Improvement in visual function and fundus findings for a patient with vitamin A-deficient retinopathy

Case Report: Nyctalopia Due to Severe Liver Cirrhosis-induced Vitamin A Deficiency

SIGNIFICANCE

Vitamin A is a micronutrient critical for retinal function. Patients with a deficiency may notice a progressive decline in night vision as rod photoreceptors become unable to regenerate rhodopsin. Although uncommon in developed nations, vitamin A deficiency should be considered in symptomatic patients with chronic, severe liver disease.

PURPOSE

This report presents a rare case of night blindness secondary to poor vitamin A metabolism due to severe liver cirrhosis.

CASE REPORT

A 62-year-old White woman presented with progressively worsening vision in dim lighting over the past 6 to 8 months. She was asymptomatic in daylight but "blind in the dark" to the extent that she was afraid to go outside at night. She had no personal or family history of night blindness or retinal disorders. Ocular health was unremarkable with dilation. Given her medical history of severe nonalcoholic liver cirrhosis, malabsorption of vitamin A was suspected and subsequently confirmed by the very low vitamin A level in her serum analysis. The patient was sent to endocrinology for evaluation, and appropriate repletion therapy was implemented. Subjective improvement in symptoms, along with better performance on visual field testing, was noted after initiating oral vitamin A supplementation for 5 months.

CONCLUSIONS

Although vitamin A deficiency is a relatively rare disorder in the United States, it should be suspected in patients with severe liver disease or other conditions causing malabsorption who experience a loss of night vision.

Bilateral compressive optic neuropathy and outer retinopathy due to optic canal hyperostosis in a child with isolated vitamin a deficiency

PURPOSE

Vitamin A plays a crucial role in rod phototransduction, with deficient levels manifesting as night blindness. Animal models have demonstrated bone dysplasia in the setting of hypovitaminosis A. We present a rare case of bony overgrowth leading to bilateral compressive optic neuropathy, combined with outer retinopathy, in a paediatric patient secondary to isolated vitamin A deficiency.

METHODS

A single case report was conducted from Toronto, Canada.

RESULTS

A 12-year-old boy with known autism spectrum disorder presented with a 9-month history of progressive painless vision loss. Vision was 20/300 and hand motion in the right and left eye, respectively. Fundus photography demonstrated bilateral optic atrophy and yellow lesions notably in the right eye far periphery. Optical coherence tomography (OCT) imaging demonstrated thinning of the retinal nerve fibre layer, alterations in the ellipsoid zone, as well as retinal pigment epithelium deposits. Computed tomography imaging demonstrated sphenoid bone thickening with narrow optic canals and moderate optic atrophy bilaterally. Full-field electroretinogram (ERG) demonstrated mildly reduced dark adapted (DA) 0.01 b-wave amplitudes and electronegative configuration of DA 3.0 and DA 10.0 ERG; the light adapted ERGs were normal. The patient was treated with pulse vitamin A therapy. Subsequently, the DA ERG normalized, outer retinal changes reversed and vision stabilised; no surgical intervention was conducted.

CONCLUSION

This case represents a rare presentation of compressive optic neuropathy with concomitant outer retinopathy secondary to isolated vitamin A deficiency. Despite improvement in outer retinal integrity on OCT imaging and ERG testing results following vitamin A supplementation, no functional improvement was obtained due to severe optic atrophy.

Posterior placoid-like maculopathy and macular hole associated with vitamin A deficiency

Purpose

To report a case of bilateral posterior placoid-like maculopathy and a macular hole associated with vitamin A deficiency.

Observations

A 72-year-old male presented with nyctalopia and progressive vision loss in both eyes. Examination and multimodal imaging were consistent with posterior placoid-like maculopathy bilaterally and a macular hole in the right eye. A workup for infectious, inflammatory, and paraneoplastic etiologies revealed a severely low serum vitamin A level. Two months after initiation of vitamin A repletion, there was improvement in best-corrected Snellen visual acuity as well as macular hole closure. A diagnosis of posterior placoid-like maculopathy in the setting of vitamin A deficiency (VAD) was made.

Conclusions and importance

VAD should be considered when symmetric posterior pole placoid-like lesions are observed and other, more common etiologies have been ruled out.

DISRUPTION OF THE OUTER SEGMENTS OF THE PHOTORECEPTORS ON OPTICAL COHERENCE TOMOGRAPHY AS A FEATURE OF VITAMIN A DEFICIENCY

PURPOSE

To describe the optical coherence tomography features of vitamin A deficiency.

METHODS

Case series includes three male patients aged 50 to 66 years with vitamin A deficiency and visual symptoms ranging from 2 to 8 months. Examination included optical coherence tomography (OCT), fundus autofluorescence imaging, full-field electroretinography6 and laboratory work-up.

RESULTS

Patient 1 had inoperable pancreatic neuroendocrine tumor and presented with worsening nyctalopia. The electroretinography showed absent rod function 2 months after the onset of symptoms, followed by a decrease of the cone function eight months after the onset. Optical coherence tomography showed poorly distinguishable outer segments of the photoreceptors with the disappearance of the interdigitation zone. At that time, vitamin A deficiency along with several other deficiencies was confirmed. After the initiation of parenteral nutrition, a substantial improvement of the patient's overall well-being was noted and the OCT showed normalization of the retinal structure. Two other patients were diagnosed with vitamin A deficiency based on similar OCT features.

CONCLUSION

Disruption of the outer segments of the photoreceptors and the disappearance of the interdigitation zone on OCT may be helpful in recognition of vitamin A deficiency. Early detection and malnutrition evaluation are especially important in patients with a history of gastrointestinal disorders who may have several other underlying deficiencies. Treatment with either enteral or parenteral nutrition not only leads to resolution of visual symptoms but vastly improves their general condition and quality of life.

Large Benefit from Simple Things: High-Dose Vitamin A Improves RBP4-Related Retinal Dystrophy

Inherited retinal diseases (IRD) are a group of heterogeneous disorders, most of which lead to blindness with limited therapeutic options. Pathogenic variants in RBP4, coding for a major blood carrier of retinol, retinol-binding protein 4, are responsible for a peculiar form of IRD. The aim of this study was to investigate if retinal function of an RBP4-related IRD patient can be improved by retinol administration. Our patient presented a peculiar white-dot retinopathy, reminiscent of vitamin A deficient retinopathy. Using a customized next generation sequencing (NGS) IRD panel we discovered a novel loss-of-function homozygous pathogenic variant in RBP4: c.255G >A, p.(Trp85*). Western blotting revealed the absence of RBP4 protein in the patient’s serum. Blood retinol levels were undetectable. The patient was put on a high-dose oral retinol regimen (50,000 UI twice a week). Subjective symptoms and retinal function markedly and sustainably improved at 5-months and 1-year follow-up. Here we show that this novel IRD case can be treated by oral retinol administration.

The Role of Vitamin A in Retinal Diseases

Vitamin A is an essential fat-soluble vitamin that occurs in various chemical forms. It is essential for several physiological processes. Either hyper- or hypovitaminosis can be harmful. One of the most important vitamin A functions is its involvement in visual phototransduction, where it serves as the crucial part of photopigment, the first molecule in the process of transforming photons of light into electrical signals. In this process, large quantities of vitamin A in the form of 11-cis-retinal are being isomerized to all-trans-retinal and then quickly recycled back to 11-cis-retinal. Complex machinery of transporters and enzymes is involved in this process (i.e., the visual cycle). Any fault in the machinery may not only reduce the efficiency of visual detection but also cause the accumulation of toxic chemicals in the retina. This review provides a comprehensive overview of diseases that are directly or indirectly connected with vitamin A pathways in the retina. It includes the pathophysiological background and clinical presentation of each disease and summarizes the already existing therapeutic and prospective interventions.

Acquired night blindness due to rod dysfunction after long-term hemodialysis

PURPOSE

To report the clinical findings in 6 patients who developed night blindness after long-term hemodialysis.

STUDY DESIGN

Retrospective case series.

PATIENTS AND METHODS

The medical charts of the 6 patients were examined. The fundus photographs, spectral-domain optical coherence tomographic (SD-OCT) images, full-field ERGs, and blood chemistry panels were analyzed.

RESULTS

The mean age of the 6 patients (4 men) at the time of diagnosis was 69.1 ± 5.9 years. The mean duration of the hemodialysis was 21.8 ± 13.4 years (7-41 years). The visual acuity of the patients was preserved at 20/30 or better except in 1 eye. Ophthalmoscopy showed white flecks that were scattered over the midperipheral retina in all the eyes. SD-OCT showed mild macular degeneration in 5 eyes. The scotopic ERGs elicited by dim flashes were absent, and those elicited by bright flashes had negative waveforms. The photopic ERGs were relatively well preserved. These data indicated a rod-specific dysfunction that may account for the night blindness. The plasma concentration of vitamin A was within the normal range in 4 of the patients and slightly lower than the normal limit in 1 of the patients. Administration of vitamin A was performed for 1 patient, and the symptom of night blindness and scotopic ERGs were improved 3 months later.

DISCUSSION

Long-term hemodialysis can be associated with the night blindness that may be caused by vitamin A deficiency, even though the plasma concentration of vitamin A in these patients was within the normal range.

Shared Features in Retinal Disorders With Involvement of Retinal Pigment Epithelium

When using spectral domain optical coherence tomography (SD-OCT) to inform the status of outer retina, we have noted discrete hyperreflective lesions extending through photoreceptor-attributable bands that have a similar presentation in multiple retinal diseases. These lesions present as either corrugated thickenings of interdigitation zone and ellipsoid zone bands or in later stages as rectangular or pyramidal shaped foci that extend radially through photoreceptor cell-attributable bands. In ABCA4-related and peripherin-2/RDS-disease (PRPH2/RDS), monogenic forms of retinopathy caused by mutations in proteins expressed in photoreceptor cells, these punctate lesions colocalize with fundus flecks in en face images. In fundus albipunctatus and retinitis punctata albescens, diseases caused by mutations in genes (retinol dehydrogenase 5, RDH5; and retinaldehyde-binding protein 1, RLBP1) encoding proteins of the visual cycle, these lesions manifest as white dot-like puncta. Similar aberrations in photoreceptor cell-attributable SD-OCT reflectivity layers manifest as reticular pseudodrusen (RPD) in short-wavelength fundus autofluorescence and near-infrared fundus autofluorescence fundus images and are linked to age-related macular degeneration a complex disease. Despite differences in the etiologies of retinal diseases presenting as fundus flecks, dots and RPD, underlying degenerative processes in photoreceptor cells are signified in SD-OCT scans by the loss of structural features that would otherwise define healthy photoreceptor cells at these foci.

Eye disorders in patients with celiac disease and inflammatory bowel disease: A study using clinical data warehouse

BACKGROUND AND AIM

To analyze the prevalence of ophthalmic manifestations in patients with celiac disease, Crohn's disease and ulcerative colitis in Munich/Germany.

METHODS

A total of 272,873 patients of Ludwig Maximilians Universitat Ophthalmological Hospital with eye disease were evaluated between 2003 and 2019. The International Classification of Diseases, 10th revision (ICD-10) of celiac disease Crohn's disease, ulcerative colitis, and all medical records which had the diagnosis of these diseases were analyzed.

RESULTS

A total of 272,873 patients were analyzed, with a mean age of 53 years, with approximately 48% female patients, and 51% male patients. We selected 72 patients with celiac disease (68% women and 32% men), with a minimum age of 8 years, maximum of 103 years, and an average of 52 years. The most common diagnoses were dry eye (32%) and cataract (12%). The mean intraocular pressure of patients with celiac disease was 15 mmHg. During the same study period, 103 patients with Crohn's disease were analyzed, with an average intraocular pressure of 14 mmHg.The minimum age of the patients was 12 years and a maximum of 93 years with an average age of 55 years, with 57% of females and 43% of males. The most common diagnoses were cataract (22%) and dry eye (19%). During the same study period, 99 patients with ulcerative colitis were analyzed, with an average intraocular pressure of 14 mmHg.The minimum age of the patients was 6 years and a maximum of 96 years, with an average age of 61 years, with 36% of females and 64% of males. The most common diagnoses were cataract (29.2%) and dry eye (12%).

CONCLUSIONS

The main ophthalmological manifestations of patients requiring eye follow-up were dry eye and cataract for all the diseases analyzed, which can be considered as coincident complications. None of the three diseases had increased intraocular pressure. Thus, celiac disease presented a profile of ophthalmological manifestation similar to the other intestinal inflammatory diseases studied.

Vitamin A deficiency after prolonged intake of an unbalanced diet in a Japanese hemodialysis patient

BACKGROUND

In industrialized countries, vitamin A deficiency (VAD) is extremely rare, except association with bariatric surgeries and hepatobiliary disorders. It is unusual that VAD develops during hemodialysis due to reduced glomerular filtration of vitamin A-binding protein. We reported the case of a 58-year-old Japanese male hemodialysis patient diagnosed with VAD.

CASE PRESENTATION

The patient undergoing hemodialysis for more than 15 years presented with progressive photophobia and night blindness and was ophthalmologically examined. He denied a history of cancer or hepatobiliary disease and reported that he loved eating prepackaged noodle bowls and foods, with prolonged low intake of fruits/vegetables. He had good visual acuity. Fundus images showed numerous white dots in the midperipheral retinae, but no degenerative changes. In baseline full-field electroretinography (ERG), b-wave responses were extremely reduced in rod ERG, a-wave amplitudes in standard-flash/strong-flash ERG were reduced to 20-25% of our controls, a- and b-wave amplitudes in cone ERG were reduced to 40-50% of the controls. Whole-exome sequencing identified no pathogenic variant for any inherited retinal disorder. He was diagnosed with VAD because of reduced serum vitamin A levels and treated with retinol palmitate. Two months after treatment commencement, the serum vitamin A level was within the normal range. Full-field ERG showed that the scotopic ERG responses markedly improved compared with baseline.

CONCLUSIONS

This is the first report of VAD associated with undernutrition in the Japanese hemodialysis population.

Ocular manifestations in celiac disease: an overview

PURPOSE

To review and highlight the ocular manifestations associated with celiac disease (CD) and presentation of their pathogenetic mechanisms.

METHODS

A thorough review of the literature was performed using PubMed to identify articles about serrated polyposis syndrome. The search was performed using the search string: ("celiac disease" OR "coeliac disease") AND ("ocular manifestations" OR "eye" OR "orbitopathy" OR "uveitis" OR "neuro-ophthalmic manifestations"). Only articles in English were reviewed.

RESULTS

Several ocular symptoms and disorders have been associated with CD and are a result of defective intestinal absorption and immunological mechanisms. These include nyctalopia, dry eye, cataract, thyroid-associated orbitopathy, uveitis, central retinal vein occlusion and neuro-ophthalmic manifestations. In addition, CD-related ocular disease may represent the first manifestation of CD.

CONCLUSION

CD may hold accountable for the development of ocular diseases of obscure etiology.

Severe Vitamin A Deficiency After Biliopancreatic Diversion

Biliopancreatic diversion is a surgical procedure that causes weight loss via volume restriction and malabsorption. It is now rarely performed due to the risk of severe nutritional deficiencies including vitamin A. We report a case of severe vitamin A deficiency due to malabsorption from a biliopancreatic diversion procedure for weight loss. By the time the patient presented to our department, she had developed blindness refractory to parenteral vitamin A treatment. A unique feature of her case is the development of a rash with vitamin A injections. This reaction has only been reported in one case series of 3 patients in the published literature. Her case highlights the importance of vitamin deficiency screening in patients after bariatric surgery, and her skin reaction to the injections is a unique side effect that is not frequently observed.

Late-onset night blindness with peripheral flecks accompanied by progressive trickle-like macular degeneration

PURPOSE

To report the clinical and genetic characteristics of 6 cases with late-onset night blindness with peripheral flecks accompanied by progressive trickle-like macular degeneration.

METHODS

Clinical and genetic data were collected from 6 independent patients who complained of night blindness in their fifth to eighth decade of life. The ophthalmological examinations included ophthalmoscopy, fundus autofluorescence (FAF), and full-field electroretinography (ERG). Whole exome sequencing with target gene analysis was performed to determine the causative genes and variants.

RESULTS

All of the patients first complained of night blindness at the ages of 40-71 years. Funduscopic examinations demonstrated white or atrophic flecks scattered in the posterior pole and peripheral retina bilaterally. FAF showed patchy hypo-autofluorescence spots in the posterior pole similar to that of the trickling type of age-related macular degeneration (AMD). The region of abnormal FAF rapidly expanded with age, and one eye developed a choroidal neovascularization. The full-field scotopic ERGs with 20 min of dark adaptation were severely reduced or extinguished in all cases. There was partial recovery of the ERGs after 180 min of dark adaptation. The cone ERGs were reduced in all cases. Whole exome sequencing revealed no pathogenic variants of 301 retinal disease-associated genes.

CONCLUSIONS

The six cases had some common features with the flecked retina syndrome, familial drusen, and late-onset retinal degeneration although none had pathogenic variants causative for these disorders. These cases may represent a subset of severe trickling AMD or a new clinical entity of acquired pan-retinal visual cycle deficiency of unknown etiology.

Treatment of vitamin A deficiency retinopathy with sublingual vitamin A palmitate

PURPOSE

To report treatment of vitamin A deficiency retinopathy with sublingual vitamin A drops.

METHODS

Case report with review of the literature.

RESULTS

A 69-year-old Caucasian woman with a history of small bowel resection presented with progressive symptoms of bilateral nyctalopia and decreased visual acuity. Ophthalmic examination revealed bilateral conjunctival xerosis and fine white granular deposits in the midperipheral retina suggestive of vitamin A deficiency. Full-field electroretinogram (ERG), multifocal ERG (mfERG), and two-color dark adaptometry revealed significant impairment of rod and cone photoreceptor function. Kinetic perimetry demonstrated depressed macular sensitivity with constriction of the finer isopters. After 5 months of treatment with sublingual vitamin A drops, the patient's vision, ERG, mfERG, dark adaptometry, and perimetry normalized. A review of the literature summarizing the electrophysiologic testing in vitamin A deficiency is also discussed.

CONCLUSIONS

This case highlights novel observations on the effects of sublingual vitamin A supplementation for acquired vitamin A deficiency retinopathy. Sublingual vitamin A may represent a viable and efficacious treatment modality for vitamin A deficiency.

Optical Coherence Tomography Assessment Before and After Vitamin Supplementation in a Patient With Vitamin A Deficiency: A Case Report and Literature Review

Vitamin A is an essential fat-soluble vitamin important for the function of various body systems. In the eye, vitamin A is essential for the synthesis of visual pigments in photoreceptors. Vitamin A deficiency is a rare condition in the developed countries and might follow bariatric or intestinal bypass surgery.We present the case of a 67-year-old male that complained of visual loss and nyctalopia. Patient had bariatric surgery 15 years before for weight loss. Low serum levels of vitamin A confirmed the diagnosis and patient started vitamin A supplementation. Visual fields, macular thickness, and ganglion cell layer thickness were recorded and monitored 1 month, 6 months, and 1 year after the beginning of therapy. Visual fields were significantly altered and central macular thickness and ganglion cell layer thickness were reduced, but the first 2 showed a significant recovery with vitamin supplementation therapy. By the 1st month of treatment patient referred a complete remission of visual symptoms. Further, we observed hyperreflective material accumulating beneath a partially disrupted ellipsoid band in the high definition optical coherence tomography that also improved progressively with vitamin repletion.Newer and more sophisticated imaging systems have increased our knowledge of the mechanisms responsible for retinal diseases. To our knowledge, this is the first description of the effect of vitamin A deficiency and vitamin supplementation on macular thickness. This case also highlights the importance of considering bariatric bypass surgery as a cause of vitamin A deficiency in developed countries.

Ophthalmologic manifestations of celiac disease

Celiac disease is an autoimmune disorder that affects the small intestine of genetically predisposed individuals. Ophthalmic manifestations are within the extra-intestinal manifestations, and can be divided into those of autoimmune disorders or those due to absorptive disabilities. This article reviewed the ophthalmologic manifestation of celiac disease. Ophthalmic symptoms are rare, but should be investigated in patients with celiac disease and taken into consideration as the first systemic manifestation.

Recurrent episodes of night blindness in a patient with short bowel syndrome

PURPOSE

To describe clinical characteristics in a patient with recurrent episodes of night blindness due to vitamin A deficiency caused by short bowel syndrome in Crohn disease.

METHODS

Retrospective analysis of best-corrected visual acuity (BCVA), kinetic perimetry, slit-lamp biomicroscopy, ophthalmoscopy, fundus photography, fundus autofluorescence (FAF), spectral domain optical coherence tomography (SD-OCT), dark adaptometry (DA) and electroretinography (ERG). Serum vitamin A level was measured.

RESULTS

A 44-year-old man with a 3-year history of night blindness suffered from a short bowel syndrome with chronic malabsorption due to ileocecal resection in Crohn disease. Both eyes had a BCVA of 0.9, Bitot's spots of the conjunctiva and no significant fundus abnormalities. SD-OCT showed no remarkable changes, whereas FAF was brighter than normal in the center of the fovea. DA showed normal cone and a lack of rod function. The dark-adapted 0.01 ERG was non-detectable, the dark-adapted 3.0 ERG severely diminished, but the light-adapted 3.0 and 30 Hz flicker ERGs were within normal limits. Serum vitamin A level was 0.11 µg/ml (normal 0.30-0.65 µg/ml). Treatment with intravenous vitamin A caused a rapid recovery of night vision and ERG. However, during the following 3 years, he had three further episodes of night blindness with loss of rod function. During each period, parenteral vitamin A substitution brought complete recovery of night vision and rod function. BCVA, fundus, FAF findings and SD-OCT remained unchanged during the course.

CONCLUSIONS

In patients with known chronic malabsorption serum vitamin A level should be regularly checked to avoid recurrent night blindness episodes. ERG might be more sensitive than serum vitamin A level and is recommended in case of night blindness but still normal vitamin A level.

Electrophysiological and microperimetry changes in vitamin A deficiency retinopathy

PURPOSE

To describe a follow-up case of vitamin A deficiency (VAD)-related retinopathy with macular involvement monitored with electroretinography and microperimetry.

METHODS

Flash (ERG), pattern (PERG), and multifocal (mfERG) electroretinography were recorded in parallel with microperimetry before and during 7-month follow-up of vitamin A treatment on a 65-year-old man presented with a 1-year history of night blindness. The patient had undergone ileostomy procedure for Crohn's disease 14 years ago. His best corrected visual acuity was 6/6 in each eye. Fundus examination revealed macular and mid-peripheral yellow-white lesions compatible with drusen.

RESULTS

Before treatment, PERG was reduced, and mfERG was reduced and delayed, worse in responses from the central rings. These results revealed evidence of bilateral macular and central cone dysfunction. The flash ERG showed reduced dark-adapted 0.01 ERG (rod response); a-wave of dark-adapted 3.0 and 10.0 ERG was normal but b-wave was reduced (negative configuration); light-adapted 3.0 ERG was slightly reduced. The flash ERG revealed evidence of bilateral generalised retinal dysfunction affecting the rod more than cone system. Microperimetry showed deep reduction in retinal sensitivity. Fixation stability was unstable with eccentric locus. During treatment, ERG and microperimetry demonstrated significant improvements. Fixation stability reached normal values after the third treatment week.

CONCLUSIONS

This case illustrates the importance of electrophysiological investigation in early VAD-related retinopathy detection correlated with microperimetry. Our findings indicate a more delayed central cone function recovery than that of generalised rod and cone function. There was a marked correlation between ERG and microperimetric changes.

Vitamin A deficiency and xerophthalmic fundus in autoimmune hepatitis and cirrhosis

PURPOSE

To report a patient with autoimmune hepatitis and cirrhosis who was diagnosed with severe vitamin A deficiency based on the findings of xerophthalmic fundus.

METHODS

Retrospective chart review.

PATIENT

A 36-year-old African American woman who had a history of autoimmune hepatitis and cirrhosis presents with peripheral retinal white spots, which led to the diagnosis of vitamin A deficiency.

RESULTS

The patient presented to the eye clinic for intermittent blurry vision 3 months after the diagnosis of liver cirrhosis secondary to autoimmune hepatitis since age 15. She also underwent partial large and small intestine resection as an infant for Hirschsprung disease. Anterior segment examination was significant for severe punctate epithelial erosions and posterior segment examination was significant for extensive white spots in the peripheral retina in both eyes. Workup showed near nondetectable levels of vitamin A (<0.06 mg/L, normal 0.3-1.2 mg/L) and retinyl palmitate (<0.02 mg/L, normal > 0.2 mg/L). After treatment with 200,000 IU of vitamin A orally, the white spots slowly resolved in ∼6 months. She never developed nyctalopia and her dry eye symptoms completely resolved.

CONCLUSION

Although rare, vitamin A deficiency should be considered in patients with liver cirrhosis especially in those with a history of intestinal surgeries. Early diagnosis and treatment with vitamin A supplementation can reverse the signs and symptoms of xerophthalmia.

Reversible vision loss secondary to malnutrition in a woman with severe anorexia nervosa, purging type, and alcohol abuse

OBJECTIVE

To report a case of severe reversible vision loss in a woman with a 7-year history of anorexia nervosa, purging type, alcohol abuse and a severely restricted, vitamin-deficient diet.

METHOD

Psychiatric, ophthalmologic, and medical records were reviewed, and a literature search was performed on visual complications associated with anorexia nervosa and malnutrition.

DISCUSSION

Ophthalmologic complications of malnutrition are rare but include both oculomotor and visual sensory disturbances. Thiamine deficiency can cause both types of disorders. Vitamin B12 and folate deficiencies are typically associated with optic neuropathy. Clinicians treating eating disorders should be aware of the potential for vitamin deficiencies and associated visual loss in patients with anorexia nervosa. This case highlights the importance of a detailed dietary history to guide vitamin rehabilitation and to minimize or reverse nutritional visual loss.

Fundus white spots and acquired night blindness due to vitamin A deficiency

To report a successfully treated case of acquired night blindness associated with fundus white spots secondary to vitamin A deficiency. An ocular examination, electrophysiologic testing, as well as visual field and OCT examinations were obtained on a 61-year-old man with vitamin A deficiency who had previously undergone gastric bypass surgery. The patient had a re-evaluation after treatment with high doses of oral vitamin A. The patient was observed to have numerous white spots in the retina of each eye. Best-corrected visual acuity was initially 20/80 in each eye, which improved to 20/40-1 OU after oral vitamin A therapy for 2 months. Full field electroretinogram (ERG) testing, showed non-detectable rod function and a 34 and 41% reduction for 32-Hz flicker and single flash cone responses, respectively, below the lower limits of normal. Both rod and cone functions markedly improved after initiation of vitamin A therapy. Vitamin A deficiency needs to be considered in a patient with white spots of the retina in the presence of poor night vision.

Reduction in estimated vitamin A intake induced by new food composition tables in Japan, where vitamin A is taken mostly from plant foods

A revised edition of the standard tables of food composition was implemented in Japan in 2005; one of the major revision points is the change of retinol activity equivalents for pro-vitamin A carotenoids. This preliminary analysis was conducted to examine whether the revision affects the estimation of vitamin A intake; and if so, to what extent. Accordingly, a field survey was conducted to collect 24-h duplicates of daily foods of citizens, and 26 adult women volunteered. Application of the procedures in the new and previous standard tables of food composition gave 537 microg retinol activity equivalent and 704 microg retinol equivalence, respectively, for daily vitamin A intake. Thus, the changes in retinol activity equivalents induced substantial reduction (by 24%) in estimation of vitamin A intake among the Japanese population, for whom pro-vitamin A carotenoids in plant foods are the major sources (76%) for vitamin A, and retinol accounts for only 35% (on the retinol activity equivalent basis).

Clinical disorders affecting mesopic vision

Vision in the mesopic range is affected by a number of inherited and acquired clinical disorders. We review these conditions and summarize the historical background, describing the clinical characteristics alongside the genetic basis and molecular biological mechanisms giving rise to rod and cone dysfunction relevant to twilight vision. The current diagnostic gold standards for each disease are discussed and curative and symptomatic treatment strategies are summarized.

Vitamin A deficiency in patients with a remote history of intestinal surgery

BACKGROUND/AIMS

Vitamin A deficiency, often presenting with nyctalopia, has been described in a number of patients with malabsorption as a result of intestinal bypass surgery and, more recently, bariatric surgery. In these reports vitamin A deficiency developed within several years of gastric or intestinal surgery. Three patients who developed decreased vision from vitamin A deficiency more than 18 years after their intestinal surgery are reported.

METHODS

A retrospective review of the clinical findings of all patients diagnosed with vitamin A deficiency, as confirmed by serological testing, over the past year in a single neuro-ophthalmic practice.

RESULTS

Four patients with vitamin A deficiency were seen, three of whom had intestinal surgery more than 18 years before the development of visual symptoms.

CONCLUSION

The authors suggest that vitamin A deficiency should be suspected in patients with unexplained decreased vision and a history of intestinal surgery, regardless of the timing of the surgical procedure.