Xerophthalmia in Jordan

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Abstract
Thirty-one consecutive patients with the ocular manifestations of vitamin A deficiency were studied. The relationship of dietary history to the occurrence of the deficiency state is discussed. The most severe ocular lesions affected the youngest children. Most of those under three years of age suffered also from kwashiorkor or marasmus and had associated infectious diseases, the most common being gastroenteritis. Following intensive vitamin A therapy the ocular lesions responded well but there was a very high mortality; 64 per cent in those with corneal lesions and 56 per cent in those in whom only the conjunctiva was affected. This was in marked contrast to the much lower mortality (15 per cent) in a group of twenty-seven consecutive patients with kwashiorkor or marasmus without ocular manifestations of vitamin A deficiency. These patients were of a similar mean age and had a comparable pattern of associated infections. As the supportive and antibiotic therapy was similar in all patients, all the evidence points to deficiency of vitamin A being responsible for the high mortality. Possible mechanisms and the implications of these results for treatment are discussed. Biochemical and hematologic data are presented for thirty-one patients with ocular manifestations of vitamin A deficiency and twenty-seven patients with kwashiorkor or marasmus, the clinical aspects of whose condition and response to treatment have been described previously. The findings are compared with those in experimentally induced vitamin A deficiency. The liver stores as well as serum levels were very low in patients with xerophthalmia; even malnourished children without ocular lesions had lower than normal serum levels and very depleted liver stores. There was no relationship between serum vitamin A and any of the serum proteins. The lowering of serum vitamin A readings in the presence of high carotenoid levels was demonstrated by group iii of this study; the mechanism and significance of this are discussed. Malnourished children with xerophthalmia (groups i and ii) have significantly lower serum vitamin E levels than malnourished children without ocular lesions (group iv). Evidence is presented of good initial response of serum vitamin A to oral therapy with the vitamin, indicating good absorption despite gastrointestinal disturbance. Following intramuscular therapy serum levels were lower initially but were ultimately comparable to those obtained with the oral route. Despite this and the good response of ocular lesions to both regimens, the mortality was very high. The depression below normal levels of total serum protein and albumin was significantly less in marasmus than in kwashiorkor. The hemoconcentrating effect of vitamin A deficiency demonstrated in the rat was possibly responsible for the significantly higher mean hemoglobin and hematocrit values in patients with severe ocular lesions (group i) compared with those in malnourished children of the same age without vitamin A deficiency (group iv).