Xerophthalmia

Xerophthalmia remains an important cause of preventable childhood blindness in low- and middle-income countries. WHO estimates that hundreds of millions of children are at risk of VAD and that clinical xerophthalmia remains a public-health concern where diets and supplementation coverage are inadequate. Exact frequency varies by region and surveillance method. It leads to dryness and damage to the ocular surface, especially the conjunctiva and cornea, which, if left untreated, can result in severe vision impairment or blindness. Understanding its causes, symptoms, and prevention is vital for safeguarding eye health.

What is Xerophthalmia?

Xerophthalmia is an eye condition caused by a deficiency of vitamin A, leading to severe dryness of the eyes and tear ducts. This deficiency leads to a dry, thickened, and lacklustre appearance of the eyeball. As the condition progresses, it can cause various symptoms, including dry eyes, night blindness, and damage to the cornea. If left untreated, xerophthalmia can ultimately result in permanent vision loss or blindness. Vitamin A supplementation is the cornerstone of treatment and can reverse early ophthalmic signs (night blindness, conjunctival xerosis, Bitot’s spots) and reduce mortality in deficient children. Corneal ulceration/keratomalacia can progress to scarring and permanent vision loss despite supplementation; early recognition and prompt treatment are essential.

Xerophthalmia, a progressive eye disease caused by vitamin A deficiency, presents with symptoms that reflect its advancing stages. These include night blindness, dry and wrinkled conjunctiva, Bitot's spots, corneal xerosis, and, in severe cases, corneal ulcers and keratomalacia.

• Dry Eyes: The eyes may feel dry, gritty, or irritated due to the lack of moisture on the eye's surface.
• Night Blindness: Difficulty seeing in low light conditions, as vitamin A is essential for the proper functioning of the retina.
• Ulcers or Scars on the Cornea: Small, superficial lesions may appear on the cornea, which can lead to scarring if left untreated.
• Bitot's Spots: White, foamy patches on the conjunctiva, which are a classic sign of vitamin A deficiency.
• Permanent Blindness: If xerophthalmia progresses without treatment, it can result in irreversible blindness.
• Conjunctival Xerosis: The conjunctiva, the clear membrane covering the white part of the eye, becomes dry and rough due to a lack of tear production, leading to irritation and discomfort.
• Corneal xerosis, a key symptom of xerophthalmia, is characterised by a dry, dull appearance of the cornea, often starting with superficial, punctate lesions in the lower nasal quadrant. 
• Keratomalacia (corneal liquefactive necrosis): severe vitamin A deficiency may cause corneal softening and necrosis (keratomalacia), which can lead to perforation, infection, scarring, and permanent visual loss if not treated urgently.
• Xerophthalmic Fundus: The retina develops characteristic white or yellowish spots due to prolonged vitamin A deficiency, affecting vision and increasing the risk of permanent eye damage.

It is crucial to recognise these symptoms early and initiate appropriate treatment with vitamin A supplementation to prevent the progression of xerophthalmia and its consequences

Xerophthalmia, a condition caused by vitamin A deficiency. It is classified by the World Health Organization (WHO) into stages based on the severity of ocular manifestations, which categorise the condition as follows:

WHO clinical classification of xerophthalmia:

• XN- Night blindness (nyctalopia)
• X1A- Conjunctival xerosis (dry, wrinkled conjunctiva)
• X1B- Bitot’s spots (foamy, keratinised patches on bulbar conjunctiva)
•  X2- Corneal xerosis (dry, hazy cornea)
• X3A - Corneal ulceration/keratomalacia affecting <1/3 corneal surface
• X3B - Corneal ulceration/keratomalacia affecting ≥1/3 corneal surface
• XS - Corneal scar(s) from previous keratomalacia
• XF - Xerophthalmic fundus (retinal changes seen with prolonged severe deficiency)

(Use these WHO codes when grading clinical findings.)

Xerophthalmia is primarily caused by vitamin A deficiency, a crucial nutrient for maintaining eye health.

• Vitamin A deficiency may result from inadequate intake, malabsorption, impaired storage, or increased physiological requirements. The deficiency of Vitamin A is rare in developed countries, but it remains a significant health issue in many developing nations. Children in these regions often lack access to vitamin A-rich foods, making them particularly vulnerable to xerophthalmia and related eye disorders.

Several factors can increase the likelihood of developing xerophthalmia, including:

• Risk groups: preschool children (6–59 months) in areas with low dietary vitamin A or low supplementation coverage are at the highest population risk; measles and diarrhoeal disease markedly increase the risk of clinical deficiency and mortality, and pregnant or lactating women may also be at risk in endemic settings (WHO, 2023).
• Illnesses like measles and respiratory infections increase the body’s demand for vitamin A, raising the risk of xerophthalmia in children.
• Infants are at a higher risk of developing critical complications, with children between 3 to 6 years of age being particularly prone to night blindness due to vitamin A deficiency.
• Additional Risk Factors in Children and Adults
• Limited access to nutritious food makes people from low-income backgrounds more vulnerable to xerophthalmia.
• Individuals unaware of the importance of vitamin A may fail to include it in their diets, increasing their risk of deficiency.
• Poor overall nutrition, especially in developing regions, leads to vitamin A deficiency, causing dry eyes and night blindness.
• Diseases like pancreatitis or inflammatory bowel disease can hinder the body’s ability to absorb vitamin A, leading to deficiency.
• Chronic liver diseases, such as cirrhosis, interfere with vitamin A storage and absorption, contributing to xerophthalmia.
• Frequent diarrhoea depletes the body's vitamin A reserves, increasing the likelihood of developing xerophthalmia.
• Excessive alcohol consumption depletes vitamin A levels, affecting eye health and increasing the risk of deficiency-related vision problems.

Who's at Risk?

Certain groups of people are more susceptible to developing xerophthalmia:

• Infants and children
• People in developing countries
• Those living in poverty

Targeting these high-risk groups with vitamin A supplementation programmes and nutrition education can help prevent the occurrence of xerophthalmia and its associated complications.

If left untreated, xerophthalmia can progress and lead to several severe complications, including:

• Dry Eye Syndrome: In the early stages, xerophthalmia presents as dry, irritated eyes, which can progress to more severe issues if not addressed promptly.
• Systemic impact: clinical vitamin A deficiency increases susceptibility to infections (e.g., measles, diarrhoea) and is associated with increased childhood morbidity and mortality; vitamin A supplementation reduces mortality in deficient populations.
• Corneal Ulceration: As the condition advances, the cornea, the clear front surface of the eye, can develop painful ulcers, increasing the risk of infection and permanent vision loss.
• Keratomalacia: This is a severe softening and thinning of the cornea, which can lead to corneal perforation and blindness if not treated urgently.
• Night Blindness: Vitamin A deficiency can impair the function of the retina, leading to difficulty seeing in low light conditions, a condition known as night blindness.
• Increased Susceptibility to Infections: Vitamin A plays a crucial role in maintaining the integrity of the eye's surface and supporting the immune system. Its deficiency can increase the risk of eye infections and other infectious diseases.

Timely diagnosis and treatment of xerophthalmia are essential to prevent these serious complications and preserve vision.

The most effective way to prevent xerophthalmia is by ensuring adequate vitamin A intake through a well-balanced diet. Consuming foods rich in vitamin A can help maintain eye health and prevent deficiency-related issues.

Vitamin A-Rich Foods for Prevention

• Dark green leafy vegetables – Spinach, kale, and collard greens are excellent sources of vitamin A.
• Yellow and orange fruits – Apricots, mangoes, papayas, and cantaloupes provide essential nutrients that support vision.
• Yellow vegetables – Squash, pumpkin, and yams are packed with beta-carotene, which the body converts into vitamin A.
• Carrots – A well-known source of beta-carotene that plays a crucial role in eye health.
• Liver – Beef and chicken liver are among the richest sources of preformed vitamin A.
• Egg yolks – Contain vitamin A and other essential nutrients that promote eye function.
• Fish liver oils – Cod liver oil and other fish-based oils provide a concentrated source of vitamin A.
• Vitamin A– Fortified foods and drinks – Many dairy products, cereals, and plant-based milk alternatives are enriched with vitamin A.

Vitamin A Supplementation

In addition to a vitamin A-rich diet, supplementation can help prevent xerophthalmia, especially in individuals at risk of deficiency. Increasing vitamin A intake through supplements is particularly beneficial for people with poor dietary intake or absorption issues. However, supplementation should be monitored by healthcare providers, as excessive vitamin A intake can be toxic and potentially fatal.

Incorporating these foods into daily meals not only helps prevent xerophthalmia but also supports overall health and well-being.

Healthcare providers use several methods to diagnose xerophthalmia:

• Medical History Assessment: The provider will review the patient’s dietary habits and overall health to identify potential vitamin A deficiency.
• Comprehensive Eye Examination: A detailed evaluation of the eyes will be conducted to assess dryness, damage, and any visible abnormalities.
• Clinical Signs Assessment: The provider will observe key symptoms such as dryness, night blindness, or corneal damage to determine the severity of the condition.
• Blood Tests: Serum/plasma retinol or retinol-binding protein can support diagnosis and assess population status, but serum retinol is homeostatically controlled and may be unreliable in mild/moderate disease or during infection. Clinical signs (WHO grading) remain central for diagnosing xerophthalmia in individual patients (Hodge, 2023).
• Night Vision and Dark Adaptation Tests: These tests evaluate how well the eyes adjust to dim lighting and how quickly they adapt to darkness.
• Impression Cytology: A sample from the conjunctiva will be analysed to detect abnormalities in the surface of the eye.

Electroretinogram (ERG): may demonstrate rod dysfunction in selected cases or research settings, but is not required for routine diagnosis; clinical history and conjunctival/corneal signs are the primary diagnostic elements.

The primary treatment for xerophthalmia is vitamin A supplementation, which can be administered either orally or through injections. The dosage depends on the individual's age and overall health condition. Early intervention with vitamin A can help restore vision and prevent further complications.

In more advanced cases where the cornea is damaged, additional treatments may be necessary. Antibiotics may be prescribed to prevent secondary infections, and in severe cases, the affected eye may need to be covered to protect it while the corneal lesion heals. Prompt medical attention is essential to prevent permanent vision loss.

Managing xerophthalmia involves a range of treatments designed to relieve symptoms and improve eye health. These include:

• Artificial Tears and Lubricants: The primary treatment for xerophthalmia involves the use of artificial tears and lubricating eye drops to alleviate dryness and discomfort. These products help to replace lost tear film and provide temporary relief from symptoms.
• Vitamin A Supplementation: Since vitamin A deficiency is a common cause of xerophthalmia, oral or topical vitamin A supplements are used to address the deficiency and promote eye health.
• Topical Anti-inflammatory Agents: In cases where inflammation contributes to symptoms, topical anti-inflammatory agents, such as corticosteroids, may be prescribed to reduce inflammation and improve symptoms.
• Tear conservation measures (punctal occlusion/plug, cautery) may be considered for chronic dry eye or where lacrimal drainage contributes to symptoms, but in true xerophthalmia, the priority is systemic vitamin A therapy and ocular surface protection; punctal occlusion is rarely the first-line treatment for vitamin A-deficiency keratopathy and should be considered only by ophthalmology specialists after systemic correction.
• Environmental Modifications: Using humidifiers, avoiding smoke and allergens, and taking breaks from prolonged screen use to reduce eye strain and dryness.
• Surgical Interventions: In severe cases where other treatments are ineffective, surgical interventions such as punctal cautery or tarsorrhaphy may be considered. These procedures help to reduce tear drainage or provide additional protection to the ocular surface.

Preventing Vitamin A Deficiency Through Nutrition

• Proper nutrition education plays a crucial role in helping individuals maximise the benefits of available food resources. Raising awareness about vitamin A-rich foods and encouraging a balanced diet can help prevent deficiency.
• Food fortification (e.g., vegetable oils, margarine, sugar, flour, and some cereals) and dietary diversification are important public-health strategies to prevent VAD. Fortification practices vary by country; specific fortified items differ regionally.
• Biofortified crops (e.g., ‘golden rice’, orange-fleshed sweet potato, biofortified maize) are potential long-term strategies to reduce VAD; adoption and programmatic impact vary by region, and implementation considerations (acceptability, regulatory approval, agricultural suitability) influence effectiveness. 

Medications for Xerophthalmia

1. Vitamin A Supplementation (Core Treatment)

The cornerstone of xerophthalmia management is high-dose vitamin A replacement therapy, as recommended by the World Health Organisation (WHO).

Recommended Vitamin A Dosage (for children):

• Age ≥ 12 months:
• 200,000 IU orally immediately
• Repeat 200,000 IU on day 2
• Third dose of 200,000 IU after 2–4 weeks
• Age 6–11 months:
• 100,000 IU orally, following the same schedule
• Age < 6 months:
• 50,000 IU orally on the same schedule

Adults with vitamin A deficiency:

Treatment (clinical xerophthalmia): follow WHO treatment schedules for clinical xerophthalmia (children): 50,000 IU for infants <6 months; 100,000 IU for 6–11 months; 200,000 IU for children ≥12 months - given on diagnosis, the next day, and a third dose 4 weeks later (use IM when malabsorption or vomiting prevents oral dosing). For older children and adults, dosing should be individualised by clinicians; in resource-limited settings, the WHO child regimen is the standard for children with xerophthalmia. Avoid routine ultra-high daily doses for adults without specialist guidance; high single doses and repeated dosing need medical oversight because of toxicity and teratogenic risk in pregnancy (WHO, 2023)(Feroze & Kaufman, 2023).

Examples of vitamin A formulations:

• Retinyl palmitate or retinyl acetate capsules: These are oral forms of vitamin A that help restore depleted vitamin A levels in the body, which is the root cause of xerophthalmia. They aid in improving tear production, regenerating epithelial tissues of the eye, and preventing further corneal damage.
• Injectable vitamin A (oil base, IM): indicated when oral administration is not possible (severe vomiting or malabsorption). Oil-based injectable preparations must never be given intravenously. Dosing and route should follow national/WHO protocols and be supervised by clinicians experienced in managing VAD. 

2. Topical Eye Treatments

These provide symptomatic relief and prevent complications associated with corneal dryness and ulceration.

• Preservative-free artificial tears (e.g., carboxymethylcellulose, hydroxypropyl methylcellulose)
• Lubricate and soothe dry eyes
• Lubricating eye ointments (e.g., paraffin-based or vitamin A ophthalmic ointment)
• Especially beneficial overnight
• Topical vitamin A/retinoids: topical vitamin A ophthalmic preparations (or retinoids) have been used in some settings for conjunctival keratinisation, but evidence is limited; these should be used only under specialist ophthalmology guidance and do not replace systemic high-dose vitamin A for clinical xerophthalmia.

3. Antibiotic Therapy (for Secondary Infections)

In advanced xerophthalmia, corneal ulcers or conjunctival infections may develop, necessitating antibiotic treatment.

• Topical antibiotics (e.g., chloramphenicol, ciprofloxacin, or erythromycin ointment)
• Used to treat or prevent bacterial superinfection
• Systemic antibiotics may be needed in cases of keratomalacia or when there is evidence of systemic infection.

4. Supportive & Nutritional Measures

• Multivitamin supplements containing vitamin A, D, E, and zinc
• Help correct concurrent deficiencies
• High-protein and vitamin-rich diet
• Emphasis on green leafy vegetables, carrots, sweet potatoes, and dairy products
• Zinc supplementation (e.g., zinc sulfate)
• May support epithelial healing and immune function

5. Preventive Strategies & Health Education

• Health education programs: Promote awareness of vitamin A-rich diets and early signs of deficiency
• Routine vitamin A prophylaxis in high-risk populations (e.g., children in developing countries)
• As per WHO guidelines, children aged 6 months to 5 years should receive periodic high-dose vitamin A in endemic areas.

Measles management: Children with measles are at high risk for xerophthalmia and should receive vitamin A as part of treatment

It is important to see a doctor if symptoms of xerophthalmia persist or worsen. Dry eyes that are unresponsive to conventional treatment, night blindness, or any other unusual vision issues should prompt immediate consultation with a healthcare provider. Early diagnosis and treatment are crucial to preventing permanent damage and restoring vision. A doctor can perform a comprehensive eye examination, assess the severity of the condition, and recommend the most appropriate course of treatment. Regular follow-up visits may be necessary to monitor the progress of treatment and make any necessary adjustments.

• Xerophthalmia is a group of eye signs and symptoms caused by vitamin A deficiency.
• The primary treatment for xerophthalmia is high-dose vitamin A supplementation, as recommended by the World Health Organization.
• Topical treatments, such as preservative-free artificial tears and antibiotics for secondary bacterial infections, may be used in conjunction with vitamin A therapy.
• Early diagnosis and treatment of xerophthalmia significantly improve outcomes and can help prevent blindness and other serious complications.
• Adequate intake of vitamin A-rich foods, such as eggs, chicken, carrots, citrus fruits, mangoes, whole milk, and green leafy vegetables, is crucial for the prevention of xerophthalmia.
• Seek urgent medical attention for night blindness, corneal pain, redness, reduced vision, or suspected ulceration. Persistent dry eyes should be medically assessed.