Lecture on Vitamin A & Its Management For 4th Year MBBS Undergraduate Students By Prof. Dr. Hussain Ahmad Khaqan

1. Vitamin A Deficiency &
Its Management
Prof. Dr. Hussain Ahmad Khaqan
 MD
 FRCS(Glasgow)
 FCPS(Ophth.)
 FCPS(Vitreo Retina)
 MHPE (KMU)
 CICO(UK)
 CMT(UOL)
 Fellowship in Medical Retina (LMU, Munich)
 Fellowship in Vitreo Retinal Surgery (LMU, Munich)
 Consultant Ophthalmologist & Retinal Surgeon
Professor of Ophthalmology
Lahore General Hospital, Lahore
Ameer Ud Din Medical College, Lahore
Post Graduate Medical Institute, Lahore
Shaukat Khanum Memorial Cancer Hospital & Research Centre ,Lahore

2. SYMPTOMS
• Night blindness
• Dry eyes
• Ocular pain
• Severe vision loss.

3. SIGNS
• Ocular: Bitôt spots (triangular, Perilimbal, gray, foamy
plaques of keratinized conjunctival debris); decreased tear
breakup time; bilateral conjunctival and corneal dryness;
corneal epithelial defects, sterile or infectious ulceration
(often peripheral with a punched-out appearance),
perforation, or scarring; Kerotomalacia (often preceded
by a gastrointestinal, respiratory, or measles infection);
fundus abnormalities (yellow or white peripheral retinal
dots representing focal retinal pigment epithelium [RPE]
defects).

4. Figure: Bitôt spots. Figure: Kerotomalacia.

5. XN Night blindness
X1A Conjunctival xerosis
X1B Bitot spot
X2 Corneal xerosis
X3A Corneal ulceration or keratomalacia with less than one-third
corneal involvement.
X3B Corneal ulceration or keratomalacia with one-third or more
corneal involvement.
XS Corneal scar
XF Xerophthalmia fundus
Table: World Health Organization Classification of
Vitamin A Deficiency

6. DIFFERENTIAL DIAGNOSIS
• Dry eye syndrome
• Retinitis pigmentosa
• Inherited chorioretinal dystrophies.

7. ETIOLOGY
• Primary: Dietary deficiency or chronic alcoholism.
Beyond 6 months postpartum, breast milk in vitamin
A-deficient mothers is unlikely to sufficiently
maintain vitamin A stores in nursing infants.
• Secondary: Lipid malabsorption (e.g., cystic fibrosis,
chronic pancreatitis, inflammatory bowel disease,
celiac sprue, postgastrectomy or post intestinal
bypass surgery, chronic liver disease,
abetalipoproteinemia [Bassen–Kornzweig
syndrome]).

8. WORK-UP
• History
• Complete ophthalmic examination
• A positive response to treatment is a simple, cost-
effective way to confirm the diagnosis
• Consider serum vitamin A level before treatment is
initiated
• Consider dark adaptation studies and
electroretinograms
• Corneal cultures if infection suspected.

9. TREATMENT CONTINUE..
Immediate vitamin A replacement therapy orally (preferred) or
intramuscularly in the following WHO recommended dosages for
clinical xerophthalmia:
• Children <12 months: 100,000 IU daily for 2 days, repeat in 2
weeks.
• Adults and children >12 months: 200,000 IU daily for 2 days,
repeat in 2 weeks.
• Women of childbearing age (reduce dose due to possible
teratogenic effects): night blindness or Bitôt spots only,
10,000 IU daily for 2 weeks or 25,000 IU weekly for 4 weeks;
any corneal lesions, give full adult dose as above.

10. • Intensive ocular lubrication with preservative-free
artificial tears every 15 to 60 minutes and
preservative-free artificial tear ointment at night.
• Treat malnutrition/underlying disease if present.
• Consider supplementing the patient’s diet with
zinc and vitamin A.
• Consider corneal surgery (e.g., penetrating
keratoplasty or Keratoprosthesis) for corneal
scars in eyes with potentially good vision.
TREATMENT CONTINUE..

11. Prophylaxis in endemic regions:
• Infants: Consider 50,000 IU.
• 6 to 12 months: 100,000 IU q4–6 months.
• Children >12 months: 200,000 IU q4–6 months.
TREATMENT