OP10.4 | Vitamin A Deficiency: Ocular Manifestations, Management and Referral — Summary & Reflection

KEY TAKEAWAYS

Vitamin A Deficiency / Xerophthalmia — Key Points:

• Vitamin A deficiency causes night blindness (rhodopsin depletion) and ocular surface keratinisation (goblet cell loss).
• WHO staging order (MUST know in order): XN (night blindness) → X1A (conjunctival xerosis) → X1B (Bitot's spots — CONJUNCTIVAL, NOT corneal) → X2 (corneal xerosis — critical threshold) → X3A (keratomalacia <1/3 cornea) → X3B (keratomalacia ≥1/3 cornea) → XS (scar) → XF (fundus).
• Bitot's spots (X1B): Foamy white triangular deposit on the TEMPORAL BULBAR CONJUNCTIVA — CONJUNCTIVAL lesion; corneas are clear at this stage.
• X2 and above = corneal involvement = urgent ophthalmology referral.
• Treatment (WHO, children >1 year): 200,000 IU on Day 1, Day 2, and Day 14.
• Measles: Give vitamin A (200,000 IU Day 1 + Day 2) to ALL measles-admitted children regardless of eye signs.
• India — NPCBVI supplementation: 100,000 IU at 6 months; 200,000 IU every 6 months from 18 months to 5 years.
• Vitamin A-rich foods: liver, egg, dairy (fat-containing), dark leafy greens, yellow/orange fruits.
• Differential: Bitot's spots vs pinguecula (adults); night blindness vs retinitis pigmentosa; keratomalacia vs bacterial keratitis.

REFLECT

Consider the child from the hook — she had night blindness and Bitot's spots (XN + X1B). She was at the stage where a single course of vitamin A supplementation could prevent permanent corneal blindness. Now think: what would have happened if the community health worker had been told 'it's just dry eyes, apply some drops and come back next month'? In your future practice — whether at a district hospital, PHC, or urban slum clinic — you will encounter malnourished children. Make it a habit to examine both eyes of every malnourished child. Look at the conjunctiva in the temporal quadrant. If you see a foamy white deposit, start vitamin A that day. Don't wait for a referral letter to come back from the district hospital.