Xerophthalmia

A short presentation on xerophthalmia,Vit A deficiency being a major cause of preventable childhood blindness in Nepal.Thanks for watching.

1. Xerophthalmia -Kshitiz Raj Pokhrel -MBBS,KUSMS DH

2. Xerophthalmia -refers to spectrum of ocular disease caused by lack of vitamin A -late manifestation of severe deficiency -Vit A deficiency primary cause of childhood blindness in nepal

3. Etiology Vitamin A deficiency Dietary deficiency-less intake,severe dieting Defective metabolism -malabsorption -malnutrition -chronic alcoholism Associated with PEM and infections esp in children

4. Vitamin A metabolism Vitamin A -fat soluble essential vitamin Sources: 1)Animal: -fish liver,liver,milk,egg,dairy product -contains active vit A

5. 2)Plant:red and yellow fruits,dark green leafy vegetables -contains carotene(pro vit A) -converts into retinol in intestinal wall

6. Vitamin A functions -vision(synthesis of retinal photoreceptor proteins ) -maintenance of body’s epithelial surfaces -immune function -skeletal growth -fertility (male and female) -hemopoiesis -anti oxidant

7. Blood phototransduction

8. WHO Classification 1982 XN Night Blindness X1A Conjunctival Xerosis X1B Bitot’s spots X2 Corneal xerosis X3A Corneal ulceration/keratomalacia <1/3 of corneal surface X3B Corneal ulceration/keratomalacia >1/3 of corneal surface XS Corneal scar due to xerophthalmia XF Xerophthalmic fundus

9. Clinical Features 1.XN(Night blindnes) (Nyctalopia) -earliest symptom in children -eye discomfort,loss of vision -detailed history to elicit -offers as a screening tool to identify xerophthalmia

10. 2.X1A(Conjunctival Xerosis) -one or more patches of dry,lustreless,non wettable conjunctiva -loss of goblet cells,squamous metaplasia and keratinization -emerging like sand banks at receding tide -in interpalpebral area of the temporal quadrants and often the nasal quadrants -later,entire bulbar conjunctiva affected -xerosis,conjunctival thickening,wrinkling and pigmentation

11. 3.X1B(Bitot’s spots) -raised,silvery white,foamy,triangular patch of keratinised epithelium -bulbar conjunctiva in the interpalpebral area -b/l and temporal,sometimes nasal

12. 4.X2(Corneal Xerosis) -punctate keratopathy (earliest change)-lower nasal quadrant -xerosis and keratinization -haziness -lustreless cornea,granular pebbly dryness

13. 5.X3A and X3B(Corneal ulceration/keratomalacia) -stromal defects due to colliquative/liquefactive necrosis -peripheral small ulcers(1-3mm),circular,steep margins,sharp demarcation -eventually large ulcers involving entire cornea -can result in perforation

14. -X3A <1/3 of corneal surface-heals with appropriate therapy - X3B>1/3 of corneal surface-may result in blindness

15. 6.XS(Corneal Scars) -stromal defects-corneal scars of different densities and sizes -pupillary area may/maynot be involved

16. 7.XF(Xerophthalmic fundus) -seeds like,raised,whitish or yellowish dot like lesions scattered uniformly over the fundus at the level of optic disc

17. Evaluation

18. Treatment 1.Local Ocular Therapy -artificial tears(0.7% hydroxypropyl methyl cellulose,0.3% hypromellose) 3-4 hrly -keratomalacia-as for bacterial corneal ulcer

19. 2.Vitamin A therapy -all stages of active xerophthalmia(XN-X3B) -oral form recommended -IM inj(severe diarrhoea,repeated vomiting)

20. Vitamin A therapy Age Vitamin A dose Frequency >1 year of age(except women of reproductive age) 2,00,000 IU vit A orally or 1,00,000 IU IM At diagnosis,next day tand after 2 weeks same dose <1 year of age(children of any age<8 kg ) Half the above dose Same Women of reproductive age(XN,X1A,X1B) 10,000 IU vit A orally Once Daily for 2 weeks Women of reproductive age(corneal xerophthalmia) 2,00,000 IU vit A orally or 1,00,000 IU IM At diagnosis,next day tand after 2 weeks same dose

21. 3.Treatment of underlying cause and associated conditions -PEM -nutritional disorders -diarrhoea and dehydration -infections -alcoholism

22. Prophylaxis 1.Short Term Approach(Vit A supplementation) Age Vit A Dose Frequency >1 year-<6 years 2,00,000 IU orally 6 monthly 6-12 months(older children <8 kg ) 1,00,000 IU orally 3-6 monthly <6 months 50,000 IU orally Upto 6 months,once Lactating mothers 20,000 IU orally Once at delivery or during next 2 months

23. 2.Medium Term Approach -food fortification 3.Long Term Approach -health promotion and education All 3 approaches combined gives the best result

24. References Comprehensive Ophthalmology by A.K Khurana,6 th edition Kanski’s Clinical Ophthalmology https://www.ncbi.nlm.nih.gov/pubmed/28613746