Severe Xerophthalmia Research Articles

Premature abandonment of global vitamin A supplementation programmes is not prudent!

Mason et al. provide an overview of vitamin A supplementation (VAS) programmes globally and conclude that the current strategy for biannual supplementation with vitamin A between 6 and 59 months of age has outlived its utility. They base their conclusions on the following main arguments. First, despite VAS programmes, global prevalence of vitamin A deficiency has not changed; second, the evidence on the effectiveness of VAS in terms of child mortality was drawn from studies undertaken over two decades ago and may not be relevant any more in the current context of reduced child mortality especially in deaths related to diarrhoea and measles. They cite heavily the decade-old but recently published Deworming and Enhanced Vitamin A (DEVTA) study in India, where a lower effect size on under5 mortality was seen. Mason et al. conclude by suggesting that dietary diversification and fortification strategies may offer a more effective set of interventions. We concur with the notion that eventually appropriate diets and interventions to reduce poverty and food insecurity may offer the best options to improve health and nutrition status across populations. However, are we at a stage when a well-established and accepted global programme should be abandoned without due attention to the feasibility, current effective coverage and cost-effectiveness of alternative strategies? We strongly believe that such a course could seriously jeopardize gains in child health and survival. There are several arguments to support our contention. First, it is important to note that twice-yearly high-dose vitamin A supplementation is not an intervention to sustainably control vitamin A deficiency, but rather an immediate, life-saving intervention to improve child survival. In the latter context, it is also incorrect to relate VAS programmes to child mortality alone. Whereas admittedly the programme was initiated three decades ago with child mortality impact in mind, it was always meant to improve morbidity outcomes as well. There is ample indirect evidence that this has indeed been achieved in many regions of the world. The current rate of reduction in diarrhoea mortality globally is disproportionate to the change in coverage of Oral Rehydration Solution (ORS) and zinc usage or indeed breastfeeding rates, and has also largely taken place in the very regions (Latin America and South East Asia excluding India) where the rate of progress in reducing child mortality and VAS programme coverage has been highest. Figure 1 shows some of the trends in vitamin A deficiency in countries of the region where population-level vitamin A deficiency and VAS coverage data over the past two decades are available. It is also notable that in contrast to the statement that rates of global vitamin A deficiency have not changed, severe deficiency has indeed disappeared in many regions. Severe xerophthalmia and childhood blindness related to this have significantly reduced and this reduction has been attributed to a combination of success of measles immunization and VAS. Similarly, diarrhoea burden, especially rates of severe and persistent diarrhoea have reduced significantly over the last two decades. The benefits of VAS may thus extend well beyond mere mortality impact. Caution must be exercised in using the results from the DEVTA study to make the case that the programme effectiveness is questionable. Numerous concerns have been expressed about the completeness of data capture in that

Clinical study on spanishneedles leaves in treatment of middle and severe xerophthalmia of menopausal females

To investigate the clinical effect of spanishneedles leaves on middle and severe xerophthalmia of menopausal females. This study was a prospective random controlled trial. Ninty-six menopausal females diagnosed with xerophthalmnia (aged from 40 to 50) were randomly divided into in two groups: group A' the spanishneedles leaves group (n=48) and group B' the control group (n=48). Both groups were treated with Forte eye drops. All patients were detected at 3, 7, 28 h before and after treatment to evaluate subjective symptoms, OSDI and four tear film indicators. Variance analysis and differential analysis on sample average or median were made on both groups before and after treatment. There were no significant difference in symptom and diction indicators between both groups before treatment. For 28 d after treatment, among middle and severe xerophthalmia samples of the spanishneedles leaves group, the mean differences showed significant improvement compared with that before treatment , OSDI and four tear film indicators also showed improvement to varying degrees. For 28 d after treatment, among middle and severe xerophthalmia samples of the vitamin C group, the mean differences showed no significant improvement compared with that before treatment , OSDI and four tear film indicators also showed no remarkable improvement. There were significant differences in OSDI, BUT, SIT, height of tear meniscus and FL between both groups. Spanishneedles leaves can effectively improve symposiums and signs of middle and severe xerophthalmia among menopausal females and thus showing clinical significance to some extent.

Acute dacryoadenitis as atypical presentation in Sjögren Syndrome

AbstractPurpose To present a case report of a patient with acute dacryoadenitis as an atypical clinical presentation of Sjögren Syndrome.Methods A 37‐year‐old female developed acute left dacryoadenitis with poor response to oral corticosteroids. She had no history of any other clinical symptoms. During the following weeks she developed cervical lymphadenopathies, arthralgia and mild asthenia. Complete blood analysis, imaging diagnostic techniques, C‐reactive protein (CRP) and autoimmunity tests showed normal results, but high levels of anti‐Ro antibodies were found, suggesting Sjögren Syndrome (SS) as the etiopathological cause.Results All symptoms and clinical findings improved after successive treatment with intravenous corticosteroids, hydroxychloroquine and azathioprine. At the present moment the patient remains stable using maintenance treatment with immunosuppressive drugs.Conclusion Chronic destruction of the lacrimal gland is the most common cause of dry eye and ocular symptoms in SS. Acute dacryoadinitis is considered an atypical manifestation of this syndrome. Classical systemic corticosteroids treatment for SS usually needs association of immunosuppressive drugs, including biological treatments as a recent new option to control the disease progression and inflammatory activity. Topic cyclosporine and pilocarpine have reported benefits for severe xerophthalmia in recent medical trials.

Tratamento das cavidades anoftálmicas secas com transplante de glândulas salivares labiais

To study the clinical effects of labial salivary glands' secretion used as ocular lubricant in anophthalmic cavities with severe xerophthalmia; to evaluate the evolution of the results; and to present the surgical technique. This procedure application in dry anophthalmic cavities is new in the literature. Prospective study of patients presenting anophthalmic cavities with severe xerophthalmia and conjunctival fornix retraction treated with labial salivary glands transplantation to the conjunctival fornices. The surgeries were performed in five patients during the period of July 2000 to January 2009. In two cases the fornix retraction was previously treated with mucosa or skin graft. The surgical procedure technique is described in details. The postoperative comparative analysis was based on the clinical picture, the cavity surface aspect, the dryness of the cavity and prosthesis and the frequency of lubricant eye drops use. In all cases both graft integration and improvement of the evaluated parameters were observed. The evolution proved the persistence and stability of the results. The salivary secretion produced by the transplanted labial glands proved to be efficient as conjunctival lubricant, well tolerated and permanent, making the use of the prosthesis more comfortable. This improvement helps to prevent the progression of the cavity retraction process. Labial salivary glands graft into the anophtalmic cavity is a simple procedure and accessible to any ophthalmic surgeon.

Bilateral microbial keratitis in a case of severe xerophthalmia following small bowel resection

Vitamin A deficiency is increasing. Early identification of high-risk patients and rapid treatment can prevent potentially fatal and blinding complications.

Corneal Epithelial Cell Fate Is Maintained during Repair by Notch1 Signaling via the Regulation of Vitamin A Metabolism

Integrity and preservation of a transparent cornea are essential for good vision. The corneal epithelium is stratified and nonkeratinized and is maintained and repaired by corneal stem cells. Here we demonstrate that Notch1 signaling is essential for cell fate maintenance of corneal epithelium during repair. Inducible ablation of Notch1 in the cornea combined with mechanical wounding show that Notch1-deficient corneal progenitor cells differentiate into a hyperplastic, keratinized, skin-like epithelium. This cell fate switch leads to corneal blindness and involves cell nonautonomous processes, characterized by secretion of fibroblast growth factor-2 (FGF-2) through Notch1(-/-) epithelium followed by vascularization and remodeling of the underlying stroma. Vitamin A deficiency is known to induce a similar corneal defect in humans (severe xerophthalmia). Accordingly, we found that Notch1 signaling is linked to vitamin A metabolism by regulating the expression of cellular retinol binding protein 1 (CRBP1), required to generate a pool of intracellular retinol.

Submandibular Gland Transfer for Severe Xerophthalmia

To report early clinical experience with a new microvascular reconstructive procedure for patients with severe xerophthalmia. Retrospective clinical series. Patients with severe xerophthalmia were referred for treatment after having exhausted all conventional means of treatment. The ipsilateral submandibular gland was transferred to the temporal fossa, as described by Macleod et al., and revascularized using the superficial temporal artery and appropriate vein(s). The submandibular duct was directed to the superolateral fornix so that the saliva produced moistened the eye. Results and complications were reviewed. Seven microvascular submandibular gland transfer procedures were performed in five patients, ages 6 to 54. The etiology of severe xerophthalmia was Stevens-Johnson syndrome in four and chemical burn in one. Follow-up time was 4 to 20 months. Successful transfer with revascularization was achieved in six of seven (86%) cases. Schirmer's test scores improved from 1.3 pretransfer to 8.1 posttransfer (P = .005). Patients experienced symptomatic relief within 1 month, and the microenvironment of the eye surface improved enough to make them candidates for visual restorative eye surgery. There were no major complications. Microvascular submandibular gland transfer is an effective approach for correcting severe xerophthalmia. The procedure should be within the skills of any reconstructive microsurgeon. This procedure offers a unique opportunity for otolaryngologist-head and neck reconstructive surgeons to help restore vision to this unfortunate group of patients.

Establishment of submandibular gland allotransplantation model in miniature swine

Autologous transplantation of the submandibular gland (SMG) into the temporal fossa with microvascular anastomosis has been successfully applied in severe xerophthalmia patients as a permanent tear substitute. However, severe xerophthalmia can be accompanied by salivary gland dysfunction, making such autotransplantation unsuitable. Therefore, SMG allotransplantation might be a solution. The aim of this study was to assess the technical feasibility of submandibular gland allotransplantation. Twelve miniature swine were randomized to serve as donors or recipients. One SMG was transplanted between a donor and a recipient. The donor SMG was revascularized by microvascular anastomosis of its vascular pedicle to the recipient lingual artery and external jugular vein. The secretory duct was implanted into the vestibule of the mouth through a subcutaneous tunnel. No immunosuppressive agent was administered. The results were assessed by visual inspection of the secretion, and histopathological examination of the transplanted SMG. Technically, all surgical procedures were successful. Clear secretion flowed out of the duct as soon as blood supply of the transplanted submandibular gland was reestablished. The secretion of the gland lasted for 5 days. As expected, an acute rejection reaction occurred after surgery because no immunosuppressive agents were used. Secretion from the transplanted SMG ceased within 5 days. A model of SMG allotransplantation can be established in miniature swine. The technique of submandibular gland allotransplantation is feasible.

Control of Vitamin A Deficiency in Vietnam: Achievements and Future Orientation

Vitamin A deficiency is one of the major nutritional deficiencies in Vietnam. The first survey, conducted in 1985-1988 showed that the prevalence of severe xerophthalmia was seven times higher than the cutoff point established by the World Health Organization (WHO) to define vitamin A deficiency as a public health problem. The result of this survey strongly convinced the government to launch a program to control vitamin A deficiency, which started in 1988. The program strategies included nutrition education, universal distribution of high-dose vitamin A capsules to children aged 6 to 36 months in combination with national immunization days, and promotion of production and consumption of vitamin A-rich foods at the family level. The implementation network was set up based on the existing preventive health structure at all administrative levels. Organizations such as the women's union and other social sectors have participated actively in the program. Surveys conducted in 1994 and 1998 showed that the prevalence of clinical xerophthalmia was significantly lower than that identified in the baseline survey and below the WHO criteria for a public health problem. The achievements of our program have demonstrated that an effective vitamin A supplementation program can be implemented successfully by the preventive health network with active community participation. In the coming years, it will be important for our program to develop approaches other than vitamin A supplementation in order to maintain the past achievements.

Vitamin A deficiency in cystic fibrosis resulting in xerophthalmia

We report a case of severe vitamin A deficiency in a patient with cystic fibrosis due to a combination of poor compliance, malabsorption and probable disordered metabolism of vitamin A in the liver. He presented with severe xerophthalmia, clinical resolution of which necessitated intramuscular vitamin A administration.

Control of Vitamin A Deficiency and Blindness

Vitamin A deficiency and its obvious consequences, xerophthalmia and blindness, are endemic in large parts of Asia and Africa. The prevalence of this deficiency is particularly high in countries of South‐East Asia like India, Bangladesh, Nepal, Indonesia and Philippines. In African countries, most cases of childhood blindness are attributed to measles. It is most likely, however, that measles precipitates severe xerophthalmia in children whose vitamin A status is marginal.

Nutritional Blindness: Xerophthalmia and Keratomalacia

In the preface to this monograph, the author states that approximately 0.5 million children in depressed populations in developing countries have severe xerophthalmia and that another 5 to 10 million children have milder forms of xerophthalmia. It can also affect persons with liver disease, malnutrition, and malabsorptive states (eg, diarrhea). To provide a more complete study of the epidemiologic, clinical, therapeutic, and pathologic aspects of the disorder, the author undertook a three-year research program in Indonesia. Retinol (an alcohol form of vitamin A) is formed in the small intestine from either provitamin A carotenoids or fat-soluble vitamin A (retinyl palmitate), where it is absorbed systemically or stored in the liver. Because retinol is so important in the visual cycle of the photoreceptors of the retina, the author found that nightblindness, with impaired dark adaptation,

Evaluation of the efficacy of programs for the control of severe xerophthalmia

Programs that improve the vitamin A status of preschool children in countries where xerophthalmia is endemic have not convincingly demonstrated prophylactic efficacy in controlling severe xerophthalmia and resultant blindness. Case-control methods applied to this problem are more efficient and less expensive than population survey methods. The effects of sample size and incomplete distribution of vitamin A on the precision of estimates of efficacy are discussed.

ORAL VERSUS INTRAMUSCULAR VITAMIN A IN THE TREATMENT OF XEROPHTHALMIA

In a controlled trial 69 children with corneal xerophthalmia were given 200 000 IU oil-miscible vitamin A by mouth and a matched group of 45 children were given 100 000 IU water-miscible vitamin A intramuscularly. Both groups received an additional oral dose the next day. There was no detectable difference in the clinical response to the two regimens, even when analysis was limited to patients with concomitant diarrhœa or protein-energy malnutrition. Although serum-vitamin-A levels were significantly higher after parenteral than oral therapy, holoretinol-binding-protein levels were not. Oral administration of vitamin A is not only more practical but appears to be just as effective as parenteral administration in the treatment of severe xerophthalmia.

Sequelae of severe xerophthalmia—a follow-up study

Two-hundred sixteen children with vitamin A deficiency were hospitalized in Hyderabad, India, between 1970 and 1977. Out of these, 22 died during hospitalization. Fifty-six children could be followed-up, of whom 32 had keratomalacia and 24 corneal xerosis. In the keratomalacia group, nine died of reasons attributable to severe protein-energy malnutrition within 3 to 4 months after discharge from the hospital, five became totally blind, nine monocularily blind, and nine had adequate vision, although four of these had leucomas. Of the blind children, no change in condition was noted in the 11 located 1 year after the initial 3 to 4 month follow-up period. Of the 24 children with corneal zerosis, two died within 3 months, 21 retained normal vision, and one had adequate vision with leucoma. The high death rate, i.e., 30% of the keratomalacia cases in this study helps to explain the low prevalence of keratomalacia observed in past and current community surveys. The high return to normalcy of vision in the corneal xerosis cases after proper treatment support the recommendation of treating all children with eye involvement before the keratomalacia state whenever possible, for greater assurance of subsequent eye improvement.

A Nutrition Rehabilitation Centre for Children with Xerophthalmia

A nutrition rehabilitation centre for treatment of children with xerophthalmia was established in Madurai, India. Treatment was based on provision of locally available food, rich in protein and beta-carotene and cheap enough for the families concerned to buy at home. This diet alone, with general medical treatment for other diseases, was sufficient to reverse conjunctival xerophthalmia and corneal xerosis. Children with more severe xerophthalmia received additional vitamin A. The records of 296 children followed up for between two months and three years were analysed. The results of treatment at the centre seemed as good as those produced by more expensive, and usually unobtainable, hospital treatment. Participation of the mother in buying, cooking, and sharing the food given to her child was of some educational value.