In a case of a blinding condition masquerading as glaucoma,1 a 35-year-old Haitian woman with rapidly failing vision on four glaucoma medications traveled to the United States for consultation and surgery. Although the OR was already booked, the consulting ophthalmologist quickly suspected a different diagnosis. “I was certain that it was not glaucoma,” said Richard D. Ten Hulzen, MD, at Mayo Clinic Florida in Jacksonville.
Dr. Ten Hulzen ruled out cancer, retinitis pigmentosa, retinal dystrophies, and inherited retinal disease. After consulting with a retina specialist, he settled on vitamin A deficiency (VAD) as the likely cause of the patient’s visual loss, even though he had never seen an actual case. VAD occurs most frequently in developing countries. In the United States, its prevalence is under 1%.
CLASSIC SIGN. Foamy Bitot spots are tell-tale signs of vitamin A deficiency.
Clinical diagnosis. The patient’s serum vitamin A levels were within normal limits, as is often the case with VAD, thus requiring clinical diagnosis, Dr. Ten Hulzen explained. Here, the findings suggesting VAD included progressive visual field loss over an 18-month period, dry eye, nyctalopia, and ocular surface keratinization. OCT imaging and slit-lamp examination revealed an absence of optic neuropathy and features of secondary glaucoma in both eyes. Her angles were open, and her IOP was normal after 24 hours off glaucoma medications.
Rx: a fast-acting, affordable treatment. As vitamin A supplementation is known to reverse dry eye symptoms and rapidly restore severe peripheral vision loss, the patient received a loading dose of 200,000 IU per day for two days, followed by a maintenance dosage of 8,000 IU per day. The treatment plan also included stopping all glaucoma medications and use of artificial tears.
The patient’s symptoms significantly improved within 11 days, and she returned to Haiti. By 5½ months, her visual fields had returned to normal, her visual acuity was 20/20 in both eyes, and her IOP was 15 mm Hg in her right eye and 16 mm Hg in her left. Color vision also was preserved.
“We were surprised at how rapidly her dry eye symptoms and visual fields improved following a course of vitamin A supplementation,” said Dr. Ten Hulzen. He noted the irony that the patient, a nurse, had spent 80% of her income on glaucoma medications, when the remedy was a supplement that costs under $10 for a 100-day supply.
1 Ten Hulzen RD et al. Am J Ophthalmol. 2022;26:101471.
Relevant financial disclosures—Dr. Ten Hulzen: None.
For full disclosures and the disclosure key, see below.
Full Financial Disclosures
Dr. Hwang Catholic University of Korea: P; Ministry of Education, Republic of Korea: S.
Dr. Manche Alcon: S; Allergan: S; Avedro: C,S; Carl Zeiss Meditec: S; Johnson & Johnson Vision: C,S; NIH: S; Novartis: S; Placid0: P,S; Presbia: S; Research to Prevent Blindness: S; RxSight: U,S; VacuMed: P,S.
Dr. Ten Hulzen None.
Dr. Wykoff Adverum: C,S; Aerie: S; Aldeyra: S; Alimera Sciences S; Allergan: C; Apellis: C,S; Bausch + Lomb: C; Bayer: C,S; Bionic Vision Technologies: C; Boehringer Ingelheim: S; Chengdu Kanghong: C,S; Clearside Biomedical: C,S; EyePoint: C; Gemini Therapeutics: S; Genentech: C,S; Graybug Vision: S; Gyroscope: C,S; Ionis Pharmaceutical: S; IVERIC Bio: C,S; Kato: C; Kodiak Sciences: C,S; LMRI: S; NGM Biopharmaceuticals: C,S; Novartis: C,S; OccuRx: C; Ocular Therapeutix: C; ONL Therapeutics: C,O; Opthea: C,S; Oxurion: C,S; Palatin: C; PolyPhotonix: C,O; RecensMedical: C,O,S; Regeneron: C,S; RegenXBio: C,S; Roche: C,S; Santen: S; Takeda: C; Visgenx: C,O: Xbrane Biopharma: S.
||Consultant fee, paid advisory boards, or fees for attending a meeting.
||Hired to work for compensation or received a W2 from a company.
|Employee, executive role
||Hired to work in an executive role for compensation or received a W2 from a company.
|Owner of company
||Ownership or controlling interest in a company, other than stock.
||Contracted work, including contracted research.
|Lecture fees/Speakers bureau
||Lecture fees or honoraria, travel fees or reimbursements when speaking at the invitation of a commercial company.
||Beneficiary of patents and/or royalties for intellectual property.
|Equity/Stock/Stock options holder, private corporation
||Equity ownership, stock and/or stock options in privately owned firms, excluding mutual funds.
||Grant support or other financial support from all sources, including research support from government agencies (e.g., NIH), foundations, device manufacturers, and\or pharmaceutical companies. Research funding should be disclosed by the principal or named investigator even if your institution receives the grant and manages the funds.
|Stock options, public or private corporation
||Stock options in a public or private company.
|Equity/Stock holder, public corporation
||Equity ownership or stock in publicly traded firms, excluding mutual funds (listed on the stock exchange).
More from this month’s News in Review