Definition

Xerophthalmia is an eye disease characterized by eye dryness due to a deficiency in vitamin A. This condition remains a significant problem in developing countries and is a leading cause of preventable blindness. According to the World Health Organization (WHO), around 254 million children suffer from vitamin A deficiency, with 45% of these cases occurring in South Asia and Southeast Asia. Approximately 8 million children are also affected by xerophthalmia, with around 350,000 new cases reported annually. Xerophthalmia not only leads to blindness but also impairs growth and increases general morbidity and mortality rates.

Causes

The primary cause of xerophthalmia is vitamin A deficiency. Vitamin A provides essential nutrients to the eyes, particularly the clear layer of the cornea. Without sufficient vitamin A, the production of lubricating fluids in the eyes decreases, resulting in dryness.

Vitamin A is obtained through diet, as the body cannot produce it independently. It is vital for absorbing light into the retina and supporting the health of other organs such as the heart, lungs, and kidneys.

Several conditions can lead to vitamin A deficiency. The most common cause is insufficient dietary intake of vitamin A. Disorders affecting vitamin A metabolism and storage can also cause vitamin A deficiency. Examples of those disorders are chronic liver disease, alcoholism, a history of upper gastrointestinal surgery, irritable bowel disease, and pancreatitis.

Risk Factor

Poverty and poor diet, especially the lack of consumption of vitamin A-rich foods, particularly animal products, is a significant risk factor of xerophthalmia. Children need adequate vitamin A for their growth and development. Deficiency in vitamin A can trigger various illnesses, including diarrhea, measles, and respiratory infections.

Several other conditions that can increase the risk of vitamin A deficiency, which in turn can increase the risk of developing xerophthalmia are:

• Alcoholism or chronic alcohol consumption.
• Cystic fibrosis 
• Celiac disease, this condition can inhibit the absorption of nutrients, including vitamin A
• Liver disease, such as cirrhosis
• Chronic diarrhea
• Radiation therapy, such as treatments for conditions such as thyroid cancer 

Symptoms

Xerophthalmia is a progressive disease. Initial symptoms may be mild but can worsen if vitamin A intake remains insufficient. Dryness of the eyes is often experienced. Other common symptoms include:

• Itchy eyes
• Soreness in the eyes
• Redness
• Blurred vision
• Increased sensitivity to light
• Night blindness

In more severe cases, blisters can form on the cornea, known as Bitot's spots. If untreated, it can lead to corneal ulcers. This is quite dangerous because blindness can occur.

Diagnosis

The process of diagnosing xerophthalmia involves a thorough evaluation of the patient's symptoms, physical examination, and diagnostic tests. The doctor will inquire about the patient's eye symptoms and the duration of symptoms. The assessment will also include exploring risk factors, particularly those indicating vitamin A deficiency.

After a detailed medical interview, the doctor will conduct a detailed eye examination. This physical examination includes visual acuity test and examining the eye's structures in detail by using slit lamp examination. During these examinations, the presence of Bitot's spots or deposits in cornea—can indicate severe xerophthalmia.

Blood tests can be performed to measure vitamin A (retinol) levels to confirm deficiency. Low vitamin A levels are indicative of vitamin A deficiency, which supports the diagnosis of xerophthalmia.

Management

Early-stage xerophthalmia can be treated effectively with vitamin A supplements, either orally or through injections. Vitamin A supplements help alleviate night blindness and restore the eye's ability to produce lubricating fluids. Patients are encouraged to consume foods rich in vitamin A, such as:

• Animal source foods, such as beef liver, chicken, salmon, tuna, mackerel, milk, cheese, yogurt, and eggs.
• Plant-based foods, such as spinach, lettuce, carrots, oranges, papaya, and watermelon.

However, if the cornea is already damaged, antibiotics may be prescribed to prevent infection. Additionally, resting or temporarily covering the eyes may be necessary to promote healing. If xerophthalmia is not treated properly, further damage to the nerves and eye tissue can occur, causing blindness.

Complications

Xerophthalmia can lead to corneal ulcers, or injuries to the cornea. Early treatment of corneal ulcers can restore vision. However, in severe cases, some may result in permanent damage, and even surgery may not fully restore vision. The most serious complication of untreated xerophthalmia is permanent blindness.

Prevention

Adequate intake of vitamin A is crucial for preventing xerophthalmia. The recommended daily intake of vitamin A varies by age and gender:

• Adult men: Approximately 3000 units daily
• Adult women: Approximately 2310 units daily
• Pregnant women: At least 2565 units daily
• Children under 13 years old: 2000 units daily
• Children under 8 years old: 1320 units daily
• Children aged 1-3 years: 1000 units daily

In many countries, there are government programs that provide vitamin A supplementation for children every six months. To prevent xerophthalmia in children, it is important to take children aged 0-5 years to local healthcare facilities (such as posyandu in Indonesia) regularly, especially during the scheduled supplementation periods.

Individuals with conditions that interfere with the absorption of vitamin A, such as alcoholism, cystic fibrosis, and liver cirrhosis, may require adjusted amounts of vitamin A, which can be higher than healthy adults. These needs should be determined and monitored by a healthcare professional.

When to See a Doctor?

Consult a doctor if you experience symptoms suggestive of xerophthalmia, such as dry eyes and difficulty seeing clearly, especially at night or in dim light.

Immediate medical attention is important for children showing these symptoms or if they are exposed to conditions that increase the risk of xerophthalmia, such as measles with rashes and fever as symptoms. Early intervention can prevent the progression of the disease and associated complications.

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