Role of Vitamin A:

Production of retinal pigments maintain integrity of epithelium supports growth Immunity

ANIMAL: liver, eggs, butter, cheese, whole milk, fish and meat PLANT: green leafy vegetables like spinach and amaranth, papaya, mango, pumpkin and in some roots like carrot.
FORTIFIED FOODS: like vanaspati, margarine, milk

XEROPHTHALMIA:
- Ocular manifestations of vitamin A

XN
X1A X1B X2 X3A X3B XS

Night blindness
Conjunctival xerosis Bitots spots Corneal xerosis Keratomalacia affecting less than one third of corneal surface Keratomalacia affecting more than one third corneal surface Corneal scar due to xerophthalmia

XF

Xerophthalmic fundus

1. Night blindness: - earliest symptom - elicited by detailed history from guardian 2. Conjunctival xerosis: - first clinical sign - dryness of conjunctiva in the interpalpebral zone with loss of goblet cells, squamous metaplasia and keratinisation. - described as emerging like sand banks at receding tide.

3. Bitots spots: - raised, silvery white, foamy, triangular patch of keratinised epithelium situated on the bulbar epithelium - bilateral and temporal - young children indicates active disease and in older individual due to sequelae of earlier disease. 4. Corneal xerosis: - earliest change is punctate keratopathy. - begins in lower nasal quadrant. - involved cornea lacks lustre.

5. Corneal ulceration/ Keratomalcia: - characterised by circular, steep margin and sharply demarcated. - if appropriate therapy instilled immediately, stromal defects involving one third cornea heal, leaving some useful vision - larger stromal defect(X3B) results in blindness - medical emergency

6. Corneal scar - sequelae of keratomalcia 7. Xerophthalmic fundus - characterised by typical seed-like, raised whitish lesions scattered uniformly over the part of the fundus at the level of optic disc.

EXTRAOCULAR MANIFESTATIONS
-

Hyperkeratosis Anorexia Growth retardation Increased risk for respiratory tract and gastro-intestinal tract infection

LOCAL OCULAR THERAPY

- Conjunctival xerosis: artificial tears - Keratomalacia: like full fledged treatment of bacterial corneal ulcer.

VITAMIN A THERAPY
WHO Recommended schedule: All patients above 1 yr ( except women of reproductive age) - 2 lakh IU orally or 1 lakh IU intramuscularly - Given immediately after the diagnosis and repeated the following day and 4 weeks later. Children under 1 yr and children of any age < 8 kg - Half the above dosage All children with corneal ulcer should receive vitamin A whether or not a deficiency is suspected.

Women of reproductive age, pregnant or not: a. With night blindness( XN), conjunctival xerosis (X1A) and Bitots spots( X1B) Daily dose of 10,000 IU of vitamin A orally( sugar coated) for 2 weeks b. For corneal xerophthalmia - Full dosage schedule ( described for patients above 1 year age) recommended

TREATMENT OF UNDERLYING CONDITION IS NEEDED

 SHORT

- TERM APPROACH

- periodic supplementation of vitamin A - WHO recommended schedule

AGE DOSAGE

Infants 6-12 months old and 1lakh IU orally every 6 any children <8 kg months Children >1 yr and under 6 yrs Lactating mothers 2lakh IU orally every 6 months 20,000 IU orally once at delivery or during next 6 months 50,000 IU orally before they attain 6 months

Infants < 6 months not breastfed

In India, according to Child Survival and Safe Motherhood ( CSSM) program: First dose ( 1 lakh IU )- at 9 months of age along with measles vaccine Second dose( 2 lakh IU )- at 18 months of age along with booster dose of DPT/ OPV Third dose ( 2 lakh IU ) at 2 yrs of age

MEDIUM TERM APPROACH

To

promote regular and adequate intake of vitamin A Food fortification with vitamin A

LONG TERM APPROACH

Aimed

at reduction or elimination of factors contributing to ocular disease It includes Promotion of breast feeding Improvement in environmental health by providing safe and adequate water supply and maintenance of sanitary latrine Immunisation against measles Prompt treatment of diarrhoea and other associated infections

 Better

feeding of infants and young children Improved health services for mother and children Health education

 Parks

textbook of Preventive and social medicine, 21st edition WHO( 1984). Strategies for the prevention of blindness in national programmes, Geneva, WHO. WHO( 1973). WHO Chr. 27(1)28.