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April 2012 Corneal diagnoses and systemic disease February 2011 EW FEATURE 51 severe dry eyes. "All of the patients that I've seen say, 'I've seen four, five, six doctors, and they've been trying to treat my dry eyes with tears or other things like plugging the puncta,'" Dr. Lee said. "But those things aren't going to help because they have a vitamin A deficiency, and the practitioner didn't check for that." Lack of vitamin A can affect the goblet cells on the cornea, as well as the tear-producing lacrimal gland. "When you don't have enough vita- min A, you lose the ability of those glands to work," Dr. Lee said. "So the ocular surface, instead of being moist and lined by moist mucosa, becomes lined by skin." The result is xerophthalmia, in which Dr. Lee finds it appears as if the surface of the eye has been turned into a dry skin. "Without vitamin A you lose the moisture production to the eyes," Dr. Lee said. However, that's not the only ocular problem. The retina is also affected by the defi- ciency. "Vitamin A is one of the key elements to start the reaction on the retina to allow light to get processed to the brain," Dr. Lee said. "If you don't get the vitamin A to the retina, the retinal cells also get dam- aged." In effect, lack of vitamin A hurts the eyes in two ways. "The first is you lose the moisture to the surface of the eye, and the second is that you lose the ability to perceive light," Dr. Lee said. The first symp- tom from the back of the eye may be night blindness. From a diagnostic standpoint, he recommends that practitioners consider a vitamin A deficiency par- ticularly in cases where a patient comes in complaining of dry eyes in concert with night blindness. "You can't look at the back of the eye and tell that someone is vitamin A defi- cient," Dr. Lee said. "You have to go by the history and look at the front of the eye." Particularly in gastric bypass cases, it may be important to press the patient, who could be em- barrassed and not necessarily forth- coming. Also telling is a Bitot's spot, caused by the buildup of keratin and marked by an oval, triangular, or ir- regular shape. If a vitamin A defi- ciency is suspected then a blood test should be ordered. Reversing the damage The good news is that if a vitamin A deficiency is found, it can be cor- rected. "If it's related to vitamin A deficiency you can do intramuscular vitamin A injections," Dr. Lee said. "Those will typically reverse this over the course of 2-4 weeks." In cases where there is still some form of intestinal absorption, it may be possible to overwhelm the condition using very high doses of liquid vita- min A or gummy vitamins. Typically adults who are not deficient are sup- posed to get 5,000 international units of vitamin A per day. To treat a deficiency, practitioners must ini- tially go well beyond this. "The first thing I would do if I couldn't do in- tramuscular injections is take 20,000 units for the first 2-3 weeks just to Keeping a Pulse on Ophthalmology get a mega-dose of vitamin A. Once you're seeing a clinical response you can get back down to the normal ranges," Dr. Lee said. In conjunction with high doses of vitamin A supplementation, use of topical cyclosporine can help to regenerate some of the goblet cells. Restasis (cyclosporine .05%, Allergan, Irvine, Calif.) is the dry eye go-to cyclosporine, but initially Dr. Lee finds vitamin A-deficient patients need an extra boost. "I typically go to a compounded 1% (cyclosporine) when I first start it just to get a higher dose," he said. "Then once they get under better control I switch them to Restasis in a month." In general, the prognosis for pa- tients is excellent when caught early. "Everyone who I've seen so far with this I have been able to completely reverse," Dr. Lee said. "The treat- ment makes the dry eyes better, the corneal clarity returns, the corneal moisture is returned, and the night blindness is completely resolved." However, if the condition is not caught early, more serious problems can ensue. "If it became end-stage, they could begin to develop some permanent retinal damage or even melting of the cornea, which would be severe," Dr. Lee said. "Those cases are much more difficult to restore." Because gastrointestinal disease is a systemic problem, ophthalmolo- gists dealing with such cases should be prepared to keep other practition- ers in the loop. In the case of gastric bypass, Dr. Lee recommended con- tacting the bypass surgeon. "We have to communicate with the gas- tric bypass surgeon what's going on," he said. "The surgeon typically will want to see the patient after we start treatment." For other condi- tions like celiac disease or cystic fi- brosis, he recommends consulting with the patient's internist. He also urges ophthalmologists to link these patients with a nutritionist to help counsel them on their future diet plan. "That has helped us in pre- venting this from happening again in these patients because most GI diseases are going to be recurrent problems," Dr. Lee said. "Patients need to get on a long-term diet to help provide a permanent solution to keep this from occurring." Overall, Dr. Lee urges practition- ers to keep vitamin A deficiency on their radar. "If you see patients who have seen multiple eyecare special- ists with complaints of dry eyes and night blindness, and you see ocular surface findings of xerophthalmia or a Bitot's spot—if those things are seen together, you need to make that link of possible GI disease," he said. "Think about ordering vitamin A levels." EW Editors' note: Dr. Lee has no financial interests related to this article. Contact information Lee: 404-556-2202, lee0003@aol.com Poll Size: 398 EyeWorld Monthly Pulse EyeWorld Monthly Pulse is a reader survey on trends and patterns for the practicing ophthalmologist. Each month we send a 4-6 question online survey covering different topics so our readers can see how they compare to our survey. If you would like to join the current 1,000+ physicians who take a minute a month to share their views, please send us an email and we will add your name. Email ksalerni@eyeworld.org and put EW Pulse in the subject line; that's all it takes. Copyright EyeWorld 2012