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    Beware Vitamin A Deficiency

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    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

    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.

    —Miriam Karmel

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    1 Ten Hulzen RD et al. Am J Ophthalmol. 2022;26:101471.

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    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.

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    Consultant/Advisor C Consultant fee, paid advisory boards, or fees for attending a meeting.
    Employee E Hired to work for compensation or received a W2 from a company.
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    Independent contractor I Contracted work, including contracted research.
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