Grand RoundsGrand Rounds

Vitamin A DeficiencyVitamin A Deficiency

Amir R. Hajrasouliha, M.D.Amir R. Hajrasouliha, M.D.

University of LouisvilleUniversity of Louisville

Department of Ophthalmology and Visual SciencesDepartment of Ophthalmology and Visual Sciences

Friday, March 7th, 2014Friday, March 7th, 2014

Patient PresentationPatient Presentation CCCC:”I am going blind”:”I am going blind”

HPIHPI: 65 y/o WM present to us with gradual : 65 y/o WM present to us with gradual decreased vision OU for the past 8-10 decreased vision OU for the past 8-10 months. He claim his vision is worse at months. He claim his vision is worse at night and indoors. He had no pain or night and indoors. He had no pain or discomfort. discomfort.

He was told by an outside He was told by an outside ophthalmologist that he will eventually go ophthalmologist that he will eventually go blind and there is no treatment available blind and there is no treatment available for his condition. He came to our clinic for for his condition. He came to our clinic for second opinion. second opinion.

Patient PresentationPatient Presentation Past ocular historyPast ocular history::

Foreign bodies in cornea removed (4 years ago)Foreign bodies in cornea removed (4 years ago)

Past medical HistoryPast medical History::

Gastric bypass 1998Gastric bypass 1998 Kidney failure on Dialysis 2010Kidney failure on Dialysis 2010 Diabetes from 2008Diabetes from 2008 HypertensionHypertension

Social historySocial history: : EtOH abuser, heavy smokerEtOH abuser, heavy smoker

ROS:ROS: Kidney failure, Heart failure, NeuropathyKidney failure, Heart failure, Neuropathy

Allergy:Allergy: NKDA NKDA

ExamExam

VA cc VA cc PP T TTPTP

EOM: Full OU CVF: Full OUEOM: Full OU CVF: Full OU

20/200

42mm

42mm

16

17(-) RAPD

20/200

ODOD OSOS

E/L/LE/L/L wnlwnl wnlwnlConjConj clearclear clearclearKK clearclear clearclearACAC formedformed formedformed

IrisIris wnlwnl wnlwnlLensLens 1+NS1+NS 1+NS 1+NS

Anterior examAnterior exam

DFE: DFE:

Red freeRed free

OCTOCT ODOD

Subfoveal deposit with no Subfoveal deposit with no fluidfluid

OCTOCT

OSOS

Subfoveal deposit with no Subfoveal deposit with no fluidfluid

Fluorescence Fluorescence angiographyangiography

Visual field Visual field

OD OSOD OS

HVF 24-2: Paracentral scotoma HVF 24-2: Paracentral scotoma ODOD

Centeral scotoma OSCenteral scotoma OS

Assessment and planAssessment and plan

68 y/o WM with gradual vision loss 68 y/o WM with gradual vision loss OU and subfoveal deposits OU and OU and subfoveal deposits OU and history of gasteric resection.history of gasteric resection. Vitamin DeficiencyVitamin Deficiency Vitiliform maculopathyVitiliform maculopathy

PlanPlanPt started on vitamins (Ocuvite) and ERG and Pt started on vitamins (Ocuvite) and ERG and EOG orderedEOG ordered

EOG shows an attenuated Arden Ratio OU. EOG shows an attenuated Arden Ratio OU. The full-field ERG reveals severe rod and cone dysfunction The full-field ERG reveals severe rod and cone dysfunction

OU. OU.

Arden Ratio Arden Ratio

=1.5 OD=1.5 OD

Arden Ratio Arden Ratio

=1.1 OS=1.1 OS

Follow upFollow up

Pt returned in 8 months with Pt returned in 8 months with improved symptom and BCVA of improved symptom and BCVA of 20/20 OD and 20/20 OD and

20/40 OS 20/40 OS

Follow upFollow up

Follow up OCTFollow up OCT

ODOD

OSOS

Vitamin AVitamin ACompounds with 20-carbon structure.

Contain a methyl substituted cyclohexenyl ring (-ionone ring),

and an isoprenoid side chain with either a hydroxyl group, and aldehyde group, a carboxylic acid group, or an ester group (retinyl ester) at the terminal C15.

All-trans-retinal

11-cis-retinal

Retinol Retinoic AcidCan’t be reduced to retinol or retinal in the

body.

Bitot spotBitot spot

Corynebacterium xerosis

Vitamin A DeficiencyVitamin A Deficiency Xerophthalmia refers to the ocular Xerophthalmia refers to the ocular

manifestations associated with vitamin A manifestations associated with vitamin A deficiency. deficiency.

These include xerosis, keratomalacia, These include xerosis, keratomalacia, nyctalopia and Bitot’s spots.nyctalopia and Bitot’s spots.

Visual cycleVisual cycle

Miyazono S et al. PNAS 2008;105:16051-16056

Case reportCase report A case report of 61 year A case report of 61 year

old male with history of old male with history of bariatric gastric surgery bariatric gastric surgery present with night present with night blindness and fundus blindness and fundus white spots. After white spots. After treatment with oral treatment with oral Vitamin A for 2 months Vitamin A for 2 months vision and ECG changes vision and ECG changes improved.improved.

Fishman et al. Fundus white spots and acquired night blindness due to vitamin A deficiency. Doc Ophthalmo 2009;119UIC chicago

Full-Field electroretinogram (ERG) responses Full-Field electroretinogram (ERG) responses before and after therapy with Vitamin A in before and after therapy with Vitamin A in dark-adapted (A) and light adabted (B) dark-adapted (A) and light adabted (B) conditionsconditions

Thank YouThank You