Topical retinoic acid in the treatment of experimental xerophthalmia in the rabbit

The purpose of this study was to evaluate the efficacy of topical retinoic acid (tretinoin) in the treatment of various stages of xerophthalmia caused by vitamin A deficiency. At the beginning of treatment, rabbits with similar disease in both eyes were given a normal diet and therapeutic doses (25,000 IU) of systemic vitamin A. One eye of each was treated with 0.1% retinoic acid in sesame oil one time per day. The other eye received sesame oil alone. Eyes with moderate disease (advanced keratinization and plaque formation) responded more quickly to topical retinoic acid (clear within three days) than did eyes treated with sesame oil (clear within seven days). No difference in time of response could be observed in corneas with milder or more severe disease (stromal infiltration and corneal vascularization).

Clinical characteristics of vitamin A responsive and nonresponsive Bitot's spots

We examined and followed up 59 patients with conjunctival xerosis with a without classic Bitot's spots. Of these, 50 were responsive and nine were unresponsive to vitamin A. Despite a recent World Health Organization classification suggesting otherwise, all cases appeared to represent the same process. In preschool children, the presence of the Bitot's spots on both sides of the corneoscleral limbus or in association with night blindness or punctate keratopathy suggests active vitamin A deficiency. Pigmentation and wrinkling were not useful diagnostic criteria and lesions isolated to the nasal corneoscleral limbus suggested a different diagnosis. At least some cases of nonresponsive conjunctival xerosis and Bitot's spots were probably sequelae of past vitamin A deficiency.

Oral versus intramuscular vitamin A in the treatment of xerophthalmia

In a controlled trial 69 children with corneal xerophthalmia were given 200 000 IU oil-miscible vitamin A by mouth and a matched group of 45 children were given 100 000 IU water-miscible vitamin A intramuscularly. Both groups received an additional oral dose the next day. There was no detectable difference in the clinical response to the two regimes, even when analysis was limited to patients with concomitant diarrhoea or protein-energy malnutrition. Although serum-vitamin-A levels were significantly higher after parenteral than oral therapy, holoretinol-binding-protein levels were not. Oral administration of vitamin A is not only more practical but appears to be just as effective as parenteral administration in the treatment of severe xerophthalmia.

[Glaucoma and the dry eye syndrome]

During the past decade 2,436 patients with primary glaucoma were treated in the Budapest Eye Clinic. Symptoms and/or signs of dry eye syndrome were seen in 108 of them, i.e., 4.43%. In 42 cases these symptoms developed during conservative glaucoma treatment. Strikingly, there were more men among these patients than in the control group of sicca patients without glaucoma and there were less patients with generalized diseases related to keratoconjunctivitis sicca in the group of glaucoma patients with dry eyes. The Schirmer test was positive in a smaller percentage and corneal staining with bengal rose was more frequent in the group of sicca patients with glaucoma than in the group of sicca patients without glaucoma. Most of the glaucoma patients with dry eyes received pilocarpine dropps. The most noteworthy electron-microscopic feature of the bulbar conjunctiva was the reduction in frequency, height and width of the microplicae on the surface of the epithelial cells. The intercellular spaces were enlarged among the superficial cells and vacuoles appeared in their cytoplasm.

Rehabilitation of xeropthalmic children. A follow-up study in southern India

Two hundred and seventy-five children were admitted to the Nutrition Rehabilitation Centre (NRC), Madurai in 1975; 213 had xeropthalmia and 62 showed no eye signs. All were malnourished, the largest single group being less than half their expected weight for age. A follow-up study was made both by means of recall to the NRC and by means of house visits to children of Madurai town. Less than half the total, but 55% of town children were found. The distribution of eye signs on admission in those who were later followed-up, corresponded with that in the total. Weight improved while at the NRC and also after return home. All existing cases of corneal xerosis healed but conjunctival xerosis remained in some. Major corneal damage through ulceration, keratomalacia and scars was present in 94 children at admission, 34 of these were followed-up. Four were blind and five had severely limited vision in both eyes, but useful vision was present in one or both eyes of the other 25 (73%) children. For example, of 15 children found blind in one eye, 13 had good vision in their other. The mortality among xerophthalmic children children while at the NRC was 6.6%, and among those visited later at home was 20%. Almost all mothers questioned, said they gave their children green vegetables, but apart from this very important precept, few other dietary suggestions were followed.

Vitamin A-responsive punctate keratopathy in xerophthalmia

Slit-lamp examination of 78 cases of xerophthalmia and 29 controls matched for age, sex, and locale indicated a direct correlation between the presence, density, and extent of punctate epithelial keratopathy and the severity of corneal and noncorneal involvement. Only 7% (four or 58) of control eyes but 60% (six of ten) of cases with confirmed night blindness, 75% (47 of 63) of eyes with conjunctival xerosis, and all eyes with corneal xerosis (47) were affected. Within one week of high-dose systemic vitamin A therapy all affected corneas had improved. None of ten patients receiving low-dose systemic therapy showed any improvement over a two-month period, whereas 61% of involved corneas actually deteriorated in the interim. Punctate epithelial keraptopathy appears to be the earliest corneal manifestation of xerophthalmia, and is already present in the vast majority of cases classically considered free of corneal involvement.

Topical retinoic acid in the treatment of corneal xerophthalmia

Eight children with corneal xerophthalmia (x2 or x3A) received standard high-protein diets and massive systemic vitamin A therapy. Retinoic acid, 0.1% in oil, was applied daily to one eye, and oil alone to the other. Topical retinoic acid proved safe and effective in speeding corneal healing, especially during the first critical days.

A clinical study of slow-releasing artificial tears

The slow-releasing artificial tear (SR-AT) is a soluble polymer in solid form. Placed in the inferior cul-de-sac and allowed to dissolve, it is used to treat dry-eye patients. The SR-AT was studied in two phases. The short-term cross-over study of 40 patients was completed in October 1976. The long-term open study is still in progress. Of 37 patients who started the long-term study, 18 are still using the inserts-a study retention of 49%.

Slow-release artificial tears and the treatment of keratitis sicca

The slow-release artificial tear (SRAT) is a biodegradable, cellulosic polymer without preservative which is inserted beneath the tarsus of the lower lid, and which provides continuous lubrication and tear film stability to the eye. The SR-AT has been shown to reduce both subjective symptoms and objective signs in patients with keratitis sicca, and is a valuable adjunct to therapy in patients with this disease.

Rose Bengal staining for detection of conjunctival xerosis in nutrition surveys

A hospital cum community based study indicated that rose Bengal staining of the eye could not only confirm clinically diagnosed cases of conjunctival xerosis but also detect those missed by clinical examination. However, some cases thus detected did not respond to a massive oral dose of vitamin A.

A nutrition rehabilitation centre for children with xerophthalmia

A nutrition rehabilitation centre for treatment of children with xerophthalmia was established in Madurai, India. Treatment was based on provision of locally available food, rich in protein and beta-carotene and cheap enough for the families concerned to buy at home. This diet alone, with general medical treatment for other diseases, was sufficient to reverse conjunctival xerophthalmia and corneal xerosis. Children with more severe xerophthalmia received additional vitamin A. The records of 296 children followed up for between two months and three years were analysed. The results of treatment at the centre seemed as good as those produced by more expensive, and usually unobtainable, hospital treatment. Participation of the mother in buying, cooking, and sharing the food given to her child was of some educational value.