1. June 28, 2014 VADX JBC 1
Xerophthalmia (VADX)

2. June 28, 2014 VADX JBC 2
VADX
• Vitamin A deficiency Xerophthalmia
(Nutritional Deficiency) is a systemic disease
affecting epithelial structure in a variety of organ
• The clinical feature are more clear in eye
• Clinical look in eye is known as Xerophthalmia
“ Dry Eye” (Xeros: Dry and Ophthalmia: Eye)
• Mild form “Night Blindness” and severe form
“Keratomalacia” in the eye

3. June 28, 2014 VADX JBC 3
VADX
• Eye signs, Xerophthalmia (“dry eye”)
recognised for many centuries
• Major cause of childhood blindness
• Major cause of child mortality
• Prevention is one of the most cost effective
intervention
• Children 2 to 6 years are in great risk

4. June 28, 2014 VADX JBC 4
Major Nutritional Deficiency
Diseases
• Protein-Energy Malnutrition (PEM)
• Vitamin A Deficiency Disorders (VADD)
• Nutritional Anaemias (Esp. Iron)
• Iodine Deficiency Disorders (IDD)

5. June 28, 2014 VADX JBC 5
VADX and Eye
• Loss of goblet cells
• Less mucin production
• Epithelial surface becomes keratinized
(Nacrosis)
• Keratinized epithelium resist wetting
• Night blindness

6. June 28, 2014 VADX JBC 6
VADX Epidemiology
• Age: Children below 6 years of age get
Xerophthalmia
• Sex: Boys are at greater risk
• Season: More in Pre-monsoon season (due
to shortage of Vit-A rich food and increased
incidence of diarrhoea) & in winter( due to
chest infections increasing demand for Vit-
A)

7. June 28, 2014 VADX JBC 7
Global Epidemiology
• Blinding Xerophthalmia is largely limited to
developing countries, especially those in
Africa, Asia and the Western Pacific
• 300000 children become blind annually

8. June 28, 2014 VADX JBC 8
Global Map of VADD

9. June 28, 2014 VADX JBC 9
Nutritional Blindness: NBS 1981
• 0.63% of population had signs of Vit. A
deficiency
• Prevalence was more in males ( 1.5: 1)
• Highest prevalent in Terai of Eastern,
Central and Far West region
0.9%

10. June 28, 2014 VADX JBC 10
Vitamin A
• Vitamin A or retinol is a fat soluble in
alcohol form
• Essential vitamin for most animals

11. June 28, 2014 VADX JBC 11
Sources of Vitamin A
• Animal Source
– Fish Liver
– Liver
– Breast milk
– Egg yolk
– Dairy Product
– Meat
• Plant Source
– Yellow and red
fruits
– Red palm oil
– Dark green leafy
vegetables

12. June 28, 2014 VADX JBC 12
Dietary Sources of Retinol
• Animal food (Retinol)
– Contains active Vit-A
– Liver -best source
– Milk products are also rich in retinol
• Plant food (Pro-Vitamin A)
– Contains carotene yellow-red pigments
– Converts into retinol in intestine wall
β-Carotenes give highest amount of retinol

13. June 28, 2014 VADX JBC 13
Functions of Vitamin A
• Vision – Photopic (Day and Night) and
Scotopic (colour)
• Epithelial cell integrity against infection
• Skeletal Growth (Reduce growth in VAD)
• Immune response
• Fertility (Male and Female)
• Anti-oxidant (Get rid of oxidative stress)
• Haemopoiesis (Iron deficiency)

14. June 28, 2014 VADX JBC 14
Cause of VADX
• Ecological, Political, Social Causes:
– Political stability
– Population density
– Infrastructure
– Land type, fertile, use and ownership
– Climate (Hot and dry), Drought
– Health services and their availability and
cost

15. June 28, 2014 VADX JBC 15
Cause of VADX…
• Household:
– Maternal education
– Family size and child spacing
– Food distribution within the house
– Quality and quantity of water supply
– Concept of kitchen garden
– Customs and taboos (beliefs)

16. June 28, 2014 VADX JBC 16
Cause of VADX…
• Individual:
– Immunisation
– Diarrhoea
– Measles
– Nutritional status
– Intestinal parasites and other infections
– Increasing demand (Measles and pregnancy)
– Malnutrition, PEM

17. June 28, 2014 VADX JBC 17
Transportation of Vit A
• After ingestion, 50-90% of retinol is
absorbed and transported to the liver where
it is stored as retinyl palmitate
• When needed it is released into the blood
bound to retinol-blinding protein (RBP)
• Retinol is removed and utilised by the target
tissues, such as photoreceptors and
epithelial tissues

18. June 28, 2014 VADX JBC 18
Physiology of Vitamin A
Transthyretin
TTR

19. June 28, 2014 VADX JBC 19
Normal Vit A Metabolism
• Food:
– Animal Food (Retinol)
– Plant Food (Carotenes)
• Intestine:
– Digestion and absorption of Vit A and transport to
intestinal lymphatics
• Liver:
– Storage of Vit A in liver as retinol
– Production of retinol binding protein (RBP) the
carrier
• Blood
– Transport of retnol bound to PBP
• Eye
– Formation of rhodopsin used in night vision (Dim
Light)
– Maintenance of healthy corneal and conjunctival cells

20. June 28, 2014 VADX JBC 20
• Food:
– Dietary deficiency of Vit A
– Protein energy malnutrition (PEM)
– Anorexia from other disease
• Intestine:
– Diarrhea, Gastroenteritis and parasites
• Liver:
– Not enough Vit A stored in the liver
– Not enough RBP synthesized
• Blood
– Low Vit A levels in the blood
• Eye:
– Night blindness
– Xerophthalmia
Cycle of Vit A Deficiency

21. June 28, 2014 VADX JBC 21
VADX Classification: WHO 1982
• XN : Night blindness (Nyctalopia)
• X1A : Conjunctival xerosis
• X1B : Bitot's spots
• X2 :Corneal xerosis
• X3A :Corneal ulceration < 1/3 of the cornea
• X3B :Corneal ulceration > 1/3 of the cornea
• XS :Corneal scars
• XF :Xerophthalmic fundus (In adult)

22. June 28, 2014 VADX JBC 22
Night Blindness
• First sign of VADX in pre school children
• Impair Rhodopsin production
• Response within 24-48 hour with Vit A
therapy
• Conjunctival xerosis and Bitot’s spot
generally accompanying

23. June 28, 2014 VADX JBC 23
Conjunctival Xerosis
• Conjunctiva dull, dry, lusterless, non-
wettable, opaque and thickened
• Loss of goblet cell and impair mucin
production

24. June 28, 2014 VADX JBC 24
Bitot's Spots
• Dirty white or slivery gray, foamy,
triangular in shape patches seen in
conjunctiva
• Usually bilateral and in the temporal
side of the bulbar conjunctiva
• Collection removed conjunctival cells

25. June 28, 2014 VADX JBC 25
Corneal Xerosis
• Dull, dry and lusterless cornea
• Superficial punctate keratopathy
• Disturbance of precorneal tear film

26. June 28, 2014 VADX JBC 26
Corneal Ulceration
• Epithelial defects in periphery of the cornea
• Dry, rough and hazy cornea
• Rapid necrosis, corneal melting,
perforation, prolapse of intraocular contents
• Red, swollen and painful eye

27. June 28, 2014 VADX JBC 27
Corneal Scars
• Difficult to distinguish these from other
causes of corneal scars
• Typically situated in the lower nasal
quadrant
• Both eyes have scars
• One eye may be more severely involved
than other

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Xerophthalmic Fundus
• Pale yellow spots near the course of the
retinal vessels and in the retinal periphery
• Disappear within 2-4 months of Vitamin-A
therapy

29. June 28, 2014 VADX JBC 29
Xerophthalmia
Management
Treatment Prevention
Vit A
Underlying Cause
PEM
Eye Care

30. June 28, 2014 VADX JBC 30
Treatment
• Prompt recognition of children with, or at high
risk of developing, active disease
• Immediate administration of massive doses of
vitamin A
• Treatment of underlying systemic illnesses
and protein-energy malnutrition
• Care of the eye

31. June 28, 2014 VADX JBC 31
Vitamin A Capsule 2 Lakh IU

32. June 28, 2014 VADX JBC 32
Treatment
• Immediately on diagnosis: Vit A
<6 months 50,000 IU
6-12 months 100,000 IU
>12 months 200,000 IU
• Next day Same
dose
• After 4 weeks Same dose

33. June 28, 2014 VADX JBC 33
Vitamin A Prophylaxis Schedule
• Infants <6 months 50,000 IU
– Non-breast-fed infants, breast-fed infants
– Whose mothers have not received supplemental
vitamin A
• Infants 6-12 months 100,000 IU
– Every 4-6 months
• Children >12 months 200,000 IU
– Every 4-6 months
• Mothers 200,000 IU
– Within 8 weeks of delivery

34. June 28, 2014 VADX JBC 34
Vitamin A Prophylaxis Schedule
• Women in reproductive age group:
– Night blindness: 10,000 IU/day for 2
weeks
• Chronic Diarrhoea, PEM, Worm
manifestation, Measles, ARI:
– Single dose 200,000 IU.

35. June 28, 2014 VADX JBC 35
Prophylaxis
• Health education on dietary sources of
Vitamin A
• Periodic Vit A supplementation
• Encourage horticulture and kitchen garden
• Fortification of Vit A in dietary items
• Immunization against measles
• Treatment of intestinal parasites
• Encourage breast feeding

36. June 28, 2014 VADX JBC 36
Vitamin A Requirements

37. June 28, 2014 VADX JBC 37
Medical Status and Diet
• Children with blinding xerophthalmia are often
severely ill, malnourished and dehydrated
• Proper treatment will save their sight & life
• General supportive care
• Rehydration
• Frequent feedings digestible protein rich food
• Control respiratory and GIT infections, TB, worm
infestations, amoebiasis with appropriate
agents( antibiotics, anthelmintics)

38. June 28, 2014 VADX JBC 38
Care of the Eye
• If cornea involved, antibiotic eye ointment 8
hrly to reduce risk of secondary bacterial
infection
• I needed use mydriatics
• Treat as bacterial corneal ulcer in corneal
infection
• Preserve structural integrity of the globe

39. June 28, 2014 VADX JBC 39
Prevention
• Dietary counseling: Mothers should be
taught how to prepare diets rich in Vitamin
A from inexpensive available sources
• Eye health education
• Administration of Vitamin-A at 4-6
months (according to age) in endemic &
hyperendemic areas

40. June 28, 2014 VADX JBC 40
Thank You