Oral versus intramuscular vitamin A in the treatment of xerophthalmia

TFOS Lifestyle: Impact of nutrition on the ocular surface

Nutrients, required by human bodies to perform life-sustaining functions, are obtained from the diet. They are broadly classified into macronutrients (carbohydrates, lipids, and proteins), micronutrients (vitamins and minerals) and water. All nutrients serve as a source of energy, provide structural support to the body and/or regulate the chemical processes of the body. Food and drinks also consist of non-nutrients that may be beneficial (e.g., antioxidants) or harmful (e.g., dyes or preservatives added to processed foods) to the body and the ocular surface. There is also a complex interplay between systemic disorders and an individual's nutritional status. Changes in the gut microbiome may lead to alterations at the ocular surface. Poor nutrition may exacerbate select systemic conditions. Similarly, certain systemic conditions may affect the uptake, processing and distribution of nutrients by the body. These disorders may lead to deficiencies in micro- and macro-nutrients that are important in maintaining ocular surface health. Medications used to treat these conditions may also cause ocular surface changes. The prevalence of nutrition-related chronic diseases is climbing worldwide. This report sought to review the evidence supporting the impact of nutrition on the ocular surface, either directly or as a consequence of the chronic diseases that result. To address a key question, a systematic review investigated the effects of intentional food restriction on ocular surface health; of the 25 included studies, most investigated Ramadan fasting (56%), followed by bariatric surgery (16%), anorexia nervosa (16%), but none were judged to be of high quality, with no randomized-controlled trials.

Vitamin A, systemic T-cells, and the eye: Focus on degenerative retinal disease

The first discovered vitamin, vitamin A, exists in a range of forms, primarily retinoids and provitamin carotenoids. The bioactive forms of vitamin A, retinol and retinoic acid, have many critical functions in body systems including the eye and immune system. Vitamin A deficiency is associated with dysfunctional immunity, and presents clinically as a characteristic ocular syndrome, xerophthalmia. The immune functions of vitamin A extend to the gut, where microbiome interactions and nutritional retinoids and carotenoids contribute to the balance of T cell differentiation, thereby determining immune status and contributing to inflammatory disease around the whole body. In the eye, degenerative conditions affecting the retina and uvea are influenced by vitamin A. Stargardt's disease (STGD1; MIM 248200) is characterised by bisretinoid deposits such as lipofuscin, produced by retinal photoreceptors as they use and recycle a vitamin A-derived chromophore. Age-related macular degeneration features comparable retinal deposits, such as drusen featuring lipofuscin accumulation; and is characterised by parainflammatory processes. We hypothesise that local parainflammatory processes secondary to lipofuscin deposition in the retina are mediated by T cells interacting with dietary vitamin A derivatives and the gut microbiome, and outline the current evidence for this. No cures exist for Stargardt's or age-related macular degeneration, but many vitamin A-based therapeutic approaches have been or are being trialled. The relationship between vitamin A's functions in systemic immunology and the eye could be further exploited, and further research may seek to leverage the interactions of the gut-eye immunological axis.

Visual field decline and restoration following vitamin A therapy for vitamin A deficiency

Purpose

To present a case of nutritional vitamin A deficiency (VAD) that caused bilateral severe dry eye symptoms and progressive visual field contraction over a 13.5-month span resulting in peripheral blindness and nyctalopia, and to document the patient's rapid visual field restoration following vitamin A therapy (VAT).

Observations

A 34-year-old Haitian woman presented for a glaucoma consultation with the following symptoms in both eyes (OU): painful dry eyes, floaters, nyctalopia, and visual field contraction over eighteen months despite treatment with four anti-glaucoma medications and intraocular pressures (IOP) in the low teens OU. The glaucoma diagnosis was eliminated due to slit lamp examination and OCT imaging, which showed an absence of both optic neuropathy and secondary glaucoma features. The patient's symptoms remained consistent with VAD. The patient's visual field decline was restored with significant documented visual field improvement occurring within only 11 days, and complete visual field restoration within 5.5 months of VAT.

Conclusions and Importance

Our case demonstrates the critical role of vitamin A in maintaining ocular health and visual field preservation. To our knowledge, this is the second reported case documenting a patient's visual field decline due to VAD, as well as visual field restoration following enteral VAT. As visual outcomes of VAT are significantly underreported in scientific literature, it is imperative that ophthalmologists are aware of its effects.

Dry Eye Disease and Vitamins: A Narrative Literature Review

Dry eye disease (DED) is a major public health problem worldwide that seriously impairs the quality of life, reduces work productivity, and poses significant economic burden. In DED, tear film instability or hyperosmolarity activates a self-perpetuating vicious cycle that may aggravate ocular surface inflammation and damage. Thus, treatment approaches should focus on interrupting this cycle and ameliorating inflammation. In addition to anti-inflammatory medications, such as corticosteroids, cyclosporine, and lifitegrast, nutrients with anti-inflammatory and anti-oxidative properties may also be effective for the treatment of DED. Evidence indicates that vitamin deficiencies may be associated with an increased risk of DED and that vitamin supplementation can be an effective treatment for DED. In the present review, we introduce the results of clinical and experimental studies on the association between vitamin deficiencies and DED. The potential efficacy of systemic and topical supplementation in the treatment of DED is also discussed.

A Review of Topical and Systemic Vitamin Supplementation in Ocular Surface Diseases

In the homeostasis of the ocular surface, vitamins play a critical role in regulating inflammatory responses and promoting cell differentiation, development and correct function. Systemic vitamin supplementation has been available for many decades; in recent years, thanks to pharmacological advancements, topical vitamin delivery has also become available in an attempt to better treat ocular surface disease (OSD) and dry eye disease (DED). In this paper, we reviewed the current evidence on the role of vitamin supplementation in OSD and DED. We originally searched the PubMed archive, inspected the references and restricted the search to pertinent papers. The body of evidence was evaluated using the amelioration of both signs and symptoms as the outcome, when available. We found that in patients with vitamin deficiency, systemic supplementation of Vitamin A is effective in treating OSD, reducing both DED signs and symptoms. Additionally, systemic supplementation of vitamin D is useful in reducing DED symptoms and increasing tear volume. Vitamin A is also effective in reducing DED signs and symptoms when administered locally. The efficacy of supplementation with other vitamins is still not fully proven. In conclusion, the inclusion of vitamins into the treatment strategies for OSD and DED allows for better treatment customization and better outcomes in these patients.

An Accidental Nutritionist

My career as an accidental nutritionist began with my immersion in cholera control, a cyclone disaster, a smallpox epidemic, and formal training in ophthalmology and epidemiology. Interest in blindness prevention inexplicably led me to (re)pioneer the effects, treatment, and prevention of vitamin A deficiency, while faced with intense criticism by many leading scientists in the nutrition community. The resulting efforts by the World Health Organization and UNICEF in support of programs for the global control of vitamin A deficiency still face vocal opposition by some senior scientists, despite having been estimated to have saved tens of millions of children from unnecessary death and blindness. This entire journey was largely an accident!

INA-RESPOND: a multi-centre clinical research network in Indonesia

Nationally representative observational and translational research is needed to address the public health challenges in Indonesia due to the geographic disparity, recently decentralized health system, and diverse infectious disease priorities. To accomplish this, the Indonesian Ministry of Health in collaboration with the US National Institute of Health has established INA-RESPOND (Indonesia Research Partnership on Infectious Disease) – a clinical research network comprising 9 referral hospitals, 7 medical faculties, and 2 research centres across Indonesia. The network provides a forum to conduct research at a national scale and to address scientific questions that would be difficult to address in smaller research settings. Further, it is currently conducting multi-centre research on the etiologies of fever, sepsis, and tuberculosis. There are opportunities to leverage existing network resources for other public health research needs. INA-RESPOND is an Indonesian-led network in a country with diverse population groups and public health needs which is poised to collaborate with researchers, universities, donors, and industry worldwide. This paper describes the network and its goals and values, as well as the management structure, process for collaboration, and future vision.

Vitamin a deficiency and clinical disease: an historical overview

Vitamin A deficiency has a plethora of clinical manifestations, ranging from xerophthalmia (practically pathognomonic) to disturbances in growth and susceptibility to severe infection (far more protean). Like other classical vitamin deficiency states (scurvy, rickets), some of the signs and symptoms of xerophthalmia were recognized long ago. Reports related to vitamin A and/or manifestations of deficiency might conveniently be divided into "ancient" accounts; eighteenth to nineteenth century clinical descriptions (and their purported etiologic associations); early twentieth century laboratory animal experiments and clinical and epidemiologic observations that identified the existence of this unique nutrient and manifestations of its deficiency; and, most recently, a flowering of carefully conducted clinical studies and field-based randomized trials that documented the full extent and impact of deficiency among the poor of low- and middle-income countries, which in turn changed global health policy.

Alcohol, vitamin A, and beta-carotene: adverse interactions, including hepatotoxicity and carcinogenicity

Isozymes of alcohol and other dehydrogenases convert ethanol and retinol to their corresponding aldehydes in vitro. In addition, new pathways of retinol metabolism have been described in hepatic microsomes that involve, in part, cytochrome P450s, which can also metabolize various drugs. In view of these overlapping metabolic pathways, it is not surprising that multiple interactions between retinol, ethanol, and other drugs occur. Accordingly, prolonged use of alcohol, drugs, or both, results not only in decreased dietary intake of retinoids and carotenoids, but also accelerates the breakdown of retinol through cross-induction of degradative enzymes. There is also competition between ethanol and retinoic acid precursors. Depletion ensues, with associated hepatic and extrahepatic pathology, including carcinogenesis and contribution to fetal defects. Correction of deficiency through vitamin A supplementation has been advocated. It is, however, complicated by the intrinsic hepatotoxicity of retinol, which is potentiated by concomitant alcohol consumption. By contrast, beta-carotene, a precursor of vitamin A, was considered innocuous until recently, when it was found to also interact with ethanol, which interferes with its conversion to retinol. Furthermore, the combination of beta-carotene with ethanol results in hepatotoxicity. Moreover, in smokers who also consume alcohol, beta-carotene supplementation promotes pulmonary cancer and, possibly, cardiovascular complications. Experimentally, beta-carotene toxicity was exacerbated when administered as part of beadlets. Thus ethanol, while promoting a deficiency of vitamin A also enhances its toxicity as well as that of beta-carotene. This narrowing of the therapeutic window for retinol and beta-carotene must be taken into account when formulating treatments aimed at correcting vitamin A deficiency, especially in drinking populations.

Ophthalmologic effects of bowel disease

Ocular findings in diseases affecting primarily the digestive tract are relatively rare; however, it is important for the physician to recognize these relationships, appropriately uncover symptoms related to the eye disease, and have the patient evaluated by an ophthalmologist if indicated. In addition, ocular inflammation may be the first indication of bowel disease (e.g., uveitis in Crohn's disease). This article describes the associations between ocular diseases and gastrointestinal diseases and their causes, signs, symptoms, prognosis, and treatment.

Xerophthalmia and vitamin A status

The existence of 'fat-soluble A' has been known for over 80 years. But until recently clinicians were almost wholly absorbed by the ocular changes accompanying deficiency (xerophthalmia), and scientists with the vitamin's metabolic role in the rhodopsin cycle. The past two decades have witnessed a revolution in clinical and scientific concerns. Xerophthalmia is now recognized as a late manifestation of severe deficiency rather than of early, mild deficiency; as the mechanism responsible for half or more of all measles-associated blindness; and as the cause of half a million or more cases of pediatric blindness worldwide. Milder deficiency increases the severity of infectious morbidity, exacerbates iron deficiency anemia, retards growth, and is responsible for one to three million childhood deaths each year. Scientists are now busy unraveling vitamin A-dependent gene regulation to explain the myriad manifestations accompanying deficiency, while clinicians are designing and supervising programs to improve vitamin A status in over 60 countries, up from only three countries two decades ago. Control of vitamin A deficiency is now a major health challenge and goal of both UNICEF and the World Health Organization (WHO). Reaching that goal requires better parameters for assessing vitamin A status, increased understanding of metabolic pathways responsible for corneal dissolution (keratomalacia) and the molecular and cellular basis by which vitamin A status mediates resistance to infection. These issues are detailed elsewhere (Sommer and West, 1996).

Serum vitamin A in relation to socio-economic, demographic and dietary characteristics in Bangladeshi children

The purpose of this study was to examine socio-economic conditions, demographic factors, use of vitamin A capsules and dietary practices in relation to the risk of low serum vitamin A. One hundred and twenty four night blind cases were identified by parents in a cross-sectional survey in Bangladesh in 1992. Age-, sex- and neighbourhood-matched controls were selected. Venous blood was collected from 87 cases and 97 controls for the determination of serum vitamin A. Information about socio-economic conditions, demographic factors, use of vitamin A capsules and dietary practices was obtained by interview. The level of serum vitamin A was strongly related to age and consumption of beta-carotene rich foods. The preschool years (2-6 years) are important risk periods for vitamin A deficiency among children. We conclude that long-term prevention of vitamin A deficiency should rely on efforts to improve local diet.

Plasma retinol level, vitamin A supplementation and acute respiratory infections in children of 1-5 years old in a developing country. Respiratory Diseases Working Group

STUDY OBJECTIVE

To evaluate the relationship between vitamin A supplementation, plasma retinol level (PRL) and incidence, severity and duration of acute respiratory infect ions (ARI) in children 1-5 years old.

DESIGN AND SETTING

A one year prospective randomized intervention study from June 1989 to May 1990 in Cikutra, a suburb of Bandung, Indonesia.

SUBJECTS AND MEASUREMENTS

Out of almost 2000 children aged 12-54 months, 269 were selected by stratified randomization. Vitamin A (200,000 IU orally) was administered at 6-monthly intervals in a double blind, placebo controlled programme. Every 2 weeks, primary health care workers collected data on respiratory symptoms in the children, and every month a pediatrician examined the children. Venous blood samples were obtained at the start and at 3 and 6 months for plasma retinol levels (PRL).

RESULTS

The mean PRL at the start of the study was 20 +/- 8 micrograms/dl; 8% of the children showed a deficient level of less than 10 micrograms/dl. The incidence or ARI was 6.7 +/- 3.5 episodes per child per year with a mean duration of 5.3 +/- 3.1 days per episode. In vitamin A supplemented children the duration of ARI was slightly shorter (5.2 +/- 3.1 versus 5.6 +/- 3.1 days, P < 0.01) but no effect on the incidence or severity of ARI was detected. Low, and especially deficient, PRL had improved after 3 months and even after 6 months, but this was unrelated to vitamin A supplementation. There was also no relationship between PRL and incidence, severity or duration of ARI.

CONCLUSIONS

Only a slight relationship is found between vitamin A supplementation and ARI duration in under-fives.

Impact of massive dose of vitamin A given to preschool children with acute diarrhoea on subsequent respiratory and diarrhoeal morbidity

OBJECTIVE

To assess the impact of vitamin A supplementation on morbidity from acute respiratory tract infections and diarrhoea.

DESIGN

Double blind randomised placebo controlled field trial.

SETTING

An urban slum area in New Delhi, India.

SUBJECTS

900 children aged 12-60 months attending a local health facility for acute diarrhoea of less than seven days' duration randomly allocated to receive vitamin A 200,000 IU or placebo.

MAIN OUTCOME MEASURES

Incidence and prevalence of acute lower respiratory tract infections and diarrhoea during the 90 days after termination of the enrolment diarrhoeal episode measured by twice weekly household surveillance.

RESULTS

The incidence (relative risk 1.07; 95% confidence interval 0.92 to 1.26) and average number of days spent with acute lower respiratory tract infections were similar in the vitamin A supplementation and placebo groups. Among children aged 23 months or less there was a significant reduction in the incidence of measles (relative risk 0.06; 95% confidence interval 0.01 to 0.48). The incidence of diarrhoea was also similar (relative risk 0.95; 0.86 to 1.05) in the two groups. There was a 36% reduction in the mean daily prevalence of diarrhoea associated with fever in the vitamin A supplemented children older than 23 months.

CONCLUSIONS

Results were consistent with a lack of impact on acute lower respiratory tract related mortality after vitamin A supplementation noted in other trials and a possible reduction in the severity of diarrhoea.

Pharmacokinetic modelling of the plasma concentration-time profile of the vitamin retinyl palmitate following intramuscular administration

Seven healthy male volunteers (21-24 y) received by the ventro-gluteal route a single dose of 100,000 I.U. of the vitamin retinyl palmitate (RP) in a water-miscible preparation (W) and 5 weeks later the same dose in an oily solution (S). After administration of W median (range) peak plasma concentrations of 5.6 (4.4-8.7). 10(3) micrograms l-1 were reached after 12 h and high levels persisted for another 50 h. At 144 h levels were still, by a factor 3, higher than baseline. Plasma levels of RP after S remained close to baseline (20-50 micrograms.l-1) suggesting negligibly low bioavailability. The plasma level profile of RP after W could well be described by use of a one-compartment model with Weibull-type absorption and Michaelis-Menten elimination. The median (range) absolute bio-availability (estimates of lower limits) was 42 (32-52) per cent.

Xerophthalmia, keratomalacia and nutritional blindness

Vitamin A deficiency remains a major cause of pediatric ocular morbidity. Over five million children develop xerophthalmia annually, a quarter million or more becoming blind. It is also a major pathway for measles-associated blindness, particularly in Africa. Treatment is practical and inexpensive, based upon the oral administration of 200,000 IU vitamin A on two successive days, at a cost of 10 cents U.S. Given the potential rapidity of corneal necrosis (keratomalacia) and the relative inaccessibility of health services to those at greatest risk, prevention is probably more important than treatment. Oral administration of high dose supplements (2000,000 IU every 3 to 6 months), vitamin A fortification of commonly consumed items, or best of all, increased dietary intake of natural sources of vitamin A will reduce the number of needlessly blind young children. Given recent evidence that vitamin A deficiency greatly increases overall mortality, even among children without evidence of xerophthalmia, the same prophylactic regimen may improve child survival by 35% or more.

Vitamin A deficiency. New knowledge on diagnosis, consequences and therapy

Due to the rapid development of biochemical analyses in the last 10 years different substances like vitamin A, with an apparent clarified metabolism and action, were re-estimated. As a result, new knowledge was presented which could be essential for human health. Some details and consequences are reviewed in this paper. Marginal deficiency, which also may occur in industrialized nations, cannot be determined with certainty by usual blood analyses. The reasons for marginal deficiency are either different diseases or unbalanced nutrition. From epidemiological research it is argued that low vitamin A intake is associated with a higher incidence of cancer in different tissues. However, vitamin A may lead by over-dosing to toxic side effects. There exists a possibility that vitamin A is teratogenic also in humans. Thus, for safety reasons, woman who can become pregnant should not be advised to supplement the vitamin more than twice the RDA of the US Food and Nutrition Board for pregnant women (10,000 I.U./day) if there is no clear-cut indication. On the other hand there are indications that malformations may also caused by vitamin A deficiency.

International Commission for Protection against Environmental Mutagens and Carcinogens. ICPEMC Working Paper No. 15/2. Metabolism and metabolic effects of ethanol, including interaction with drugs, carcinogens and nutrition

Different pathways of alcohol metabolism, the alcohol dehydrogenase pathway, the microsomal ethanol-oxidizing system and the catalase pathway are discussed. Alcohol consumption leads to accelerated ethanol metabolism by different mechanisms including an increased microsomal function. Microsomal induction leads to interactions of ethanol with drugs, hepatotoxic agents, steroids, vitamins and to an increased activation of mutagens/carcinogens. A number of ethanol-related complications may be explained by the production of its first metabolite, acetaldehyde, such as alterations of mitochondria, increased lipid peroxidation and microtubular alterations with its adverse effects on various cellular activities, including disturbances of cell division. Nutritional factors in alcoholics such as malnutrition are discussed especially with respect to its possible relation to cancer.

Impact of vitamin A supplementation on childhood mortality. A randomised controlled community trial

450 villages in northern Sumatra were randomly assigned to either participate in a vitamin A supplementation scheme (n = 229) or serve for 1 year as a control (n = 221). 25 939 preschool children were examined at baseline and again 11 to 13 months later. Capsules containing 200 000 IU vitamin A were distributed to preschool children aged over 1 year by local volunteers 1 to 3 months after baseline enumeration and again 6 months later. Among children aged 12-71 months at baseline, mortality in control villages (75/10 231, 7.3 per 1000) was 49% greater than in those where supplements were given (53/10 919, 4.9 per 1000) (p less than 0.05). The impact of vitamin A supplementation seemed to be greater in boys than in girls. These results support earlier observations linking mild vitamin A deficiency to increased mortality and suggest that supplements given to vitamin A deficient populations may decrease mortality by as much as 34%.

Effects of vitamin A deficiency on the ocular surface

Vitamin A deficiency remains an important cause of ocular morbidity among patients with chronic liver disease and lipid malabsorption, and is a major cause of blindness in developing countries. Early ocular surface changes include keratinization of the conjunctiva and development of superficial punctate keratopathy. More severe deficiency results in corneal keratinization, ulceration, and necrosis. Vitamin A is necessary for normal differentiation of nonsquamous epithelium; keratinization is a direct consequence of its deficiency. Exposure exacerbates the process and surface phenomena, especially localized drying from loss of mucus-secreting goblet cells, reduced aqueous tear production, and irregularities of the keratinized surface may all contribute to stromal melting, which can occur in the absence of inflammatory infiltration or bacterial invasion. Surface abnormalities respond rapidly to systemic vitamin A. Significantly, corneal changes disappear long before the reappearance of goblet cells. Inflammation sometimes masks or reverses the xerotic process.

Treatment of corneal xerophthalmia with topical retinoic acid

Retinoic acid 0.1% in arachis oil was applied to one eye and arachis oil alone to the other eye, of each of 19 patients with equivalent degrees of corneal xerophthalmia in the fellow eyes. Even with concomitant systemic vitamin A therapy, topical retinoic acid was associated with more rapid healing of corneal lesions in a substantial proportion of cases. Application of retinoic acid three times a day produced no significant side effects; application five times a day, however, resulted in moderate to severe conjunctival injection and increased corneal vascularization and scarring.

Hepatic fibrosis after long-term administration of ethanol and moderate vitamin A supplementation in the rat

Rats were fed up to 9 months diets supplemented with vitamin A in an amount that, by itself, had no apparent adverse effect on the liver. When associated with chronic ethanol administration, vitamin A supplementation strikingly exacerbated ethanol-induced abnormalities: fat accumulation was increased and numerous giant mitochondria were observed. Furthermore, lesions appeared which ethanol alone does not produce in rats, namely necrosis, inflammation, and fibrosis. Vitamin A supplementation increased the number of fat storing cells (lipocytes) which positively correlated with vitamin A accumulation in the liver. However, when vitamin A supplementation was combined with ethanol administration, vitamin A levels in the liver and the number of fat storing cells decreased and numerous myofibroblasts appeared in association with abundant collagen fibers. There was also hepatic inflammation and necrosis, accompanied by a rise in serum glutamate dehydrogenase, SGOT, and SGPT and a decrease in retinol binding protein and vitamin A. We conclude that amounts of vitamin A, which by themselves appear harmless, may produce severe liver lesions when associated with chronic ethanol consumption.

Goblet cell response to vitamin A treatment for corneal xerophthalmia

In 11 patients with active corneal xerophthalmia, conjunctival biopsies were obtained at various intervals after massive-dose systemic vitamin A therapy. Goblet cells began to repopulate the inferonasal quadrant of the conjunctivas after two weeks, and they reached normal concentrations after one month. Corneal healing proceeded much more rapidly than that, suggesting that a full complement of mucus-secreting conjunctival goblet cells is not essential for restoration and maintenance of normal corneal appearance.

Tear production in vitamin A-responsive xerophthalmia

Schirmer tests showed decreased tearing (less than 15 mm of wetting) in 32 of 54 eyes (59%) of a representative group of patients with corneal xerophthalmia but in only four of 60 eyes (7%) of age-, sex-, and neighborhood-matched controls (P less than .001). The occurrence of decreased tearing was directly related to protein status: eight of 18 eyes (44%) of children with serum transferrin levels below 50 mg/100 ml but only 13 of 62 eyes (21%) of children with higher levels produced less than 15 mm of wetting (P less than .01). Among otherwise well-nourished children, the occurrence of decreased tearing was directly related to the severity of xerophthalmia and thus to vitamin A status. We found decreased tearing in eight of 86 eyes (9%) of a group of unpaired controls, in nine of 38 eyes (24%) of children with conjunctival xerosis, and in 17 of 62 eyes (27%) of children with corneal involvement (P less than .01).