Xerophthalmia

Symptoms Of Xerophthalmia

The symptoms of xerophthalmia depend upon the severity of deficiency and age of the patient and gradually progresses through the following stages: 

Night blindness (impaired sensitivity of the eye to light)

This is the first sign of xerophthalmia in which the person is not able to see in dim light and may bump into objects and/or show reduced mobility.

Conjunctival xerosis

It is characterized by the dull, dry, thick, wrinkled appearance of the conjunctiva. It develops due to changes in mucin secretion that lubricates the conjunctiva. 

Bitot spots

It refers to whitish, foamy, opaque deposits on the conjunctiva. 

Corneal xerosis

Cornea appears dull, dry and hazy in appearance.

Corneal ulceration or Keratomalacia

Corneal xerosis often leads to ulcers and softening of the cornea. It can even perforate and destroy the cornea of the eyes..

Corneal scars

Scarring of the cornea is a late and severe symptom of xerophthalmia.

Xerophthalmic fundus

It refers to the structural changes in the fundus (the inside, back surface of the eye). 

Causes Of Xerophthalmia

• A form of vitamin A, called retinal, combines with a protein called opsin to form rhodopsin, an essential light absorbing molecule needed for vision in dim light and color sensitivity.
• Vitamin A also plays an important role in maintaining a clear vision by supporting the functioning of the cornea which is the protective outer layer of the eye
• Vitamin A helps to stimulate the lacrimal glands to produce moisture in the eyes and avoid issues like dry eyes.

The deficiency of Vitamin A is the main cause of xerophthalmia. The causes of the deficiency include:

A. Inadequate dietary intake of Vitamin A

 Low intake of dietary sources of Vitamin A can be attributed to:

• Insufficient food supply

• Chronic alcoholism

• Highly selective eating

• Difficulty in swallowing

• Mental illness

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B. Impaired absorption of Vitamin A 

The leading causes of insufficient absorption of Vitamin A are diseases affecting the pancreatic, liver, and intestines like:

• Chronic liver disease (progressive damage of liver for more than 6 months)

• Inflammatory bowel disease (inflammation in the digestive tract) 

• Pancreatitis (inflammation of the pancreas)

• Celiac disease (hypersensitivity to certain foods leading to impaired digestion)

• Pancreatic insufficiency (improper functioning of the pancreas) 

• Short bowel syndrome (improper absorption of nutrients from food)

• Chronic diarrhea

• Upper gastrointestinal surgery

• Giardiasis (intestinal infection accompanied by fever and diarrhea)

• Abetalipoproteinemia (impaired absorption of fats and vitamins)

C. Reduced storage of Vitamin A

The reduced storage of Vitamin A due to the following reason can also cause xerophthalmia. 

• Liver diseases

• Cystic fibrosis (inherited disorder that mainly affects lungs and digestive system)

Risk Factors For Xerophthalmia

The following factors can trigger Vitamin A deficiency and eventually lead to xerophthalmia:

Age

Infants and children are more prone to xerophthalmia due to their higher need of Vitamin A for the growth and development. Children are also more prone to intestinal infections that may impair the absorption of Vitamin A.

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Malnutrition

Malnutrition can lead to multiple vitamin deficiencies including Vitamin A deficiency. People living in developing countries are more prone to xerophthalmia due to more chances of malnutrition. 

Zinc deficiency

Malnutrition, especially zinc deficiency, decreases the level of active Vitamin A in the body and increases the chances of developing xerophthalmia. 

Pregnancy 

Pregnant and lactating women are at higher risk of developing xerophthalmia due to increased chances of Vitamin A deficiency in this period. Neonates born to Vitamin A deficient mothers are at higher risk of developing xerophthalmia.

Poor lactation 

Breast milk provides various essential nutrients to neonates that are required for normal growth and development. It also protects the infants from various infections in the initial years of life. Inadequate breastfeeding in infants younger than 6 months also increases the risk of xerophthalmia. 

Medical conditions

Some diseases such as chronic liver disease, liver cirrhosis, diarrhea, inflammation of the pancreas, and inflammatory bowel disease make the person more vulnerable to xerophthalmia. 

Comorbidities 

The various diseases such as pneumonia, jaundice, vomiting, and septicemia also increase the risk of xerophthalmia. 

Low socioeconomic status

Poor people are more prone to Vitamin A deficiency as they cannot afford proper meals to fulfill their nutritional requirements.

Lack of education

People who are not properly educated about the importance of proper nutrition are more prone to nutritional deficiences like those of Vitamin A.

Alcoholism 

The excessive consumption of alcohol lowers the level of Vitamin A in the body and predisposes to xerophthalmia. 

Diagnosis Of Xerophthalmia

A thorough dietary, medical, social history including alcohol intake is taken from the patient having signs of xerophthalmia. In case of specific indications of night blindness or severe xerophthalmia, treatment with Vitamin A is started immediately. The diagnosis is mostly based on the symptoms. 

Physical exam

The doctor first examines the eyes of the patient for any signs such as dry eyes and spots that are characteristic of xerophthalmia. The physical exam also includes assessment of jaundice. 

Blood tests

Serum Vitamin A/retinol

This test measures the level of Vitamin A in the body. The ocular symptoms related to Vitamin A deficiency have been shown to develop at concentrations <10mcg/dL.

Serum retinol binding protein

Vitamin A is transported to the tissues in the form of retinol after binding with the retinol binding protein (RBP). The level of RBP reflects retinol concentration which in turn gives an idea about Vitamin A status. The normal level of serum RBP is 30-75 ug/ml. 

Serum zinc

The decreased level of zinc is also associated with xerophthalmia. The normal levels of serum zinc are 75-120 mcg/dL. 

Dark adaptometry and night vision threshold tests

These tests are used to diagnose night vision defects. 

Electroretinogram (ERG)

ERG measures the electrical activity of the retina in response to a light stimulus, non-invasively. ERGs are recorded using an electrode placed in contact with the cornea. 

Impression cytology

In this, the specimens of the conjunctiva (clear tissue covering the white part of the eye) are studied for the presence of goblet cells (highly specialized cells that produce and secrete mucins, responsible for hydration and lubrication of eyes). A decrease in the amount of these cells is also an indicator of Vitamin A deficiency. 

Specialist To Visit

Any patient who is experiencing visible symptoms such as dry eyes, must consult the doctor immediately. 

The diagnosis of xerophthalmia is done by an ophthalmologist, a physician specializing in diseases and surgery of the eye. 

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Prevention Of Xerophthalmia

All the following factors that maintain an adequate level of Vitamin A play a role in preventing xerophthalmia:

Consuming adequate Vitamin A

The best way to prevent xerophthalmia is to take an adequate amount of Vitamin A through a healthy balanced diet rich in Vitamin A food sources such as carrots, milk, fish, eggs, green vegetables, yams, and sweet potatoes. 

People who are on restrictive diets or facing some issues in getting adequate amounts of Vitamin A, should take the recommended dose of Vitamin A supplements. 

Appropriate intake of Vitamin A is also very important during pregnancy and lactation to build stores of retinol in the liver. 

Environmental sanitation 

The chances of Vitamin A deficiency increases in the presence of certain diseases such as respiratory tract infections, tuberculosis, diarrhea, and worm infestations. Proper sanitation of the living environment helps in reducing the prevalence of these diseases. 

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Vaccination

Certain vaccine-preventable diseases such as measles serve as a precipitating factor for xerophthalmia. Immunization helps in the elimination of such factors and may help in preventing xerophthalmia.

Home-care For Xerophthalmia

1. Consume Vitamin A rich food 

People should consume food rich in Vitamin in their diet such as: 

• Carrots

• Broccoli

• Fish

• Fortified cereals

• Beef

• Liver

• Eggs

• Chicken

• Mangoes

• Whole milk

• Green leafy vegetables

2. Wear glasses

Wearing glasses is a good practice as it reduces the pressure from the eyes and is helpful for the people suffering from night blindness. It also helps the eyes to focus in a better way. 

3. Avoid looking directly in the dark

The people suffering from night blindness should avoid looking at the dark source directly as it may adversely affect the pupil (black center of the eye). 

4. Eyes exercises

Patients having xerophthalmia should keep their eyes in motion by looking in different directions, focusing at different points and blinking their eyes. It serves as an eye exercise and helps in the recovery of the eyes. 

5. Adaptation to darkness

The people who are at initial stage of xerophthalmia i.e night blindness should try to adapt to darkness by sitting in a dark room for 20-30 minutes daily. They should also wear a sleep mask while sleeping. This will make the eyes comfortable in darkness and also help to prevent severe eye disorders. 

6. Eye massage

Eye massage is a very powerful tool to improve the overall health of the eyes. It should be done only under the supervision of an expert as improper technique can damage the eye lens. To do eye massage:

• Put slight pressure on both the eyes with the palms

• Keep that pressure for around 5-10 seconds

• Vision will turn white instead of black for a slight moment

• When the black vision comes back, open the eyes

• This will significantly improve vision in the dark

• Regular eye massage can prevent night blindness to some extent

Complications Of Xerophthalmia

Vitamin A deficiency can cause various complications due severe malnutrition. It also increases the chances of mucosal infections. Keratomalacia and night blindness can also be life threatening in children.

High doses of Vitamin A can treat early symptoms such as conjunctival xerosis and night blindness. Corneal xerosis may however sometimes lead to permanent vision loss.