Xerophthalmia secondary to alcohol-induced malnutrition

TFOS Lifestyle: Impact of lifestyle challenges on the ocular surface

Many factors in the domains of mental, physical, and social health have been associated with various ocular surface diseases, with most of the focus centered on aspects of dry eye disease (DED). Regarding mental health factors, several cross-sectional studies have noted associations between depression and anxiety, and medications used to treat these disorders, and DED symptoms. Sleep disorders (both involving quality and quantity of sleep) have also been associated with DED symptoms. Under the domain of physical health, several factors have been linked to meibomian gland abnormalities, including obesity and face mask wear. Cross-sectional studies have also linked chronic pain conditions, specifically migraine, chronic pain syndrome and fibromyalgia, to DED, principally focusing on DED symptoms. A systematic review and meta-analysis reviewed available data and concluded that various chronic pain conditions increased the risk of DED (variably defined), with odds ratios ranging from 1.60 to 2.16. However, heterogeneity was noted, highlighting the need for additional studies examining the impact of chronic pain on DED signs and subtype (evaporative versus aqueous deficient). With respect to societal factors, tobacco use has been most closely linked to tear instability, cocaine to decreased corneal sensitivity, and alcohol to tear film disturbances and DED symptoms.

Sequential endogenous endophthalmitis, fungal keratitis, bacteremia and vertebral osteomyelitis in a person who injects drugs

Purpose

To describe multiple ocular (and non-ocular) manifestations of disease that can present in a person who injects drugs (PWID). We report a case of a patient consecutively presenting across multiple visits to an ambulatory eye care clinic as the initial point of contact for endogenous endophthalmitis, fungal keratitis, bacteremia, and psoas abscess with vertebral osteomyelitis within a matter of weeks.

Observations

A 51-year-old male with past medical history of alcohol use disorder and injection drug use was initially seen in an eye clinic three days after suffering vision loss in the left eye associated with floaters, photophobia, and eye pain. After initial workup and treatment for panuveitis, endogenous endophthalmitis was suspected. A pars plana vitrectomy was performed, and intravitreal medications were given. A pathogen was never isolated from vitreous samples. Two weeks later, the patient presented with complaints of pain, blurry vision, and foreign body sensation in his opposite (right) eye. Examination revealed a corneal ulcer later identified as a Paecliomyces fungal infection. Two weeks after this, he developed fever, chills, and right-sided flank pain radiating to his testicles. Following evaluation by the emergency department and subsequent hospitalization after bacteremia was noted, he was found to have a right-sided psoas abscess with lumbar vertebral osteomyelitis. Fluid was drained, cultured, and grew methicillin-sensitive Staphylococcus aureus (MSSA). At his last visit, his best-corrected visual acuity was 20/20 OS and 20/30 OD despite central corneal scarring. It was only after hospitalization that he affirmed recent injection drug use, despite being queried about it through the course of his infections.

Conclusions and importance

Injection drug use is an increasingly common concern for all healthcare providers as the opioid crisis in the United States remains widespread. This case highlights multiple potential infectious processes which may impact persons who inject drugs when seen by eye care providers. It also describes difficulties in caring for people who inject drugs who may not provide critical and timely information relating to their injection drug use and/or may delay care even when faced with potentially vision- and/or life-threatening conditions.

Xerophthalmia and Its Associated Factors among School-Age Children in Amba Giorgis Town, Northwest Ethiopia, 2018

INTRODUCTION

Xerophthalmia is a general term applied to all the ocular manifestations from night blindness through complete corneal destruction (keratomalacia) due to vitamin A deficiency. Xerophthalmia is the main contributing factors for childhood blindness in developing countries. However, there is limited evidence that can implicate the current situation. This study aimed to determine the magnitude of xerophthalmia and associated factors among school-age children in Northwest Ethiopia.

METHODS

A community-based cross-sectional study was conducted on 490 children, age range of 6 to 12 years. The study participants were selected through systematic random sampling method. Data were collected using a pretested structured questionnaire and ophthalmic examination with different ophthalmic instruments. The analyzed result was summarized and presented using descriptive statistics. Binary logistic regression was used to determine the factors associated with xerophthalmia. Variables with a p value of <0.05 in the multivariable logistic regression analysis were considered as statistically significant.

RESULTS

A total of 484 study participants with a response rate of 98.8 were involved in this study, and their median age was 8 years with IQR of 4 years. The prevalence of xerophthalmia was 8.26% (95% CI: 5.8, 10.7). Family income less than 1000 Ethiopian birr (AOR = 4.65, 95% CI: 1.31, 16.4), presence of febrile illness (AOR = 2.8, 95% CI: 1.49, 6.11), poor consumption of fruits and vegetables (AOR = 3.18, 95% CI: 1.30, 7.80), and nonimmunized status (AOR = 3.43, 95% CI: 1.49, 7.89) were significantly associated with xerophthalmia.

CONCLUSIONS AND RECOMMENDATIONS

The prevalence of xerophthalmia was high as compared to the World Health Organization criteria for public health significance. Factors identified for xerophthalmia in this study are low income, the poor dietary practice of fruits and vegetables, and the presence of febrile illness and not immunized. Hence, it is a public problem that needs attention.

Vitamin A Deficiency Presenting with 'Itchy Eyes'

We present the case of an 88-year-old female living in metropolitan Melbourne, Australia who developed vitamin A deficiency manifesting as ‘itchy eyes’ due to a bizarre dietary habit. Slit lamp examination revealed Bitot's spots and a subsequent vitamin A serum level test revealed severe deficiency. An electroretinogram showed grossly reduced a- and b-wave amplitudes consistent with generalised rod and cone dysfunction - these parameters showed marked improvement 5 months post supplementation. This case highlights the presence of vitamin A deficiency in the developed world and that a careful dietary history should be taken when assessing a patient complaining of ‘itchy eyes’. Timely diagnosis and treatment may result in dramatic resolution of symptoms and signs as well as prevention of serious morbidity.

Acquired night blindness due to bad eating patterns

We report a case of acquired night blindness in a developed country (Spain) without risk factors for nutritional deficiency disease or family history of hereditary retinal disease. A 76-year-old woman presented with acquired night blindness of 6-month progression. After a thorough inquiry about eating patterns she becomes suspicious of vitamin A low dietary intake, which is analytically confirmed and successfully treated. Despite being very uncommon in our environment and even more in patients without digestive problems, in a patient reporting acquired night blindness vitamin A deficiency should not be discarded until eating patterns have been investigated. It might be especially relevant in certain socioeconomic situations and eating disorders such as bulimia or anorexia nervosa.

Night blindness and Crohn's disease

Signs of malnutrition are common clinical features in Crohn's disease; and bowel resection, commonly needed in these cases, can aggravate malnutrition. These patients are at risk of developing vitamin A deficiency, which can lead to night blindness. We present a 60-year-old male, with history of Crohn's disease and multiple resections for strictures and fistulas leading to short bowel syndrome, with progressive bilateral loss of night vision (nyctalopia). Serum vitamin A level was markedly depleted (11 µg/dL, reference 20-120 µg/dL), and full-field electroretinogram testing demonstrated extinguished scotopic (rod function) responses and decreased amplitudes of photopic responses on 30 Hz flicker (cone function). He was started on vitamin A supplementation (initially intramuscular). His vitamin A level was back to normal (78 µg/dL), and night vision problems subjectively improved. Patients with Crohn's disease should be inquired about night vision problems. The presence of nyctalopia should prompt vitamin A level measurement and ophthalmology referral for further evaluation.

Xerophthalmia--a potential epidemic on our doorstep?

PURPOSE

Xerophthalmia refers to the ocular manifestations associated with vitamin A deficiency, including xerosis, keratomalacia, nyctalopia and Bitot's spot. Hypovitaminosis A is well-recognised in developing countries, but is rare in the developed world. Most cases in the latter relate to fat malabsorption. Conditions in which vitamin A metabolism or storage is deranged (chronic liver disease, including alcoholism) are also aetiologies. We wanted to see whether this was common in our department.

METHODS

Oral vitamin A supplements were given to patients who presented with hypovitaminosis A.

RESULTS

All patients were found to have hypovitaminosis A on biochemical testing and responded dramatically to oral vitamin A supplementation, resulting in an improved final visual outcome.

DISCUSSION

This series demonstrates that prompt recognition and treatment of xerophthalmia can lead to rapid recovery and avert significant visual morbidity. The prevalence of xerophthalmia is likely to increase in the developed world largely owing to alcoholic liver disease. It is thought by some that we are on the verge of a potential epidemic. We hope that by increasing the profile of this important public health issue, we may be able to influence future prevalence of hypovitaminosis.

The adverse effects of alcohol on vitamin A metabolism

The objective of this review is to explore the relationship between alcohol and the metabolism of the essential micronutrient, vitamin A; as well as the impact this interaction has on alcohol-induced disease in adults. Depleted hepatic vitamin A content has been reported in human alcoholics, an observation that has been confirmed in animal models of chronic alcohol consumption. Indeed, alcohol consumption has been associated with declines in hepatic levels of retinol (vitamin A), as well as retinyl ester and retinoic acid; collectively referred to as retinoids. Through the use of animal models, the complex interplay between alcohol metabolism and vitamin A homeostasis has been studied; the reviewed research supports the notion that chronic alcohol consumption precipitates a decline in hepatic retinoid levels through increased breakdown, as well as increased export to extra-hepatic tissues. While the precise biochemical mechanisms governing alcohol's effect remain to be elucidated, its profound effect on hepatic retinoid status is irrefutable. In addition to a review of the literature related to studies on tissue retinoid levels and the metabolic interactions between alcohol and retinoids, the significance of altered hepatic retinoid metabolism in the context of alcoholic liver disease is also considered.