Dr. Sujata Dwivedi,D11801
Purpose
To report a case of Vitamin A deficiency induced keratomalacia in an elderly lady and the challenges in its management.
A seventy-three year-old-Indian woman presented with chief complaint of pain in left eye since 1 week, following a blunt injury with her own hand. She also reported gradual blurring of vision for last seven months in both eyes. She was using carboxy methyl cellulose 0.5% eye drops and HPMC 2% eye ointment every two hourly. In systemic history, she had diabetes and cardiac ailment for last twenty years. She had also undergone gastric surgeryfor complicated hernia fourteen years ago. .
On ocular examination, unaided vision was 6/60 in both eyes. Right eye tear meniscus had mucoid discharge. Bulbar conjunctiva and cornea had lustureless look, which took diffuse staining on fluorescein. Rest of the anterior segment was normal. Left eye cornea had a peripheral epithelial defect of 5.5 mm x 3.0 mm, with 70% thinning. There was minimal infiltrate at the edge. Anterior chamber had one mm hypopyon in the left eye. Corneal scraping of infiltrate were sent for KOH mount and gram stain.
To know the reason of non-responding dry eyes, detailed history was taken. On detailed questioning, it was found that the patient had been diagnosed six months ago withdry eyes and was put on lubricants. When she didn’t improve, multiple other ophthalmic consultations were made. With each consultation, lubricant drops were increased but her blurring kept on worsening. She said that the maximum blurring of vision occured at night when she can’t even able to walk. This night blindness like features with lustreless look of cornea and history of gastric surgery raised the suspicion of vitamin A deficiency. She was asked to bring complete records of gastric surgery.
KOH was negative and gram stain revealed gram positive cocci, gram positive bacilli and gram negative bacilli. With this clinical picture a provisional diagnosis of both eye xerophthalmia, left eye infective keratitis with corneal melt was made.
She was advised Moxifloxacin 0.3% eye drops hourly in left eye and carboxymethylcellulose 1% hourly in both eyes. Her surgical records revealed that fourteen years back she had strangulated paraumblical hernia. Surgery involved resection of gangrenous jejunum, ilium, ascending colon and part of transverse colon. Since vitaminA deficiency was considered to be arising not from poor nutrition but fromr poor intestinal uptake, parenteral route for administration of Vitamin A appeared a better choice. Intramuscular Injection of 200000 IU was advised.
Next day, there was decrease in the size of infiltrate and hypopyon, but thinning progressed with appearance of descemetocele. Glue was applied to area of melt. The patienthad not taken VitaminA injection as it was not available over the counter and special order was placed. She was advised to get serum retinol levels done and start oralVitamin A tablets. Serum retinol levels were 8 µg/100 ml, which fall in deficient range according to WHO recommendations. As injections became available after three days, two doses were given on consecutive days. Within three days corneal surface started to improve and hypopyon resolved. A third dose of injection was repeated after a week. She was asked to consult a gastroenterologist so that other nutritional deficiencies could be picked up and vitamin A doses adjusted. Her ocular surface became normal in six weeks. After three months serum retinol levels improved to 29µg/100 ml with weekly vitamin A tablet.
Discussion: We diagnosed xerophthalmias and keratomalacia in an elderly lady. There were three hurdles in the management of this case i.e. delayed diagnosis, difficulty in procuring injectable vitamin preparation and lack of any recommendations for these kind of patients. Keratomalacia due to vitamin A deficiency has been mostly reported in malnourished children. Only few cases have been reported in adults. As a consequence, diagnosis is often delayed in adults. In our patient too, early xerophthalmic features of blurred vision were attributed to senile dry eye for six months. She kept on worsening, despite extensive lubricant application. Very low serum retinol levels confirmed the diagnosis. On literature search, we could not find specific recommendation of Vitamin A supplementation in a person who had undergone complete small intestinal resection. We faced a lot of difficulty in procuring injectable Vitamin A, because children are treated with oral drops and adults with tablets. Indications for parentral administration are limited to severe anorexia, septic shock, edematous malnutrition or inability to take oral supplementation.
Conclusion: Keratomalacia due to Vitamin A deficiency can occur in adults . Literature reveals that unlike children, diagnosis in adults is often delayed and there are no guidelines for prevention and management. Surge in bariatric surgeries is further likely to increase such cases. Hence a high index of suspicion is required so that diagnosis and management is not delayed . Similarly any person undergoing surgical intestinal resection should be counselled regarding dietary modifications and Vitamin A supplements.