreatic/intestinal surgery. Leading cause of childhood blindness in the developing world. Stages of Vitamin A Deficiency: o Stage 1 – Night blindness o Stage 2 – Conjunctival Signs (Bitot Spots) o Stage 3 – Corneal Signs (SPK, Corneal Ulcers) o Stage 4 – Corneal Scars, Xerophthalmia Fundus Vitamin A is necessary for the maintenance of specialized epithelial tissues; the loss of goblet cells leads to dryness and xerosis. V. Treatment, management Initiate oral Vitamin A replacement therapy Frequent preservative-free artificial tear drops or ointment to lubricate the ocular surface Treat the malnutrition/underlying disease If significant scarring, consider a corneal transplant or keratoprosthesis VI. Conclusion Vitamin A Deficiency is most common in underdeveloped countries, and is due to malnutrition, malabsorption, and poor vitamin metabolism. It affects 5 million children world-wide every year The most common symptoms reported are night blindness, dry eyes, and blurry vision. Upon examination, most will have some degree of xerosis, keratomalacia, puncate epithelial erosions, and if severe corneal ulcers. Once vitamin A supplementation is initiated, most patients have a fairly quick recovery. VII. Sources Rice, Amy L., Keith P. West Jr, and Robert E. Black. "Vitamin A deficiency."Comparative quantification of health risks: global and regional burden of disease attributes to selected major risk factors. Geneva: World Health Organization (2004): 211-56. Smith, Richard S., Thomas Farrell, and Thomas Bailey. "Keratomalacia."Survey of ophthalmology 20.3 (1975): 213-219. 2 Robert Adam Young Sommer, Alfred. Nutritional blindness. Xerophthalmia and keratomalacia. Oxford University Press, 1982. Sommer, Alfred. "Xerophthalmia, keratomalacia and nutritional blindness." International ophthalmology 14.3 (1990): 195-199. West Jr, Keith P., and Ian Darnton-Hill. "Vitamin A deficiency." Nutrition and health in developing countries. Humana Press, 2008. 377-433. 3 .