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50 EW FEATURE Eyeing continued from page 49 February 2011 Corneal diagnoses and systemic disease April 2012 Following gastric bypass, patients may deal with xerophthalmia of the conjunctiva from hypovitaminosis A. The eye here has fluorescein dye pooling in beads on the region of xerosis just prior to Bitot's spot formation Slit lamp photo showing central corneal haze, scarring, and xerophthalmia of the con- junctiva from hypovitaminosis A following gastric bypass surgery Source (all): W. Barry Lee, M.D. A patient with a Bitot's spot characteristic of hypovitaminosis A one of the most important vitamins for ocular health. "If you block that part of the intestine you have signif- icant risk of a vitamin A deficiency," Dr. Lee said. "There was a study done in 2004 that looked at vitamin A-deficient patients, and 70% were vitamin A deficient 4 years after (gastric bypass) surgery, even on multivitamins." The study, by Guy H. Slater, M.D., published in the January 2004 issue of the Journal of Gastrointestinal Surgery, looked at the different vitamin deficiencies that occurred in patients following gas- tric bypass surgery. As early as 1 year after the surgery, 50% of bypass pa- tients were vitamin A deficient. From an ophthalmic stand- point, vitamin A is the one of prime Ophthalmologists continued from page 44 Cambridge, Mass.]," Dr. Lee said. "The enzyme supplements delay and/or prevent severe renal and heart failure and can save a life. Un- fortunately, the enzyme is extremely expensive, sometimes costing $250,000 annually. It is typically given as an IV infusion." Ocular symptoms often can go untreated unless the patient devel- ops cataracts. "[Patients] don't usually get vi- sual loss from the corneal changes," Dr. O'Halloran said. Ophthalmologists treating Fabry's disease patients will find themselves co-managing the patient with a multitude of other practi- tioners, including renal specialists, dermatologists, geneticists, and neurologists. "Psychiatry would be good, too," Dr. O'Halloran said. "As with any chronic disease, especially when death is a pretty solid potential out- come, psychological counseling is definitely needed." Dr. O'Halloran said a multispe- cialty hospital is a good place for Fabry's disease patients to be seen. "They [will] have access to a lot of physicians, and it's easier to do tests. A diagnosis will come more quickly," he said. The future of treating the rare disease is gene therapy and stem cells. "This is one of the diseases that stem cell therapy has the potential to make a huge impact on," Dr. O'Halloran said. EW Editors' note: The doctors mentioned have no financial interests related to this article. Contact information Lee: 404-556-2202, lee0003@aol.com O'Halloran: 858-309-7702, hohalloran@rchsd.org T Monthly Pulse he majority of respondents (77%) feel comfortable medically managing a patient with peripheral ulcerative keratitis (PUK) on their own. In severe cases, surgical management and rheumato- logic workup is often required, yet only a minority selected those options. It is important to remember that PUK can be an ocular manifestation of a systemic vasculitis, and collaborating with rheumatology is crucial to manage these more severe cases. Regarding a patient with floppy eyelid syndrome, the initial course of action selected by respondents was nearly equal between all options. A sleep study to rule out sleep apnea is a crucial life-saving diagnostic test that should be recommended to all of these patients as one of the initial treatment strategies, even as the clinician is evaluating the patient for keratoconus and for a possible referral to oculoplastics for a lid-short- ening procedure, if more conservative measures fail. Finally, it is interesting to note that while corneal verticillata may be associated with all of the diagnosis options given, most respondents (90%) associate the finding primarily with amiodarone medication use, which is likely to be the most common of the conditions in which clini- cians will see it. Clara Chan, M.D., and Vincent de Luise, M.D., cornea editorial board members interest. "Vitamin A controls the clarity of the cornea and the health of the retina," Dr. Lee said. "So there is retinal damage and clouding of the cornea, and those can lead to corneal and retinal blindness if not treated." Another condition that can lead to the deficiency is celiac disease, which involves an allergy to gluten, commonly contained in bread. "Those patients can get an induced vitamin A deficiency from lack of nutrients," Dr. Lee said. "Cystic fi- brosis can be another one that can cause lack of absorption of vitamins in the intestine." Typically the scenario that most ophthalmologists see at the slit lamp is what appears to be a patient with